Methods
Interpreters and healthcare providers who work with Somali patients were recruited to help learn about depression in the Somali community. All interviews were one-on-one except for one focus group of interpreters. In total, two health care providers and five interpreters were interviewed regarding their knowledge of this topic including common beliefs, traditional treatments, and advice for other healthcare providers. The profile was then reviewed by Refugee and Immigrant Health Promotion Program staff, including Carey Jackson, MD, director of the International Medicine Clinic at Harborview Medical Center, Seattle. A Somali community leader/educator and a consulting psychiatrist of the International Medicine Clinic then did further review.
Epidemiology
Brundtland points out that “it is established that an average of more than 50% of refugees present mental health problems ranging from chronic mental disorders to trauma, distress and great deal of suffering.”
Clinical Features
In Somalia, mental state is divided into two categories: the mentally ill and the mentally healthy. Some may call the groups sane and insane. There is no continuum of mental illness as there is in the United States. There is still a major stigma and shame associated with mental illness. For this reason, this illness is often hidden from family, friends, and physicians. The general belief is that once a person has depression or another mental illness, s/he will never get back to their mentally healthy baseline. Some say their mental stability can never be trusted again.
Many Somalis believe depression was not a serious issue in the health of the Somali population in Somalia or that it did not exist there until the start of the civil war in the 1990s. Others believe it existed but was not recognized or treated. With war came relocation, refugee camps, malnutrition, trauma, and death. Their clan-based and family centered society was largely destroyed, as many people were killed and/or separated from their families, lacked financial support and were forced to adapt life from a nomadic society to Western society. For these reasons, their social support was greatly disrupted. It is believed that as a result of all these changes, people started experiencing depression.
Causes of sadness or depression include separation from family, loss of community and country, trauma including rape and torture, guilt from survival, economic hardships, housing instability, and assimilation difficulties including language and work. In the US, parents are also finding they have lost their power in their family, as they often have to rely on their English-speaking children to translate, pay the bills, and generally help them get along in their new country. In addition, the Americanization of their school-going children is also a big source of worry, as their children are taking part in behaviors and beliefs not supported by their parents. In Somalia it is commonly accepted that parents discipline their children in a more physical manner that what is acceptable in the United States. As a result parents are finding it difficult to discipline their children.
Many Somali feel that depression and other forms of mental illness are not a problem until it begins to interfere with their daily lives. For this reason, Somalis exhibiting crying spells and some trouble sleeping will not seek any help if they are able to carry on their responsibilities. Consequently, not functioning well is a sign of depression. This can include not eating, sleeping, interacting, concentrating, or taking care of family and children and staying at home. Patients will complain of being tired, not functioning well and various somatic complaints. Common somatic complaints include headaches, abdominal pain, and general body aches.
The Somalis are deeply religious, and the Muslim faith greatly affects their response to traumas and sadness. Firstly, they often see traumas as “God’s will.” They are chosen by Allah to deal with these traumas. Secondly, the Koran states that a person who commits suicide will go to hell. As a result, it is believed that suicide ideation and suicide attempts happen less frequently than we see in the general population.
Treatment
Experts point out that treatment of depression and other medical illnesses must be approached holistically. In a study by Guerin et al , they advocate for spending time exploring with Somali patients about their families, community relationships, living conditions, and economic situations. If these areas of their life are unstable, it is important to get social work and other counselors available to help to address these issues. By doing this, some of their sadness and worry will be addressed. Initially, it is more important to address current stressors than past traumas. Importantly, their traditional beliefs including reading the Koran and praying must be incorporated into any family and community counseling.
In order for patients to be most comfortable, if possible, Somali women should have a female health care provider, and likewise, Somali men should have a male health care provider. It is essential for the health care providers to carefully explain the diagnosis and treatments, and at the same time, listen to, incorporate, and facilitate Somali views on depression and traditional treatments. Health care providers must destigmatize depression, give hope for treatment, lend support, and listen to the patient’s concerns.
As many Somalis fear that they are at risk for deportation from the United States and medical experimentation, it is important to verbalize that the office/clinic is a safe, confidential environment, and that the provider’s job is to ensure excellent healthcare. It is very important to mention that many Americans are diagnosed with depression. Treatment may improve their symptoms. In a highly traumatized population, treatment may alleviate symptoms, but complete resolution of symptoms is rare. Let patients know that those with depression are still part of society, and are very often, functioning parts of society.
If an antidepressant is warranted to treat depression, it is essential to carefully explain the medication, side effects, and course of action. In the case of SSRIs, it is important to mention that it takes weeks for this type of medication to work, and in order for this medication to work it must be taken everyday, even if feeling well. In addition, side effects may truly scare the patient, and it will be helpful to give them a sense of what side effects occur more commonly.
There are many reasons why a Somali patient may fail medical management. Firstly, there may be other psychiatric co-morbidities that make it difficult to treat depression. These include PTSD, dementia, and anxiety, and these are often misdiagnosed as depression. Careful screening for these other psychiatric illnesses is essential. Drug and alcohol abuse is very rare among the Somalis secondary to their strong religious faith. However, one stimulant that is sometimes used, most typically by Somali males, is qat.
This is a substance that can be purchased from dealers in Seattle, but the cost of this drug frequently prohibits its use and it is classified as an illegal drug/controlled substance. Secondly, overwhelming, unresolved social difficulties including housing, lack of social activities such as sports and Somali community entertainments events, job, and language continue to be a main concern for patients. In addition, lack of thorough instructions and information about the prescribed antidepressant from health care providers is a problem.
Lastly, beliefs still exist regarding experimental medicine. Some patients still believe that “the government hospital” tests medications on Africans, and in this way, patients may not take the antidepressants that have been prescribed.
Patients should be referred to a psychiatrist if there is a medication failure after six weeks of an adequate dose of antidepressant. A psychiatrist will be essential to do a more thorough psychiatric work-up, especially focusing on the issue of other psychiatric co-morbidities including PTSD.
Translation and Language Equivalents
In a study done at University of Rochester, a number of Somali refugees were interviewed regarding their beliefs and understanding of depression. There are a few key Somali words regarding mental health.
MURUG is generally defined as sadness. It can mean a daily sadness, stress, or disappointment, but it can also mean a very serious depression that is associated with physical manifestations. These physical manifestations include headache, loss of appetite, crying, trouble sleeping, social isolation, feeling hot, and hair loss. The main causes of murug are thought to be trauma of war, life in refugee camps, and financial stress while living in the United States.
WAALI is defined as crazy, mad, and generally mentally unfit. A person described as waali has behaviors that include “talking nonsense,” or not talking at all, wandering streets aimlessly, taking off clothes in public, and dressing inappropriately. Waali is caused by extreme shock or trauma. This severe form of depression cannot be treated with medications.
GINI is a very extreme form of mental illness, and it is translated as a mental sickness. This is a particularly stigmatizing form of mental illness that is caused by supernatural beings or spirits created by God. The gini is very powerful and can exert control over actions and behaviors of those afflicted. It is characterized by intense fear, bad dreams, disorientation, and sometimes violent behavior towards others. Because spirits cause this form of mental illness, treatment from a physician is deemed useless. Instead, the service of a spiritual leader, sheikhs and clan leaders is needed.
Cultural knowledge and Traditional Treatments
Again, mental illness is hugely stigmatized in the Somali community. In Somalia, few physicians are trained as psychiatrists. There is only one hospital that deals with mental health issues in the whole country. Like the rest of the medical hospitals in Somalia, it is understaffed and generally lacking resources for smooth operation. In general, this psychiatric hospital takes care of severely ill and psychotic patients. Those who have visited that hospital will remember visions of patients strapped and chained, patients yelling and talking non-sensibly, and others sitting in their own excrement.
Somali’s treatment for depression begins at home. The strong religious faith of the Somalis aids with the treatment of depression. Reading the Koran and praying is the first step of treatment. In fact, it is very common to use the Koran readings for dealing with both physical and mental health problems. In severe cases of depression, the family will involve a sheik, or priest from the mosque, to assist with treatment. The sheik will read from the Koran, and the patient will repeatedly be beaten by stick or by hands and then giving Tahliil to make the devil come out.
In addition, Somalis also rely on complimentary and alternative medicine. Some of the commonly used modalities include massage therapy with anise oil and physiotherapy. Massage is most useful for pain, especially headaches and backaches.
Other Considerations
Treatment for mental illness in the “not crazy” population of Somalis is a new concept for this group. In order to fully address these issues, adequate time needs to be invested in the doctor-patient relationship and learning about the contextual issues surrounding their health and explaining their diagnosis, the epidemiology, and the treatments including follow up procedure plan. With this time, comfort, and solid relationship, strides can be made in treating this new and growing group.
Summary of Recent Research:
Using PubMed as well as other research databases, articles with abstracts available were found from the last 10 years relating to the topic of Somalis and depression. Of the studies, five were from the UK, four from the USA, one each from Canada and Australia and one each from the African nations of Ethiopia and Uganda. There were no large-scale studies; the number of subjects ranged from a low of 6 to a high of 207 with a mean of 71 and a median of 28.
Prevalence: In a study of elderly Somalis in London in 1995, 99% reported low life satisfaction scores with 24% indicating a high probability of clinical depression and 21% reporting suicidal thoughts; however, 33% reported themselves “fairly well satisfied” with their life. Likewise, a 2001 study also set in London of 28 elderly Somali men found a high percentage with low life satisfaction scores and a high incidence of probable depression. Conversely a 2001 US study found only a 5% incidence of depression but a 55% incidence of anxiety.
Characteristics and Factors: In the aforementioned study of elderly Somalis in London (n=72), 51% reported excessive worrying and 58% had difficulty sleeping. Half reported having no family members living with them. This study found increased incidence of depression for those with chronic health problems and increased age.
In a study of 94 Somali women, Young found increased depression among young women and decreased life satisfaction scores for those who emigrated for political reasons and wish to return to their country of origin. In a 2001 ethnographic study of older Somali men, several factors decreased life satisfaction and increased vulnerability to depression: low family support, loneliness, inadequate access to community services and inability to return home.
Also social isolation, low level of control over one’s life, helplessness and social degradation were common themes identified in people said to be depressed. This study also correlated low life satisfaction scores with high expectations about medical and social care.
In a 2003 UK study of a random sample of Somali people in the London Borough of Greenwich (n=180), Bhui found increased depression with each identifiable pre-migration traumatic event and increased depression with a higher total trauma score. This study explored suicidal thoughts and found factors that correlated with increased suicidal thoughts included over 7 years of residence post-migration, pre-migration unemployment and recent arrival. Those who had been in prison in Somalia and women had fewer suicidal thoughts.
One qualitative study found that Somalis thought that depression was a new phenomenon for them and that the causes were war, death of loved ones, separation from family and home as well as spirit possession and curses. They found, as discussed above, varying terms that Somalis use to describe mental illness.
The possible influence of qat was explored in two studies. A 1997 UK study of Somalis living in London (n=207) found that 78% used qat and 76% report using it more than they did in Somalia. Adverse psychological effects included sleep problems, anxiety and depression. Another study found that qat use correlated with increased suicidal thoughts.
One study explored the effects of 9-11 and found that Somalis with a previous diagnosis of PTSD had a decreased sense of security and safety, experiencing what the authors called “secondary traumatization”.
Buffers: As stated above, an experience as a prisoner in Somalia seems to be protective against depression and suicidal thoughts. Other buffers against depression were found to be family support, religious practice and contact with Somali peers.
References
1. Brundtland, G., Mental health of refugees, internally displaced persons and other populations affected by conflict. Acta Psychiatrica Scandinavica, 2000. 102: p. 159-161.
2. Guerin, B., et al., Somali conceptions and expectations concerning mental health: some guidelines for mental health professionals. New Zealand Journal of Psychology, 2004. 33(2): p. 59-68.
3. Carroll, J.K., Murug, Waali, and Gini: Expressions of Distress in Refugees From Somalia. Prim Care Companion J Clin Psychiatry, 2004. 6(3): p. 119-125.
4. Silveira, E. and S. Ebrahim, Mental health and health status of elderly Bengalis and Somalis in London. Age Ageing, 1995. 24(6): p. 474-80.
5. Silveira, E. and P. Allebeck, Migration, ageing and mental health: An ethnographic study on perceptions of life satisfaction, anxiety and depression in older Somali men in east London. International Journal of Social Welfare Vol 10(4) Oct 2001, 309-320, 2001.
6. Stutters, A. and J. Ligon, Differences in refugee anxiety and depression: Comparing Vietnamese, Somalian, and former Yugoslavian clients. Journal of Ethnic & Cultural Diversity in Social Work, 2001. 10(1): p. 85-96.
7. Young, M., Acculturation, identity and well-being: the adjustment of Somalian refugees. Sante Ment Que, 1996. 21(1): p. 271-90.
8. Bhui, K., et al., Traumatic events, migration characteristics and psychiatric symptoms among Somali refugees: Preliminary communication. Social Psychiatry and Psychiatric Epidemiology, 2003. 38(1): p. 35-43.
9. Griffiths, P., et al., A transcultural pattern of drug use: Qat (khat) in the UK. British Journal of Psychiatry, 1997. 170(3): p. 281-284.
10. Kinzie, J., et al., The effects of September 11 on traumatized refugees: Reactivation of posttraumatic stress disorder. Journal of Nervous and Mental Disease, 2002. 190(7): p. 437-441.
Further Reading
Abdullahi, M. D. (2001). Culture and customs of Somalia. London: Greenwood Press.
Drug Addiction Help and Alcohol Recovery Services | Crescent Life