Understanding Mental Health & Culturally Responsive Mental Health Interventions Among Bhutanese Refugee Population in the United States: A Systematic Scoping Review

Background: Bhutanese refugees constitute the largest group of Asian refugees resettled in the U.S. In addition to facing post-resettlement challenges, this population has been a subject of considerable psychological investigation due to alarming rates of anxiety symptoms, PTSD, depression, substance misuse and documented evidence of high suicide rates. Further, mental health concerns remain a huge stigma among the Bhutanese community, which is often unaddressed due to gaps in service delivery and utilization. There is an urgent need for an in-depth understanding of mental health and development of culturally responsive interventions that can promote mental well-being among this hidden population.

Purpose: The purpose of our systematic scoping review is: to provide a scientific understanding of Bhutanese mental health; understand efficacy of intervention strategies that have been used in the Bhutanese context, and propose recommendations for advancing research and interventions to improve well-being of Bhutanese refugees resettled in the U.S.

Methods: We created a six-staged overarching scoping review framework to guide our inquiry: research question; study identification; study selection; data synthesis; results collation and community consultation.

Study search was conducted from February 2019 through February 2020 on seven databases. Inclusion criteria comprised empirical and conceptual studies: published in peer-reviewed journals; published in English; conducted among Bhutanese refugees in the U.S., focused on mental health outcomes and interventions. Grey literature, studies not focusing on mental health, and not conducted in the U.S. were excluded. The three-staged screening and selection process included: initial search and duplicate removal, title and abstract review, and full study review.

Data synthesis included extraction of data—study purpose, methodological characteristics, and results—from each study to provide a numerical summary and an overall understanding of mental health and interventions. A thematic framework was used to index, annotate, code and reference study results to identify generic themes and group the studies into thematic clusters. Key results were then extracted from each study for an overview map.

Results: Reviewed studies (N=31) included empirical (27) and conceptual (4) studies. Majority of empirical studies used qualitative (48%), quantitative (40%) and mixed methods (11%) research approaches. Majority of the studies focused on Bhutanese youth and adults (85%), children and youth (7%), and older adults (7%). Theoretical frameworks included: ecological model; bio-ecological systems model; interpersonal psychological theory of suicidal behavior; cultural model of suicide; trajectory model; conservation of resources theory; cultural trauma and coping; social capital framework; PEN-3 cultural model and Nepali ethnopsychology. Most common mental health measures were: Harvard Trauma Questionnaire, the Hopkins Symptoms checklist and the Patient Health Questionnaire. Across studies, five overlapping thematic clusters were identified in relation to mental health: migration stressors; social convoy; suicide; culture, trauma and resilience, and mental health services and interventions.

Conclusion and Implications. Study findings contribute to understanding the cultural context of mental health grounded in Bhutanese context, crucial for developing culturally tailored interventions and a foundation for future studies. Findings also highlight the importance of data disaggregation, which help establish the scope of the problem, unmask sub-population differences, and make vulnerable groups more visible.