Sharmila Shetty, MD

Immigrant, Refugee and Migrant Health Branch

Centers for Disease Control and Prevention

Georgia Coalition of Refugee Stakeholders Meeting

November 8, 2012

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 2012, 17 Bhutanese suicides reported in 10 states

� Handful of suicides also in Burmese,

Sudanese, Burundi

International Organization for Migration (IOM) Assessment

� High numbers of completed and attempted suicides in

Nepal camps

� In Jan 2010, IOM assessment on suicide risk factors of

Bhutanese refugees in Nepal

� Results:

� 67 completed and 64 attempted suicides from 2004-2010

� Victims of gender-based violence more likely to attempt or

complete suicide

� Association between suicide and hx mental illness in family

� Prevalence of untreated mental illness high

� Recommended similar assessment in US

ORR Request for Assistance

� Centers for Disease Control and Prevention (CDC)

� Refugee Health Technical Assistance Center (RHTAC)

� TA provider of ORR

� Objectives

� Characterize suicides

� Identify risk factors associated with suicidal ideation

� Formulate recommendations for stakeholders

Field Partners

� State Refugee Health Programs

� Local refugee resettlement agencies

� Bhutanese community leaders

� Mental health experts at state/local level

Study Design

1. Psychological Autopsies

� In-depth interviews with close contact of suicide victims

� Describe epidemiology, patterns, and events around suicide

� Understand mental health picture of victims

2. Cross-sectional survey of Bhutanese community in US

� Understand mental health picture of Bhutanese refugees in US

� Identify risk factors for suicidal ideation

� Survey of randomly selected Bhutanese refugees in 4 states

FINDINGS: PSYCHOLOGICAL AUTOPSIES

Number of Suicide Events Feb 2009-Feb 2012

17 reports of suicide

1 car

accident

16

confirmed

suicides

14

consented

interview

Number of Suicides in the US by year,

Feb 2009 – Feb 2012 (n=16)

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)

Time Since Arrival

Time from Arrival to Suicide, by Gender

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

Characteristics of Completed Suicides

� 7 (50%) had friends/neighbors who attempted suicide

� 3 (21%) had 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

Characteristics 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)

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?

Psychological Autopsies Summary

� Most suicide victims

� were unemployed males

� had language barriers

� Only 2/14 had previously diagnosed MH condition

� Only 1 sought help from MH provider

CROSS-SECTIONAL SURVEY

Cross-sectional Survey: Methods

� Representative, randomly selected sample of

Bhutanese refugees from 4 states• Georgia (Clarkston, 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 present

• Target 579 refugees

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

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)

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/clothing216 (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)

Poor access to counseling services 84 (20)

Significant Risk Factors Associated with Suicidal Ideation

� Not being provider of family

� Post-traumatic stress disorder

� Depression

� Being unable to find work

� Increased family conflict

� Wished that people would just leave you alone

Cross Sectional Survey Summary

� About half employed (vs. 14% in suicide victims)

� Majority faced language barriers

� 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/RECOMMENDATIONS

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

Interventions in Refugee Camps in Nepal

� Developed intervention guidelines for cases of

completed/attempted/threatened suicide

� Trained counselors on more in-depth identification and

treatment of suicidal cases

� Trained IOM doctors and resettlement staff on

recognition of psychosocial problems

� Increased number of visits to camp by psychiatrist

� Discussed incorporating psycho-social aspects into

cultural orientation classes

Interventions in USQuestion, Persuade, Refer (QPR) Training

� QPR training helps gatekeepers recognize warning

signs of suicide and how to question, persuade, and

refer someone to help

� “CPR for suicide prevention”

� In fall 2010, RHTAC adapted core QPR training to be

more culturally appropriate to Bhutanese refugees

� 10 Bhutanese refugees certified as QPR trainers

� RHTAC created Refugee Suicide Prevention Training

Toolkit

Refugee Suicide Prevention Training Toolkit

www.refugeehealthta.org

Suicide Prevention Poster

Available in English,

Nepali, Arabic, Burmese,

Karen

RecommendationsResettlement Network

1. Provide wrap-around support for

families/communities of recent suicides

2. Standardize reporting of suicides� Community--> RHC�ORR

� Include attempts

3. Engage state Suicide Prevention Coordinator

4. Familiarize with local MH resources and services� Use cultural brokers

RecommendationsResettlement Network

� Conduct QPR trainings

� Pathways to Wellness Community Adjustment Support

Groups

� Focuses on ways to use community to sustain wellness

� Training materials available Dec 2012

� Minimize contagion effect

RecommendationsORR

� Support culturally appropriate, community-based

suicide prevention activities

� E.g. women’s sewing, religious singing, sports groups

� Continue to support vocational training

� Coordinate collection of psychological autopsy info

� Support development of social media tools to promote

suicide prevention messages

RecommendationsOther Federal Partners

� UNHCR to manage expectations of family separation

� PRM to follow up on recommendations of IOM report

and update US refugee stakeholders

� CDC to update domestic refugee screening guidelines

on mental health

Acknowledgements

� 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

Resources

� RHTAC website: report, suicide prevention tool kit

� www.refugeehealthta.org

� Pathways to Wellness

� http://www.lcsnw.org/pathways/index.html

� Georgia Crisis & Access Line

� 1-800-715-4225

� National Suicide Prevention Lifeline

� 1-800-273-TALK (8255)

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official

position of the Centers for Disease Control and Prevention.

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 with interpreter by CDC or state

Refugee Health Program staff

Psychological Autopsies

� 21 page questionnaire

� Demographics

� Mental health history

� Details of suicide

� Social networks

� Trauma events

� Post-migration stressors

� Open-ended questions

� Informed consent

� “Change in mood: depressed, nervous,

withdrawn”

� “Anxiety; told family that he was frustratedwith

this place; used to get angry all of a sudden”

� “Left gold earrings for daughter the day before”

What were some of the warning signs?

Training of Interviewers

� Two day training in each city

� 6-8 interviewers per city

� Topics

� Research Ethics

• Informed Consent

• Confidentiality

� Best practices for interviewing

� Role playing with questionnaire

� Distressed respondent protocol

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

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)

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