Psychiatric Issues in the Somali Refugee Population

September 4, 2013
Jerome Kroll, MD

,
Ahmed Ismail Yusuf, MPH

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 Somali Civil War in January 1991, a significant portion of the Somali population has become displaced persons either within Somalia and the Horn of Africa, or more widespread to Europe and North America. At the present time, there are sizable groups of Somali persons living in Minneapolis, Columbus (Ohio), Nashville, Atlanta, Boston, and Seattle. Minnesota hosts over 50,000 Somalis, constituting one of the largest concentrations of Somalis outside of the Horn of Africa.

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 clinic in Minneapolis, we saw patients with interconnected problems of PTSD, depression, grief, and demoralization that is the common burden of all displaced persons.1 The clinical picture of combined PTSD/depression was considerably more common in women than in men, especially in women age 30 years and older. Compounding the violence incurred during the early months of the Civil War within Mogadishu and adjacent regions in the south of the country was the experience of chronic exposure to daily threats and aggression in overcrowded refugee camps in Kenya and, to a lesser extent, in Ethiopia. There, the refugee population-composed primarily of women and young children-were subjected for years to raids by hostile local tribesmen, as well as by predatory male teenagers living within the camps themselves.2

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.4Pharmacological and physiological effects are similar to amphetamines, but a slight alteration in chemical structure results in a much milder stimulant effect.5 Khat use is ordinarily socially regulated, but the breakdown of social and family structures in Somalia after 1991 allowed its use among young adolescents in amounts and frequency that previously never had been permitted. As with early and excess use of marijuana, there appears to be a correlation with onset of psychoses in early adulthood.6

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 Vitamin D deficiency to psychoses and depressive illnesses.8

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 provide care to refugee populations should appreciate that an essential and integral component of care involves considerable effort in helping patients in many social and legal spheres. These involve obtaining medical benefits; assisting with the entire panoply of housing, day programs, special medical clinics, and vocational programs; and immigration issues, such as assistance in applying for citizenship or sponsorship of relatives in Africa who wish to join the patient in the US. In addition, as with many refugee populations, Somali individuals suffer from underdiagnosed and undertreated chronic medical illnesses, primarily hypertension and diabetes, as well as excessive tobacco use in males. Stress from these many issues contribute to the illness burden of the refugee patient, and confront the psychiatrist with redefining the role and boundaries of the community psychiatrist.

Disclosures:

Dr Kroll is Chief Psychiatrist at the Community-University Health Care Clinic in Minneapolis and Professor of Psychiatry Emeritus at the University of Minnesota Medical School. Mr Yusuf is Case Manager at Community-University Health Care Clinic, University of Minnesota Medical School, Minneapolis, Minn.

References:

1. Kroll J, Yusuf AA, Fujiwara K. Psychosis, PTSD, and depression in Somali refugees in Minnesota. Soc Psychiatry Psychiatr Epidemiol. 2011;46:481-493.
2. Horn R. Exploring the impact of displacement and encampment on domestic violence in Kakuma refugee camp. J Refug Studies. 2010;23:356-376.
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. Chronic khat use and psychotic disorders: A review of the literature and future prospects. Sucht. 2007;53:9-22.
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]