Depression and suicidality in an Afghan refugee: A case report

Introduction

Refugees from war-torn nations who settle in the United States (US) and other western nations suffer from significant rates of mental illness, most commonly post-traumatic stress disorder (PTSD) and depression (Fazel, Wheeler, & Danesh, 2005). The prevalence of depression, anxiety, and PTSD is estimated to be as high as 20% in certain refugee populations (Bogic, Njoku, & Priebe, 2015). Afghanistan, in particular, serves as a significant source of refugees. Recent studies suggest an increased level of depression, post-traumatic stress disorders, and other psychiatric co-morbidities in refugees from Afghanistan (Alemi, James, Cruz, Zepeda, & Racadio, 2014). Several factors contribute to this increase in psychiatric conditions, including pre-migration experiences of trauma. After immigration, post-migration factors like acculturation, lack of social support, and experimentation with alcohol and drugs also contribute to the evolution of depression and decreased life satisfaction in refugee populations (Birman & Tran, 2008). This is further complicated if the refugee is unable to find a suitable vocation allowing for economic stability and access to healthcare and community resources. Studies show that job placement and security are often inadequate for refugees, and that those encountering economic hardship after migration experience more psychological distress (Simich, Hamilton, & Baya, 2006). In addition, refugees typically have expectations of a better life experience in their adoptive country, and disappointment about the quality of life contributes to the development of psychiatric illness.

Given the importance of both pre- and post-migration factors in determining mental health outcomes, it is critical that pre-migration screening methods improve and that post-migration surveillance methods are developed to identify early psychiatric symptoms and facilitate treatment.

The following case illustrates an example of an Afghani refugee who experienced social isolation and subsequent depression after immigrating to the United States and illustrates the importance of mental health services for refugee populations.

Case Report

Mr H is a 31 year old Afghani male who immigrated to the United States as a refugee. Leading up to his immigration, he worked with the US Special Forces as a translator. He reported being dedicated to his work with the US military, developing close relationships with military personnel, and continuing his service despite receiving two combat related injuries. After six years, however, his involvement with the US military became known to local Afghans who opposed US involvement in the country. Mr H began receiving death threats and his family was forced into exile. He ultimately sought asylum in the US to protect himself and his family. While Mr H was allowed to re-settle in the US, his parents and other family members remained in Afghanistan.

Once in the US, Mr H was placed in an unskilled night job working at a travel transit site. His experience working in this setting was challenging, as he reported being profiled by his co-workers and accused of appearing suspicious due to his Afghani background. Mr H felt betrayed by these accusations given his military service which had put himself and his family at risk. He found it difficult to build relationships with his co-workers in this work environment as he felt they did not trust him and harbored animosity against him due to his ethnicity.

In addition to this job, Mr H began working at another location during the day, in order to earn enough money to pay his rent and support his family in Afghanistan. During this time, he started experiencing significant depression, which was complicated by long daily work hours, decreased self-care, loss of appetite, and lack of sleep. He also reported feelings of worthlessness, guilt from abandoning his country, a sense of alienation, an inability to reciprocate socially without being marginalized, lack of an identity, anger, remorse, and despair. He also reported abusing alcohol, stating that, “there were no restrictions and I could have whatever I wanted.” However, his alcohol use decreased after his initial resettlement, eventually ceasing altogether in the months leading up to his presentation.

As time went by, he became increasingly isolated with no social support or sense of community. He was unable to establish meaningful relationships with his roommates and had no connection to local refugee or Afghan groups in the community. He stated that he felt the refugee center that he initially worked with had done all they could for him, and that he was ultimately alone. He also began ruminating and expressing the ideology that “I helped the US army and made enemies in my homeland, now I am the enemy here in the US, how is this fair?” Eventually he became so despondent that he wrote cheques amounting to his entire life savings, sent them to his family, and attempted to commit suicide by stabbing himself repeatedly in the neck, chest, and abdomen.

He was found by a roommate after his suicide attempt, and underwent emergency surgery at a trauma center. His trauma-based symptoms were significant for five self-inflicted stab wounds to the mid neck zone, left chest, and mid-epigastrium.

He was medically stabilized after surgery and transferred to the psychiatry service. On admission to the psychiatry service, Mr H displayed significant depressive symptoms including suicidal ideation, insomnia, and decreased appetite. However, he was amenable to therapy and medication. He scored a 48 on the Montgomery-Asberg Depression scale (MADRS) during his first week on the inpatient psychiatric unit. Based on the patient's depressive symptoms and suicidality he was initiated on both pharmacotherapy with escitalopram 10mg as well as daily supportive psychotherapy. This treatment plan was developed given evidence supporting the benefits of combined therapy over either modality alone in the setting of major depression (de Maat et al., 2008; Filakovic & Eric, 2013).

The goal of the daily psychotherapy sessions was to improve Mr H's self-esteem while offering encouragement and strategies to help him better manage his feelings of hopelessness. Reassurance and validation were provided in order to help decrease his feelings of shame regarding his depression. In addition, we praised him for taking concrete steps at reframing his attitude and goals towards life in the US. Strategies were also developed to help improve his quality of life and professional opportunities.

During his first week, Mr H had a minimal response to treatment with inconsistent MADRS scores ranging between 22 and 48. In addition to his depressed mood, he continued to struggle with insomnia and a decreased appetite, and so the treatment team switched him to mirtazapine 15mg to target these symptoms. He responded well to this regimen with his MADRS score trending down to 18 after one week of therapy with mirtazapine. Mr H was ultimately stabilized on this regimen of mirtazapine 15mg at night. After several weeks of daily supportive therapy in addition to his medication, Mr H became significantly more hopeful and future oriented. His last MADRS before discharge was a 10 constituting a clinically significant reduction in depressive symptoms. The treatment team was able to coordinate Mr H's discharge with an extended family member living in North America. However, the patient was initially hesitant to include his family, as he reported, “I would be a failure if I ask them to help me, I am too proud to burden them with my sob story.” His hesitance to involve his family seemed to stem from the stigma he attached to mental health and suicide. He expressed a great deal of anguish from the responsibility of supporting his family in Afghanistan financially as well as guilt for having tried to take his own life. Ultimately, however, his resistance to involving his family softened, and he was discharged to the care of his family member, with the hope of establishing a more suitable career and living situation.

Ideally, we would have connected Mr H with an affiliated outpatient clinic where he could be seen and followed closely. However, the logistics of his family situation made this difficult. While attempts were made to encourage Mr H to seek close psychiatric follow-up as well as to continue his antidepressant medication, his discharge location was remote from our inpatient psychiatric facility, and we were unable to ascertain his long-term outcome.

Discussion

This case presents the challenge refugees face in re-integrating into society after immigrating. Consistent with our patient's case, studies have shown that the experience of war trauma coupled with discrimination and marginalization in a new country increase the risk of developing depressive symptoms in refugee populations (Molsa, Kuittinen, Tiilikainen, Honkasalo, & Punamaki, 2016). Pre-migration experiences of violence coupled with post-migration loss of family, social supports, and the struggle to adapt to cultural differences in the US all contribute to the risk of developing mental illness in refugee populations.

With refugee crises continuing to occur around the world, a standardized and validated method for screening patients for mental illness is essential. While comprehensive health screenings are provided for most refugees, there is evidence that as few as one third of refugee health screens include standardized mental health assessments (Polcher & Calloway, 2016).

Equally important is the implementation of standardized post-migration surveillance for psychiatric symptoms that develop in refugee populations after re-settlement. Studies indicate that refugees who experience discrimination after settling in their adoptive country have significantly higher rates of emotional problems and aggressive behavior (Beiser & Hou, 2016). Additional post-migration factors such as difficulty finding work, poverty, and concern about family may also contribute to the development of psychiatric symptoms (Aragona, Pucci, Mazzetti, Maisano, & Geraci, 2013).

The implementation of a standardized pre- and post-migration surveillance process could aid in identifying and treating mental illness in refugees settling around the world. We suggest an approach to refugee mental health screening and treatment that focuses on initial identification of individuals at risk as well as scheduled surveillance assessing for post-migration development of psychiatric symptoms in order to better facilitate early intervention (Figure 1). One possible method for implementing a model like this could utilize a two-step screen and confirm approach which has been shown to be effective in recent studies investigating ways to best identify and treat refugees in need of mental health care (Llosa et al., 2017). Under such an approach, refugees undergoing the initial re-settlement process could be administered a general screening assessment such as the WHO-UNCHR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASS). Lay interviewers without mental health expertise could administer this kind of assessment quickly with the goal of referring individuals with positive screening assessments to mental health providers. In order to confirm a diagnosis and initiate treatment after a positive screening assessment, a more stringent tool like the Mini International Neuropsychiatric Interview (MINI) could be administered by a trained mental health professional. (Sheehan et al., 1998). The MINI is an established and well validated diagnostic psychiatric interview that has been used successfully in refugee populations and could serve as an effective method for diagnosing and guiding treatment in refugees (Llosa et al., 2017). Scheduled re-assessment screens with a tool like the WASS could also be coordinated after re-settlement to identify refugees who develop symptoms during the initial post-migration period as well as for those who were missed during preliminary pre-migration screening assessments. Universal adoption of a screening model like this may help to identify refugees at risk for psychiatric illness and aid in facilitating timely treatment (Polcher & Calloway, 2016). OPEN IN VIEWER

Timing the implementation of psychiatric screening is another important element to consider in designing a screening model. In the case of Mr H, his depression evolved over time during his first year of resettlement, complicated both by his traumatic experiences prior to resettlement as well as his post-migration stressors. This pattern of gradually worsening depression with an eventual suicide attempt is consistent with studies that have linked suicidality to stressors in refugee populations such as low quality of life, tenuous employment status, history of trauma, and economic hardship (Akinyemi, Atilola, & Soyannwo, 2015; Sundvall, Tidemalm, Titelman, Runeson, & Baarnhielm, 2015). Consistent with this, a significant percentage of refugee suicide attempts have been observed to occur within the first year of resettlement (Staehr & Munk-Andersen, 2006; Vijayakumar, 2016). Recognizing this pattern has important implications towards optimizing the timing of treatment and screening to help refugees struggling with mental illness. Scheduled screening for the development of new depressive symptoms may be most effective during the time period after initial resettlement but within the first year. Optimizing the timing of screening may help capture evolving mental health issues that were not detectable on arrival before they escalate to the point of suicidality.

Importantly, while implementing this kind of model, care would have to be taken to avoid the exclusion of individuals based on positive screening assessments. While the benefits of early detection and treatment are clear, these benefits would have to be balanced against risks of losing the opportunity to re-settle based on the diagnosis of a mental illness. Establishing ways to safeguard against discrimination would be essential in the implementation of any screening model.

In addition to effective screening, finding ways to overcome stigma surrounding mental health is another important aspect of implementing psychiatric care for refugees. In our case example, Mr H seemed to respond best to members of our treatment team that shared cultural backgrounds and experiences with him. In particular, one of the physicians on our treatment team was able to share the story of how her parents had migrated to the United States and faced a similar struggle in encountering discrimination when they first arrived. She shared how her family faced difficulties in finding meaningful work, but were ultimately able to find secure employment and stability. This shared history made it easier for Mr H to discuss his experience of discrimination and led to a more open relationship with the treatment team. This improved treatment dynamic following a cultural connection with a member of the treatment team is consistent with studies showing that the recognition of culturally specific beliefs and experiences related to mental health may improve treatment in refugee populations (Alemi, Weller, Montgomery & James, 2017). Collaborating with refugee support organizations and other community organizations may be another effective method in providing culturally sensitive psychiatric care to refugee populations. (Pejic, Hess, Miller & Wille, 2016). While our case draws from a refugee experience in the US, the principles of the proposed screening model could be applied to any country accepting refugees throughout the world.

Conclusion

The difficulties in assimilating to life in a new country are not new. However, current trends indicate that there is a significant unmet need for mental health services to aid refugees. Meeting this need is critical to the welfare of individuals seeking refuge around the world.