Depression and Somatization in Community Based AsylumSeekers

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Depression and Somatization in Community Based
Asylum-Seekers

• Implications for Forensic Nursing

Rachel Regan Boersma, PhD, RN RachRB_at_ix.netcom.com
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The Population of Interest

• Asylum-seekers are a subset of refugees or
  persons of concern to the UN High Commissioner
  for Refugees (UNHCR)
• They move across borders in search of protection
  and apply for protection based upon the
  well-founded fear criteria
• They have been or fear being persecuted because
  of race, religion, nationality, membership in a
  social group, or political opinion

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Persons of Concern to UNHCR January 1, 2004
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Global Conflict 1992-2001
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Literature Review

• Pre-migratory experiences are compounded by
  post-migratory stressors (Ager,2002
  Kivling-Bodén Sundbom, 2002)

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Literature Review

• Higher rates of emotional illness occur in
  refugee populations than in the host population
  (Aroian, 1988, 1996)
• Somatic manifestations of dysphoria and
  depression are consistently noted by
  international investigators (Keyes, 2000 Gureje,
  Simon, Ustun Goldberg, 1997)

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Literature Review

• Torture survivors often hold an underlying
  assumption that something is wrong with their
  bodies despite evidence to the contrary
  (Korzinski, 1997)

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Purposes of Study

• To contribute to our understanding of the human
  experience of community based asylum-seekers by
  determining the relationship of predictor
  variables to depression and somatization
• To direct attention to an underserved population
  of interest to forensic nurses

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Proposed Theoretical Model
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Theoretical Framework

• The proposed model adapted the Learned
  Helplessness Model - described as a laboratory
  model of depression in man (Klein Seligman,
  1976)
• A person experiences uncontrollability resulting
  in disruptions in motivation, emotion, and
  learning
• Uncontrollability is conceptually related to
  uncertainty, a major component of all illness
  experiences

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Literature Review

• Depression is concurrently related with feelings
  of lack of control and uncertainty (Edwards
  Weary, 1998)
• Torture is practice in over 100 nations around
  the world (Amnesty International, 2003
  Glittenberg, 2003)
• Refugees experience isolation when separated from
  family, despite physical safety (Barnes, 2001)
• Decreased self-esteem, depression, and social
  phobia are associated with disfiguring skin
  conditions (Koo Lebwohl, 2001)

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Literature Review

• Torture victims having numerous scars and greater
  disfigurement experience higher rates of
  depression (Edston, 2003)
• Unemployment is strongly associated with levels
  of depression in refugees (Keyes, 2000)
• Lack of supportive relationships adversely
  affects the health of refugees (Simich, Beiser
  Mawani, 2003)
• Intercessory prayer improved health outcomes in
  recent systematic clinical trials (Townsend,
  Kladder, Ayle Mulligan, 2002)

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Sample

• A non-probability convenience sample of community
  based asylum-seekers from New England (N 117)
  representing approximately 3.5 of the illegal
  aliens in New England
• Gender - 59.8 male and 40.2 female
• Age Range from 23 to 57 years old

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Sample

• Drawn from 24 different countries
• Range of Time in the Asylum-seeking Process was
  from 0 to 9 years

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NE Illegal Aliens -2000 US Census
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• Preliminary Analysis

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Significant Predictors and Moderators

• Total episodes of trauma and traumatic scars were
  positively correlated with HSCL depression scores
• Less time in the asylum-seeking process was
  correlated with lower HSCL depression scores

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Significant Predictors and Moderators

• Scars caused by persecutory trauma were
  positively correlated with SCL-90 somatization
  scores
• Family support in the U.S. was correlated with
  lower SCL-90 scores

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Significant Predictors and Moderators

• Forced migration from Africa was significantly
  correlated with higher HSCL depression and SCL-90
  somatization scores
• Forced migration from Europe was correlated with
  lower HSCL depression scores

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• Research Question 1

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Research Question 1

• To what extent do traumatic experiences, waiting
  time in the asylum-seeking process, and leaving
  family behind explain the score variances on the
  HSCL and SCL-90 outcome measures in a group of
  community based asylum-seekers?

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Results

• Two canonical correlations were produced and one
  was significant (p .021)
• 11 of the variance in outcome measure scores
  could be explained by
• Lower trauma exposure
• More time in the asylum-seeking process
• Not having to leave family behind during forced
  migration

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• Research Question 2

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Research Question 2

• After controlling for demographics, does being
  employed, having at least one family member
  present in the U.S. for support, using prayer for
  support, and having scars moderate the
  relationship between the uncontrollable bad
  events and the HSCL and SCL-90 outcome measures?

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Results

• The HSCL scores were regressed in on
  significantly correlated demographics,
  predictors, moderators, and their cross-products
• Step 1 Results - Demographics
• Significant and accounted for 17 of the variance
  in HSCL scores

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Results

• Step 2 Predictors and Moderators
• Significant and accounted for an additional 10.8
  of the variance in HSCL scores
• Step 3 Cross-products
• Not significant - accounted for 5.3 of the score
  variance, no evidence of moderation
• A total of 33.3 of the variance in HSCL scores
  was explained by this model

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Results

• The SCL-90 scores were regressed on significantly
  correlated demographics, predictors, moderators,
  and their cross-products entered in steps
• Step 1 - Demographics
• Significant and accounted for 8 of the variance
  in SCL-90 scores

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Results

• Step 2 Predictors and Moderators
• Accounted for 2.3 of the variance in SCL-90
  scores step was not significant
• Step 3 results Cross-products
• Accounted for 8.1 of the variance in SCL-90
  scores one interaction term was significant
• A total of 18.4 of the variance in SCL-90 scores
  was explained by this model

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Summary

• Hierarchical multiple regression analyses
  demonstrated that forced migration from Africa or
  Europe accounted for 17.2 of the variance in
  HSCL depression scores and 8 of the variance in
  SCL-90 somatization scores

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Summary

• Migrating from Africa was significantly related
  to higher scores on both outcome measures
• Migrating from Europe was related to lower scores
  on the SCL-90

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Summary

• Trauma exposure, time in the asylum-seeking
  process, leaving family behind during forced
  migration, having trauma induced scars, and
  having family support in the U.S. accounted for
  10.8 of the variance in HSCL depression scores
  and 2.3 of the variance in SCL-90 somatization
  scores
• No moderation effect was evident between the
  predictors and the HSCL depression scores

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Summary

• Having family support in the U. S. however
  moderated the relationship between time in the
  asylum-seeking process and the SCL-90 scores
• For asylum-seekers without support, the longer
  they waited in the process, the higher were their
  somatization scores
• For asylum-seekers with support, time waiting
  appeared to have little effect of their
  somatization scores

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Discussion of Findings

• African migrants carried the highest
  pre-migratory trauma load including significantly
  higher rates of sexual assault and torture and
  the highest rate of leaving family members behind

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Discussion of Findings

• Steele et al. (2003) found that a history of
  pre-migratory trauma was associated with higher
  rates of HIV-risk taking behavior
• This studys findings supported previous work
  (Boersma, 2003) that African migrants are exposed
  to higher levels of pre-migratory trauma than
  other world regions, therefore attending to
  trauma symptoms in this group could have a
  significant impact on reducing the risk of HIV
  transmission

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Discussion of Findings

• Europeans may wait longer in the asylum-seeking
  process but they had lower rates of physical or
  sexual assault, lower rates of torture, and were
  the least likely of any of the groups to leave
  family behind during migration

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Discussion of Findings

• PHR researchers study of detained asylum-seekers
  found that waiting time in the asylum process was
  the best predictor of depression in their
  population
• This study did not support those findings in
  community based asylum-seekers with family
  support, however, somatization scores for those
  without family rose as the waiting-time in the
  asylum-seeking process lengthened

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Discussion and Implications

• No asylum-seekers in this study were symptom free
• Nationally, the estimate of illegal immigrants in
  2000 was 8,490,491 therefore only 3.5 of the
  national population (297,167) suffered with
  symptoms related to forced migration, the social
  and economic burden is staggering
• Implications exist in at least four domains,
  education, practice, research, and policy

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Discussion and Implications

• Educational implications
• Culturally congruent care
• The impact of globalization on practice and our
  professional ethical mandates
• Social justice and human rights education belong
  in nursing curricula
• The effect of persecution, trauma, and torture on
  an individual and the diverse ways the resulting
  distress can be experienced cross-culturally

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Discussion and Implications

• Practice implications
• Professional practice involves direct care
  recipients and non-experienced others, Nortvedts
  (2001) neighbors neighbor
• Silence and inattention is tantamount to
  complicity and we risk another S.S. St. Louis
  with our inaction

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Discussion and Implications

• Policy implications
• Current 109th Congress H.R. 418 REAL ID Act of
  2005 passed raising the burden of proof required
  of asylum-seekers in direct contradiction to
  international law the 1951 Convention Relating
  to the Status of Refugees must prove reasonable
  fear of persecution standard raised to central
  reason standard AND immigration officers and
  judges may deny applicants based on demeanor,
  perceived candor, or their responsiveness

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Discussion and Implications

• Research implications
• Longitudinal studies of this population for
  health effects of forced migration
• Better discrimination between somatization and
  organicity
• Persecutory methods and implications for policy
  changes
• Practitioner research what holds us back from
  becoming more involved?

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• Si vis pacem, cole justitiam
• If you desire peace, cultivate justice.

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