
Psychiatric Issues in the Somali Refugee Population
This article highlights several features of medical and social importance that are somewhat unique to the Somali refugee community in the US.
[[{"type":"media","view_mode":"media_crop","fid":"17393","attributes":{"alt":"Mental health treatment for refugees","class":"media-image media-image-right","height":"245","id":"media_crop_7533685177284","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"947","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"","typeof":"foaf:Image","width":"174"}}]]This article will present the major patterns of psychiatric morbidity in the Somali community of Minnesota, assessing several features of medical and social importance that are somewhat unique to this refugee community because of Somalia’s history, culture, characteristics, and longevity of its Civil War.
Since the outbreak of the
Several features of Somali history and culture that impact uniquely upon psychiatric syndromes are that the population has been (1) overwhelmingly ethnic Somali, and therefore not subject to the ethnic violence of other civil wars, and (2) overwhelmingly Sunni Muslim, and therefore not torn apart by religious sectarianism and terrorism. The violence and inability to form a stable government have been based upon clan and caste mistrust and animosity, rather than on religious ideological differences. One additional feature unique to Somali refugees that has psychiatric import has been the accepted custom, especially among men, of chewing khat, an indigenous plant that contains cathinone compounds having stimulant properties milder than, but closely akin to, amphetamines.
In our inner city
In our clinic, self-reports of rape and other forms of violence were initially under-reported in the refugee population, both for reasons of personal and social shame and because of the religious sense that complaining about hardships in the life that “God has written for you” borders upon blasphemy. We also saw a very high percentage (80%) of men under age 30 years with psychotic illnesses of acute, stormy, confused, and violent presentations, far in excess of what we had seen in other refugee groups.1 Risk factors leading to these acute psychoses appear to be childhood head injury, early childhood starvation, early and uncontrolled khat use in adolescents far in excess of that permitted in pre-Civil War Somali society, and the overall differential effects upon young boys and girls of early violence and social disruption.
Role expectations of manliness-loyalty to the clan and protection of the homestead-may have brought pressures unique to young males raised in this patriarchal society. Employing a mythical lineage identity, the clan would organize in groups to expand or defend its power base, depending upon whom one is hearing. Through this process, men of each clan forced an armed confrontation with those of other clans. Consequently, boys who were not yet of fighting age (early adolescence and even late childhood) took part in the horrors of civil violence and were scarred for life. The psychological effects of such a burden, it seems, later matured into psychotic illnesses. The weight of clan responsibility had doubled the dangers they were exposed to, as the young men were taught to defend their clan, to defend their mothers and sisters from rape; and to defend their fathers, brothers, and cousins as well as defending themselves and their honor. Yet death, rape, and destruction all arrived, regardless. Now the great grief that resulted brought about irreconcilable psychological scars that might breed a cluster of psychoses in Somali men who came of age in the Civil War and its immediate aftermath.
The other major risk factor unique to refugees from the Horn of Africa is the use of khat.3 Khat is a psychoactive alkaloid derived from the Catha edulis plant. Khat chewing is a legal and socially accepted recreational activity in the Horn of Africa countries and parts of the Middle East. Leaves of the plant are chewed slowly over the course of 3- to 4-hour khat sessions, usually restricted to men, in which a mild euphoria, accompanied by expansive plans and endless possibilities, are nourished, only to fade by the next morning.4
Pre- and post-natal malnutrition is a prominent risk factor for failure to thrive and for pathological neurological and psychological development. There was a drought and subsequent famine in 2002-2004 following the Civil War, with an estimated childhood death rate of 30% to 40%.7 Prenatal malnutrition has been linked to development of psychotic illnesses in young adults. Vitamin D deficiency is endemic in African refugees living in northern Europe and North America. Several researchers have linked
Attaining citizenship is a source of great stress for many Somali persons with a mental illness that interferes with learning of new material, including the English language and the facts of US history and civics. Failure to obtain citizenship places a disabled person at risk of losing all federal benefits (ie, health insurance, medical insurance, housing assistance), as well as losing the legal protection given to US citizens. Loss of disability benefits often means that the Somali individual is unable to send money back to relatives in refugee camps or in Somali, a failure that involves loss of face at both personal and clan levels of expectations. The psychiatrist is often called upon to provide a lengthy N-648 waiver form for a patient, attesting that the patient’s disability is severe enough to make learning English impossible. Small discrepancies among various documents can lead to suspicions on the part of the government of dishonesty or malingering, deadly for a citizenship applicant. For young men, minor drug charges or domestic assault charges might lead to a felony conviction with subsequent deportation, now that the US recognizes the provisional Somali government.
The psychiatrists and community health centers that
Disclosures:
Dr Kroll is Chief Psychiatrist at the
References:
1. Kroll J, Yusuf AA, Fujiwara K.
2. Horn R.
3. Douglas H, Boyle M, Litzeris N. The health impacts of khat: A qualitative study among Somali-Australians. Med J Aust, 2011;195:666-669.
4. Nakajima M, al’Absi M, Dokam A, et al. Gender differences in patterns and correlates of khat and tobacco use. Nicotine Tob Res. 2013;15:1130-1135.
5. Odenwald M.
6. Large M, Sharma S, Compton MT, et al. Cannabis use and earlier onset of psychosis. Arch Gen Psychiatry. 2011;68:555-561.
7. Moore PS, Marfin AA, Quenemoen LE, et al. Mortality rates in displaced and resident populations of central Somali during 1992 famine. Lancet. 1993;341:1478-1479.
8. Dealberto MJ. Clinical symptoms of psychotic episodes and 25-hydroxy vitamin D serum levels in black first-generation immigrants. Acta Psychiatrica Scandinavica. 2013;doi:10.1111/acps.12086. [Epub ahead of print]
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