Factors Associated with Depression, Anxiety, and PTSD Symptoms Among Bhutanese-Nepali Refugees

Background: Lhotsampas, the ethnically Nepali and Nepali-speaking Bhutanese, were forcefully relocated by Bhutan government in early 1990s due to their ethnicity and religious background. Beginning 2008, after spending years in various refugee camps in the Southeastern Nepal, they began resettling in the United States. Given their suicidal rates were shown to be alarmingly high by the 2013 CDC report, it is crucial to identify factors associated with behavioral health conditions that may contribute to their high suicide rates. However, there exists little to no empirical data regarding behavioral health conditions on this significant and growing refugee community in the United States. The purpose of this study was to examine sociodemographic, immigration, acculturation, social support, and health factors that contribute to their depression, anxiety, posttraumatic stress, and alcohol use disorders.

Methods: Using a convenience sampling method, eighty-four adults from Bhutanese-Nepali were interviewed between July 2016 and April 2017 either in Nepali or in English. For this study, four behavioral health conditions were examined as outcome variables: Hopkins Symptom Checklist was used to assess symptoms of depression and anxiety; Refugee Health Screener-15 was used to assess symptoms of post-traumatic stress disorder (PTSD); and Alcohol Use Disorder Identification Test was used to assess symptoms related to alcohol use disorders (AUD). A series of linear regressions were modeled with sex, age at U.S. arrival, English language proficiency, social support, and self-reported health included as predictor variables.

Results: Of the 84 participants, 49 (58.3%) were women. The median age was 28.5 years old, and 44 (53.7%) reported graduating from high school or having their GED. Majority (84.5%) reported Hinduism as their religion. All spoke Nepali as their primary language. Given their refugee background, 82 (97.7%) stayed at refugee camp for more than 17 years on average. Median length of stay in the United States was about 7 years. Fifty-three (63.1%) reported speaking English “not well.” Descriptive analyses showed that mean score for PTSD symptoms was 10.3 (SD=8.7) and 31 participants (36.9%) met the cutoff score for PTSD; the mean score for depressive symptoms was 1.5 (SD=0.50) and 23 participants (27.4%) met the cutoff score for depression; the mean score for anxiety symptoms was 1.5 (SD=0.49) and 18 participants (21.4%) for anxiety disorder; and the mean score for AUD symptoms was 1.0 (SD=2.36) and 3 participants (3.6%) met the criteria for AUD. The results of linear regression analyses revealed that being women was significantly associated with all four behavioral health symptoms (depression, anxiety, PTSD, and AUD); self-reported health status was negatively associated with depression, anxiety, and PTSD symptoms; and being older at U.S. arrival was significantly associated with higher anxiety symptoms.

Implications: The results from this study suggest that a large portion of the Bhutanese-Nepali refugees experience depressive symptoms, PTSD, and anxiety. Being female was identified as a common risk factor for all behavioral health symptoms examined in this refugee group. The research contributes by filling in the current literature gap regarding Bhutanese-Nepali refugees’ mental health status and needs after third country resettlement.