Cambodian Refugees Suffer from Psychiatric Illness at High Rates Two Decades After Escaping Homeland Terror

Nearly two-thirds of the adults studied in the largest Cambodian refugee community in the United States suffered from post-traumatic stress disorder (PTSD) and more than half had major depression two decades after escaping widespread violence by fleeing to the United States, according to a RAND Corporation study issued today.

The RAND Health study, published in the Aug. 3 edition of the Journal of the American Medical Association, shows a surprisingly high rate of psychiatric illness among refugees traumatized during the reign of the Khmer Rouge in the 1970s.

Researchers from RAND; the Program for Torture Victims; and California State University, Long Beach, studied a representative group of adult Cambodian refugees who live in Long Beach. The city is the home of more than 17,000 residents of Cambodian origin who fled their homeland following the reign of the Khmer Rouge, who ruled from 1975 to 1979.

Although the study examined only one refugee community, researchers believe their findings apply to other Cambodian communities in the United States as well. And unlike earlier studies of traumatized immigrants, the RAND study fully assessed participants for psychiatric disorders rather than simply screening for some evidence of the illnesses.

All of the refugees surveyed reported experiencing some trauma in their native land, such as having a relative or friend murdered. In addition, 70 percent said that since coming to the United States they had been exposed to violence, such as being a victim of robbery.

“These rates of post-traumatic stress disorder and depression among Cambodian refugees are shockingly high,” said Grant Marshall, a RAND psychologist and lead author of the study. “Even 20 years after escaping, people who went through this horrific experience still suffer serious psychiatric illness.”

“Refugees who immigrate from violent regions of the world can have a substantial need for mental health services,” Marshall added. “Our findings suggest we need to do a better job of meeting the mental health needs of these refugees once they arrive in the United States. We need to give them the tools necessary to succeed in a new land.”

The study is the first to assess the mental health of traumatized refugees years after their arrival in the United States. Other studies have screened refugees for mental health problems relatively soon after their arrival.

Researchers found that among 490 adult refugees ages 35 to 75, almost all reported experiencing near-death due to starvation before coming to the United States. Another 90 percent had a family member or friend murdered by the Khmer Rouge, and 54 percent reported being tortured before coming to the United States.

Researchers found evidence that refugees who were exposed to more types of trauma in their homeland were more likely to suffer from one of the psychiatric illnesses.

The study found that 62 percent of the Cambodian refugees studied suffered from PTSD and 51 percent had major depression in the past 12 months. By contrast, in the general U.S. population only about 3 percent of people suffered from PTSD and about 7 percent had major depression in the past 12 months.

The RAND study also found that 4 percent of the Cambodian refugees had alcohol or drug problems. Many of the refugees suffered from both PTSD and depression. Only 30 percent of research participants had none of the psychiatric disorders that were studied.

Most of the Cambodian immigrants studied were poor, had little education and had low English language skills. A total of 69 percent of study participants had incomes below the federal poverty level and 72 percent received government assistance.

The level of alcohol problems reported by refugees was lower than that seen in the general U.S. population, Marshall said. Other studies suggest alcohol abuse is high among people with PTSD and higher rates of alcohol abuse have been reported in other studies of Cambodian immigrants. The low levels reported in the new study may result from alcohol being viewed as socially unacceptable in the Cambodian community or participants underreporting, Marshall said.

Cambodians are one of the largest refugee groups in the United States, with about 150,000 people admitted since 1975.

After a coup in 1970 in Cambodia, a civil war led to an eventual takeover by the Khmer Rouge in 1975. Out of a population of 7.1 million in 1975, as many as 2 million Cambodians were killed during the four-year reign of the Khmer Rouge. In addition, 1 million people were killed in civil wars before and after the period.

Supported by funding from the National Institute of Mental Health and the National Institute on Alcohol Abuse and Alcoholism, the RAND study appears in a special edition of JAMA that focuses on studies related to violence and human rights. Other authors of the study are Terry Schell and Marc Elliott of RAND, S. Megan Berthold of RAND and the Program for Torture Victims-Los Angeles, and Chi-Ah Chun of California State University, Long Beach.

RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care quality, costs, and delivery, among other topics.