The Epidemiology and Research Literature Summary section of EthnoMed’s Somali Refugee Mental Health Cultural Profile was updated with new information based on a review of research articles published 2004-2015. The updates are presented separately here in order to maintain the structure and length of the original article. Text from the original article is in italics below.
Limited research has been conducted examining the prevalence of mental illness among Somali refugees. Available research has suggested that refugees are at risk for the development of a variety of psychological disturbances including depression, anxiety and posttraumatic stress disorder (PTSD). However, inconsistent results have been reported regarding the prevalence and severity of psychopathology among Somali refugees. The discordant results within the literature may highlight the complexity of cross-cultural inquiry, interpersonal variability in psychological resiliency and the development of psychopathology, or result from methodological inconsistencies (Bhui et al, 2003)
Migration, Resettlement & Readjustment
Refugee migration, resettlement, and readjustment into a host country place refugees at risk for a number of physical health concerns and psychological difficulties (Palinkas et al., 2003). The act of migration poses psychosocial stressors by fragmenting social, vocational, and economic resources for refugees as they encounter this transitional period of their lives. The process of relocation may put refugees at risk for mental illness in relation to such mediating variables as level of stress, acculturation, employment status, individual personality characteristics, and experiences during the various stages of migration (Bhugra, 2004).
Coming from a collectivistic society, Somali refugees may experience trouble adjusting within Western, traditionally individualistic societies. Perception of their native land and misconceptions of the prospective host country have been suggested to predict level of readjustment, particularly for young Somali refugees (Rousseau, Said, Gagne, & Bibeau, 1998).
This is especially salient in the early stages of adjustment to a new country where loss of homeland, stigmatized refugee identity, poor socioeconomic conditions, loss of former social and professional status, and changes in gender roles challenge refugee identity and add to pre-migration stressors. Many refugees expect high living standards in the country of relocation, but find their social status, economic status and professional status devalued due to stigmatized ‘refugee’ identity (Warfa, Curtis, Watters, Carswell, Ingleby, & Bhui, 2012). Upon entering a host country refugees may be subject to racism or discrimination (experiences likely at conflict with expectations of life in the host country) and may not have access to resources needed to construct a new life. See below, for more information on the effects of discrimination on anxiety and depression in youth.
Level of adaptation is a key factor in the wellbeing of refugee patients. Political, social, physical, and psychological factors prevent many refugees from adequately adapting to life in their host country. Specifically, residential mobility in the host country has been highlighted as a significant mental health risk in the literature on Somali refugees (Mohamud et al, 2004; Palmer, 2006; Warfa et al, 2006). Residential status in the host country is often in flux due to socioeconomic factors. Difficulty finding employment, for example, often leads to additional residential moves following expatriation. Recent research within samples of Somali refugees has provided preliminary evidence to suggest that frequency of change in residential status within the first five years in the host country is strongly related to depression even after controlling for age, gender, and area of residence (Mohamud et al., 2004).
A 2012 study found there was an increased occurrence of psychiatric disorders among refugees who had moved within the last five years (Bhui, Mohamud, Warfa, Curtis, Stansfeld, Craig, 2012). Research examining mediating factors in the development of psychopathology within a sample of Somali expatriates found overall educational history and employment status in the host country to be related to lower risk for anxiety, depression, and PTSD (Bhui et al., 2006). Previous research has indicated that loss of social status, such as vocational status, may be linked to increased levels of depression in older Somali male refugees (Silveira & Allebeck, 2001). It was also found that residential mobility stress was mediated by the strength of the community found in the area of relocation (Bhui et al, 2012).
Migration and Gender Roles
In a qualitative study done on migration experiences, Somali men reported experiencing a decrease in social status attached to their identity as a ‘refugee’. In follow up interviews some men listed gender role changes influencing their sense of self in their country of relocation. While men vocalized a decrease in social status, some women reported experiencing increased opportunity and social status upon entering the new country due to the change in expected gender roles. Some men vocalized that this change in gender role, combined with the decrease in social status and employment opportunities caused them feelings of emasculation and loss of positive self-identity. (Warfa, Curtis, Watters, Carswell, Ingleby, Bhui, 2012).
Depression and Anxiety
Due to their high prevalence and comorbidity, depression and anxiety have been studied in conjunction in the existing literature looking at Somali mental health. One study examining the prevalence of depression, anxiety and PTSD in 143 Somali refugees residing in the United Kingdom found depression and anxiety to be present in 33.8% of the sample (Bhui, 2006). Individuals at particular risk for psychological disorder included respondents recruited from primary care settings and users of a stimulant known as khat. Suicidality was reported in 9.1% of the sample. Further, risk of suicide was correlated with major depression and generalized anxiety within this sample. Consistent with these authors’ hypotheses, results indicated a high level of psychiatric comorbidity in that 80% of participants meeting diagnostic criteria for PTSD also met criteria for anxiety or depression.
A similar study of 180 Somali refugees found depression and anxiety to not be positively correlated with suicidal ideation (Bhui et al, 2003). Contrary to findings from previous research, this study found torture to have a non-significant relationship to psychological disorder. Further, individuals exposed to combat or imprisonment exhibited a lower risk for depression, anxiety and suicidal ideation. Suicidal ideas were most common in those with 7 or more years of expatriate residential status whereas depression and anxiety were more predominant among individuals with recent arrival status, potentially indicating the prevalence of a psychosocial adjustment component in those experiencing affective difficulties.
Stutters and Ligon (2001) found anxiety to be highest among 20 Somali refugees when compared to refugees from either the former Yugoslavia or Vietnam. Elevated anxiety was found to be particularly present in Somali males. However, these differences failed to reach statistical significance in this small sample.
A study done comparing native Finns and older Somali refugees relocated to Finland observed the relationships between depression, somatization, alexithymia, sense of coherence and social support. It found, as expected, that Somalis manifested more somatic symptoms of depression, while native Finns reported more cognitive symptoms. This was thought to be associated with Somali collectivist versus Finnish individualistic cultural experience. Somali collectivist values focused more on social experience, therefore attributing mental distress to external rather than internal sources.
Conversely, Finnish individualistic cultural structure taught native Finns to internalize mental distress or disorder causing increase in cognitive symptoms of depression and anxiety. The study also found that in both groups high levels of alexithymia (the inability to identify and describe emotion in oneself) was connected to somatization, but that alexithymia was correlated more with depression among the native Finns. In both groups, sense of coherence (a measure of individual agency) and social support were associated with lower levels of depression (Kuittinen, Punamaki, Molsa, Saarni, Tiilikainen, Honkasalo, 2014).
PTSD
Previous research has found intensity of experience and duration of trauma exposure to be related to increased levels of posttraumatic stress symptomatology (Buydens-Branchey, Noumiar, & Branchey, 1990). Rasmussen, Crager, Baser, Chu, & Gany (2012) found that PTSD and major depressive disorder onset was 9 years pre-migration for refugees compared to 7 years post-migration for voluntary migrants. This suggests that for refugee groups PTSD often stems from traumatic experiences in the home country.
Gerritsen et al (2006) found Somali refugees to have experienced exposure to the highest number of traumatic events (M = 7.6 out of a possible 17; SD= 3.9) but among the lowest levels of depression, anxiety (16.7%) and PTSD (4%) when compared to refugees of other nationalities. Of the most endorsed traumatic events reported ‘forced separation from family members’ and ‘unnatural death of family or friend’ occurred with the greatest frequency. Recently, PTSD has been shown to correlate with current major depressive disorder and agoraphobia (Bhui et al, 2006). Somali refugees have also exhibited higher rates of PTSD-related psychoticism than other refugee groups; however no causal hypotheses have been offered in the existing literature for this finding (Bhui et al, 2003).
The low association between combat experience and mental illness noted above is at odds with previous research conducted with East African community samples (Jaranson et al, 2004) as well as recent research conducted with Somali ex-combatants (Odenwald et al, 2007). For example, Jaranson and colleagues (2004) found torture to be a significant risk factor for a variety of physical and mental health difficulties including PTSD in a sample of 1134 East African refugees (Somali N = 622). It is important to note the variability among refugees in the degree of traumatic exposure and posttraumatic stress in order to avoid culture-based overgeneralizations and type I error (false positive) as clinicians (Halcon et al, 2004).
A 2011 study conducted at the mental health unit of an inner-city community clinic in Minnesota assessed rates of psychoses, PTSD, and depression from 2001-2009 for Somali patients. They compared these to non-Somali patients October 2007-October 2009. It found that 80% of Somali male patients aged 18-30 (N=104) presented with psychosis (including schizophrenia, mania, drug-induced psychosis, and otherwise non-specified psychosis), compared with 13.7% of non- Somali patients (N=65) and 32.5% of Somali women (N=25). For patients aged 51 years or older, levels of psychosis were equal among Somali men and women. Rates of psychosis were higher among Somali compared to non-Somali patients for all age groups, until 51 years and older. The high rates of psychosis among Somali males under 51 was thought to be influenced by risk factors, such as war trauma experience, early malnutrition from famines, head trauma, excessive khat consumption then marijuana abuse in later adulthood, and culturally rigid social roles (Kroll, Yusuf, Fujiwara, 2011).
In a study by Molsa et al. (2014) in Finland, it was found that the most salient post-traumatic stressor among Somali refugees was an inability to speak the local language. This study shows language barriers and their effect on emotional status are important to keep in mind while working with refugees. Post traumatic emotional stressors have been shown to trigger PTSD symptoms and therefore it may be beneficial to a patient’s wellbeing to refer them to language classes to help relieve post traumatic stressors that could contribute to PTSD symptomology.
Comorbidity of depression and PTSD is common among Somali refugees thus suggesting the need for clinicians to assess for psychological loss at a number of different levels (e.g. interpersonal, social, economic) when working with members of this group. Unlike symptoms of depression which tend to fluctuate in response to recent stressors, PTSD symptomatology and diagnoses may be more persistent over time (Sack et al, 1993). HADStress is a screening tool which assesses presence of four somatic PTSD symptoms: dizziness, headache, sleep issues, and changes in appetite. It is shown to be effective in recognizing possible PTSD among Somali refugees to then refer for further clinical evaluation, diagnosis and treatment. This tool may help practitioners understand the level of PTSD symptoms for patients who may be reluctant to discuss the cognitive symptoms they are experiencing (Westermeyer, Campbell, Lien, Spring, Johnson, Butcher, Hyland, Thuras, Jaranson, 2010).
It is important for clinicians to develop long-term treatment strategies for posttraumatic stress symptoms while also assessing and reassessing for longitudinal changes in depression (related to concurrent readjustment issues). However, the use of exposure-based psychotherapies, a common evidence-based treatment approach for PTSD, may be an incomplete psychological treatment approach or even contra-indicated when working with refugee groups due to the multiple layers of trauma experienced in these populations (Guerin, Guerin, Diiriye, & Yates 2004). See also: A Tailored Approach to Trauma Intervention, an article about a Seattle-area pilot project “Islahul Qulub: Islamic Trauma Healing” that combines prayer, prophet narratives, and guided discussion in a six-week PTSD intervention program tailored for Somalis suffering in the aftermath of war-torn conflict.
Hypertension and Diabetes
Medical disorders potentially related to chronic stress or pervasive changes in diet and lifestyle have been observed in Somali refugees as evidenced by a high prevalence of hypertension and diabetes in this group (Kinzie, 2007). In one study preliminary results indicated that hypertension affects approximately 43% in a sample of refugees whereas diabetes can be seen in 12-18%. Similar rates of hypertension were observed across groups; however the highest rates of diabetes were seen in the Somali group with 48% of diabetic Somalis also presenting with hypertension. Studies examining health risks among American veterans has shown a relationship between chronic PTSD and hypertension/ diabetes, offering a potential explanation for similar results observed in Somali refugees (David, Woodward, Esquenazi, & Mellman, 2004; Kinzie, 2007).
The hypertension medicine prazosin (which affects the alpha 1 norepinephrine receptor) has been found to be effective in reducing PTSD re-experiencing symptoms, such as trauma-related nightmares (Bennett, Zatzick, & Roy-Byrne, 2007). Research has been conducted to evaluate its effectiveness in minimizing intrusive flashbacks during awake states. A literature review of 10 clinical studies of the effects of prazosin on the treatment of PTSD was done and all of the studies conducted found that prazosin was an effective treatment for nighttime symptoms of PTSD and for reducing overall severity of PTSD symptoms. The clinical studies showed a range of dosing in administration of prazosin; typically beginning at 1mg and monitoring for hypotension, then gradually increasing to 2-6mg at night. Some studies showed a maximum dosing of up to 10-16mg of prazosin at night (Green, 2014).
Psychotherapy/Counseling
Problems with mental health are sometimes associated with unhealthy social relationships, dark spirits, and misconduct in social settings (Molsa, Punamaki, Saarni, Tiilikainen, Kuittinen, & Honkasalo, 2014). A case study of a 55 year old refugee living in the U.S. for the past 17 years provides an example of the effects of stigma on patient-clinician interactions. The patient presented with somatic mood disturbance symptoms and declined suggested referral to psychiatric services several times. When the patient reported somatic symptoms of PTSD, a psychiatrist was brought in at a follow-up visit, causing the patient increased anxiety symptoms. When the psychiatrist began focusing on somatic symptoms, the patient became more comfortable. When the clinician asked the patient about his belief in jinn spirits and the effect on his wellbeing, the patient became more trusting of the psychiatrist and more involved in his mental health treatment.
By reframing psychiatric evaluations in ways that avoid Western mental health terminology, the clinician was able to build trust with patient and surpass stigmatized expectations of the Western mental health system. By integrating Islamic customs and beliefs, focusing on somatization, and asking questions about jinn spirits the psychiatrist was able to encourage the patient to become more involved and adherent in the treatment process (Boynton, Bentley, Jackson, & Gibbs, 2010).
A case study of a Somali refugee relocated to the Netherlands exemplifies engagement with cultural identity in order to address mental health status. The 40 year old patient reported lack of concentration, difficulty sleeping, anxiety and depressive feelings, as well as social isolation. The patient was referred to a psychiatrist who after a few sessions asked an anthropologist to talk to the patient.
Upon asking the patient about his cultural background, the anthropologist was able to understand the patient holistically and improve his treatment. He learned that the patient’s tribal identity was much more important and meaningful to the patient than his nationalistic identity. By asking him questions about the tribe he came from, the anthropologist was able to surmise that the reason for his isolation was the status of his tribe within the Somali tribe hierarchy. The patient reported being ignored by other relocated Somali refugees in the Netherlands due to his low tribal status. The patient was animated when he began talking about his cultural background, something he hadn’t discussed with anyone since his arrival in the Netherlands.
Central to the formation of the patient’s identity, this story had been excluded from all previous dialogue surrounding his mental health care. Sharing his experience allowed him to connect with the anthropologist and establish trust. It also allowed the anthropologist to connect him with community organizations where the patient was assured that he would not be discriminated against due to his tribal background (Groen, 2009).
This case study shows the importance of placing the patient as the expert on their own culture and the practitioner as an interested listener. By allowing a patient to share his/her cultural background, the practitioner allows the patient’s frame of reference to dominate instead of his/her own. This atmosphere provides the practitioner with information necessary to more fully understand the patient’s background to aid in making a culturally sensitive diagnosis and designing a more successful treatment plan.
Khat (Chat, Qat) and Other Drugs
Although substance abuse is uncommon within Somali society, use of an East African stimulant with amphetamine-like qualities called khat(pronounced cot, also spelled qat) has been associated with mental illness in Somali refugees (Bhui et al, 2006). Khat is typically chewed and has become increasingly available internationally in recent years.
Khat use has been associated with somatic disorders such as oesophatitis, gastritis, duodenal ulcer, hepatic cirrhosis, autoimmune hepatitis, migraine, cerebral haemorrhage, pulmonary oedema, and myocardial infarction. Psychologically it has been associated with euphoria, increased confidence, enhanced alertness, depression, anxiety, mood instability and mania. (Omar, Jenkins, Altena, Tuck, Hynan, Tohow, Chopra, & Castle, 2015). Khat use appears to be more common among Somali males although recently gender differences in usage as well as age differences have become less prominent in Western countries, where women and younger age groups are starting to use it more frequently (Omar et al. 2014).
A study on khat use in the Somali community of South London found that exposure to traumatic experiences was not associated with khat use. The study also found khat use among Somali people to be moderate and to have little association to psychotic symptoms, anxiety or depression when in non-conflict zones. Providers need to be aware of low level psychotic symptoms and their effect on the patient as well as the risk for anxiety and depression among Somali refugees, irregardless of khat use (Bhui & Warfa, 2010).
Opinions and conversations surrounding khat vary drastically within the larger community, with many starkly opposed to khat use and others highly supportive of usage as a cultural tradition and a pro social behavior. Khat is seen by some community members as a spiritual food and a part of Somali culture, though only for spiritual leaders who use its stimulant qualities to stay up later to pray at night (Osman & Soderback, 2011). It has been found that unemployed or lower socioeconomically situated Somalis are more likely to use khat problematically.
In a qualitative study done in Australia, all 48 Somali participants reported khat use being associated with social problems such as family breakdown and violence, decreased socializing, isolation and social withdrawal. Of those surveyed, 58% reported khat use as perpetuating unemployment, 50% stated that it contributed to neglect of social roles and responsibilities, and 73% reported an association with mental health problems such as mood instability, disturbed behavior and psychotic symptoms. Australian community members also described symptoms such as “sense of fear” or paranoia, hallucinations, and withdrawal symptoms caused by khat usage. Khat use is also associated with cigarette usage. Australian community members stated that, “khat chewing and cigarettes go together. There is not a khat chewer who does not smoke or if there are, they are very few” (Omar et al, 2015).
Khat usage may also contribute to increased social isolation. In Omar et al.’s (2015) study, many Australian Somali community members described those who used khat as a marginalized social group. They discussed khat users as outsiders or a “subculture”, who were separated from the mainstream Somali culture due to their interest in khat as well as their disturbed sleep-wake cycles. In contrast, Osman et al. (2011) found more positive opinions surrounding khat and socialization. Khat was reported by Swedish Somali refugees to increase user sociability and conversation. It is perceived as normal to offer khat at social gatherings such as parties or weddings, and is considered a sign of respect by some. Khat was also reported to increase concentration and make it easier to memorize and learn. Overall perception of khat was that it promoted a sense of belonging to Somali culture and helped keep Somali culture alive (though this opinion was more likely to be held by the men interviewed in the study).
Somali community members in Australia were interviewed on ways to reduce khat use among the community. Forty-six out of the 48 individuals interviewed supported the use of health promotion education strategies, 41 supported increasing recognition of problematic khat use, and 36 supported focusing on established users (generally mature older men) and younger men at risk of developing problematic khat use habits. One person who was interviewed highlighted the importance of oral interventions, as opposed to pamphlets and graphics, attributing this preference to the Somali culture’s preference for oral communication. Strategies such as use of social networks like families, community services, and culturally relevant ways of sharing knowledge were supported. Most participants were against making khat illegal and turning users into criminals (Omar et al., 2015). This is contrary to the study done in Sweden (where khat is already an illegal substance), where participants voiced support for increasing policing of khat smuggling, in order to decrease usage in their community (Osman & Soderback, 2011).
With vastly varying opinions and research surrounding khat within the community, it is important for practitioners who are concerned about khat use in their patient or in a population to discuss personal perceptions of use with that patient/community. Opinions on khat are not homogenous throughout this population and therefore practitioners should not assume beliefs based on age, gender, or socioeconomic status of their patient.
Marijuana
In a study done in a mental health clinic in Minnesota, it was found that 40% of psychotic cases seen in the clinic among Somali young men were preceded by marijuana use, suggesting that marijuana may play a role in triggering psychotic symptoms (Kroll et al, 2010).
Youth
Major events in such a malleable stage of brain and identity formation can drastically alter the course of a young person’s life. Changing the balance of risk and protective factors can alter development and affect mental health status of those who experience these changes in the formative years of adolescences. Forced migration and settlement in a foreign country can therefore influence the development of young refugees causing increased emotional distress. Somali adolescents who have experienced trauma need attention in order to address post migration environmental factors which have been shown to powerfully relate to presence of PTSD symptomology (Ellis, Lincoln, MacDonald, Cabral, 2008).
A study on mental health service utilization among Somali adolescents in Northeastern U.S. compiled information on gateways to mental health care. The study found a distinct generation gap between adolescents and their parents with regards to their view on mental health and mental health care. Many older Somali refugees looked down upon Western mental health institutions, even though when interviewed their adolescent children said they would consider seeking help from a Western mental health source.
Adolescents were found to fear burdening their parents with their mental health problems, but also having higher likelihood of seeking some form of care when their parents were informed. Youth reported the hiding of problems to be central to Somali culture and that self-managing mental health was considered a “sign of autonomy, integrity and maturity”. Youth were identified as “needing help” by family and community members only after they attained a negative reputation due to doing drugs or dropping out of school. When youth developed a negative reputation they were ostracized by the community, therefore causing increase in mental health problems.
Though community talk can serve as a protective mechanism in terms of reporting mental help need, this finding shows that the development of negative reputation and subsequent treatment by the community can actually be harmful to a youth’s mental health (Ellis, Lincoln, Charney, Ford-Paz, Bensen & Strunin, 2010).
The study also found dissonance between the services adolescents sought versus the services their parents sought for them. 11.5% of parents whose children were identified as ‘in need of aid’ (N=26) sought any help (other than prayer) for their child’s mental health needs. The two most cited services sought out included prayer (11.5%) and informal religious options (11.5%). The youth who considered themselves “in need of aid” were much more likely to seek aid (42.3%). Instead of religion, the two most common sources of help enlisted were informal help from family (61.5%), and informal help from a friend (57.7%). Prayer was listed by 23.1% of youth seeking help and 42.3% sought out informal religious options (numbers equal greater than 100% due to choosing multiple types of help). (Ellis et al., 2010).
A 2010 study focused on acculturation stressors, such as discrimination, and their effects on the mental health of Somali adolescents. This study found that 72% of Somali adolescents reported experiencing at least one discriminatory act. The most common listed reasons for discrimination were related to religious identity, ethnicity, race and being a new immigrant. It also found a strong connection between discrimination, depression and anxiety among Somali adolescents. For Somali boys, increased participation in American culture, deemed ‘American acculturation’, correlated with lower levels of depression and anxiety. For Somali females, both Somali acculturation and American acculturation were correlated with lower levels of depression and anxiety.
Many girls reported that the donning of the head scarf made it harder for them to hold American social identity and avoid discrimination. Due to vastly differing gender norms between Somali and American cultures, it can be harder for younger Somali girls to navigate new Americanized gender norms while balancing family and community gender role expectations. Many Somali communities and families attach negative reputations to girls who do not choose to wear the head scarf, somewhat forcing them to choose Somali identity expression over American expression. Many girls reported feelings of pride and increased self-reflection related to the decision to wear the head scarf.
However, for Somali boys who do not wear an external symbol of this identification with Somali acculturation, it was easier to acculturate to an American social identity, in order to fit in with Americans and avoid discrimination. It was also reported because of this that boys experienced more race-based discrimination, while girls experienced more religious-based discrimination (Ellis, MacDonald, Klunk-Gillis, Lincoln, Strunin, & Cabral, 2010).
School-based discrimination may be avoided by integrating culturally sensitive mental health care into school clinics and helping teachers better understand the mental health of students who come from traumatic backgrounds. Mental health professionals may consider incorporating religious leaders to support and promote mental health services to help educate parents to become more supportive of their child’s mental health needs, destigmatize the use of mental health services, and provide youth with home environments that are supportive and understanding of mental health issues (Ellis, Lincoln, Charney, Ford-Paz, Bensen & Strunin, 2010).
The use of the UCLA Posttraumatic Stress Disorder Reaction Index for DSM IV was found to be reliable and valid for screening PTSD among Somali refugee adolescents. (Ellis, Lhewa, Charney, & Cabral, 2006).
Older Somali Refugees
Older Somali immigrants and refugees have been found to struggle more with mental and somatic health problems. Among refugees, older age (65 years and over) has been reported as a high risk factor for mental health problems, surpassing other factors such as war experience or economic status. Factors affecting older refugees in particular include scarcity of accessible resources to meet social and cultural demands, decrease in social participation, lower levels of language proficiency and lower participation in friendships and native institutions. Older adult refugees have also been found to look down upon Western biomedical conceptualizations of mental illness and therefore are less likely to seek help for emotional distress from Western sources (Mölsä et al., 2014).
Mölsä et al.’s (2014) study with older Somali refugees in Finland, found health-related quality of life, current health status, and subjective quality of life were found after regression models to be significant for depressive symptoms, somatization, and somatic complaints. It also found that pre-migration traumatic events were associated with high levels of depressive symptoms, psychological distress and somatization symptoms. Longer residency in Finland was significantly associated with a decrease in somatization symptoms and slightly associated with an increase in depressive symptoms. Low income, unstable employment, and refugee status were found to be main causes of declining mental health. Although native Finns and Somali refugees were found to have equal levels of clinical depression, Somali refugees were found to have a higher level of depressive symptoms. Stronger language proficiency correlated with better self-care, but also slightly correlated with increased symptoms of depression (Mölsä et al., 2014).
In another study by Kuittinen et al. (2014), somatic versus cognitive depressive symptomology was studied among older aged native Finns and Somali refugees relocated to Finland. They found, as expected, that Somali refugees had higher levels of somatic depressive symptoms, whereas native Finns had higher levels of cognitive depressive symptoms. They also found that association between alexithymia (the inability to identify or describe emotion in oneself) and depression was higher among the Finnish group than the Somali group, but that the correlation between somatization and depression was higher in the Somali group. For both groups strong Sense of Cohesion (a scale used to measure personal autonomy) was associated with decreased depressive symptomology.
Additional Resources
Mental Health Risks and Resilience among Somali and Bhutanese Refugee ParentsReferences
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