Characterizing the Mental Health Care of U.S. Cambodian Refugees

Abstract

Objective

This study examined U.S. Cambodian refugees’ utilization of mental health services across various provider types, levels of minimally adequate care, and mode of communication with providers.

Methods

Face-to-face household interviews about past 12-month mental health service use were conducted as part of a study of a probability sample of Cambodian refugees. The analytic sample is restricted to the 227 respondents who met past 12-month criteria for posttraumatic stress disorder (PTSD) and/or major depressive disorder.

Results

52% (N=127) of Cambodian refugees who met diagnostic criteria obtained mental health services in the past 12 months. Of those who obtained care, 80% (N=102) visited a psychiatrist and 52% (N=66) a general medical provider. Only 9% (N=11) had seen other mental health specialty providers. Virtually all respondents who had seen a psychiatrist (100%; N=102) or a general medical doctor (97%; N=64) had been prescribed a psychotropic medication. Approximately 45% (N=71) had received minimally adequate care. The large majority of Cambodian refugees relied on interpreters to communicate with providers.

Conclusions

Cambodian refugee rates of mental health service utilization and minimally adequate care were comparable to individuals in the general U.S. population. In contrast to those of a nationally representative sample, Cambodian refugees obtained care almost entirely from psychiatrists and general medical doctors and nearly all were receiving pharmacotherapy. Given this pattern of utilization, and the persistently high levels of PTSD and depression found among Cambodian refugees, treatment improvements may require identification of creative approaches to delivering more evidence-based psychotherapy.

Nearly 125,000 Cambodian refugees reside in the United States (U.S.) having emigrated nearly three decades ago after being subjected to one of the most brutal and traumatic conflicts of the past century (1, 2). Although many years removed from their overseas tribulations, the Cambodian refugee community continues to suffer from high levels of posttraumatic stress disorder (PTSD) and major depression (3). To explain Cambodian refugees’ enduring mental health problems, many have pointed to the low rates of mental health service use in the Asian-American community (1, 4).

Despite research documenting that Asian Americans are less likely than their non-Asian counterparts to seek help for mental health problems (5), the best available evidence indicates that lack of utilization, in itself, is unlikely to explain the persistent mental health problems experienced by Cambodian refugees. Specifically, Marshall et al. (2006) found that Cambodian refugees with major depression and/or PTSD had received mental health treatment in numbers comparable to that found among diagnosable individuals in the general population.

Given that the failure to access services does not appear to fully explain the enduring high levels of PTSD and major depression in the Cambodian refugee community, a question arises as to the nature of care that is being provided to Cambodian refugees. The current study was undertaken to characterize the sources and types of mental health services provided to a representative sample of Cambodian refugees and to generate potential insights into ways in which care might be improved. As a framework for comparison, we sought to determine the proportion of Cambodian refugee clients who could be described as having received minimally adequate treatment (6). Moreover, we investigated the mode of communication between providers and Cambodian refugees (e.g., use of interpreters) given previous research documenting linguistic barriers to care (4, 7). Though refugees are required to adjust their status to lawful permanent residents after a year in the U. S., and thus technically are no longer refugees, we continue to refer to this study’s participants as “refugees” to denote the circumstances under which they entered the country and their distinct pre-migration experiences that often differ from immigrant groups. Prior studies on refugee mental health services have focused mainly on standardized treatments delivered in controlled trial settings, while studies of services delivered in naturalistic settings have been limited to refugee clients of specialized centers or clinics (8). This is the first study to conduct a more in-depth investigation of the nature of mental health care among a representative community sample of refugees particularly with respect to minimally adequate treatment.

Method

Participants and Sample Design

Participants were drawn from a follow-up study of Cambodian refugees who were originally interviewed between October 2003 and February 2005. A three-stage random sampling design was employed of a geographically contiguous area consisting of the four census tracts with the largest proportion of Cambodians in Long Beach, California, home to the largest single concentration of Cambodian refugees in the United States (U.S.). Eligible participants were between 35 and 75 years of age and had lived in Cambodia during some portion of the Khmer Rouge regime. Overall, 87% (N=490) of those who screened eligible completed the initial interview. Detailed information about the sampling design of the original study is provided elsewhere (9).

Between January 2011 and March 2012, follow-up interviews were conducted to collect more comprehensive information about the use of mental health services. Approximately 72% (N=331) of the original study participants took part in the follow-up interview. Analyses in the current study are restricted to the 227 participants who met diagnostic criteria for PTSD and/or major depression disorder in the 12 months prior to the follow-up interview as defined by the Composite International Diagnostic Interview (CIDI) version 2.1 (10). Ninety-seven percent (N=219) met criteria for past 12 month PTSD (59% with PTSD only (N=132); 37% with co-morbid depression (N=87). Participants had a mean age of 60.1 (SD=9.72) and 66.6% (N=167) were female.

Procedures and Measures

Face-to-face, fully structured, household interviews were conducted in Khmer by bilingual lay interviewers, who received extensive training and supervision. Written informed consent was obtained and participants were provided with a nominal financial incentive. Study procedures were approved by the RAND institutional review board.

Instruments were translated into Khmer and back-translated into English using recommended procedures (11). The two English versions of the interview were compared for equivalency and discrepancies. Discrepancies were reconciled by the original translators and one additional translator who was not involved in the initial translations.

To assess receipt of mental health care, respondents were asked if they had received help for their depression, anxiety, drug addiction or alcoholism, or other mental health problems in the past five years (the period of time since the baseline interview) from each of the following providers: a “psychiatrist,” a “family doctor or medical doctor,” or a “psychologist, social worker, or other mental health professional” (from here on referred to as “non-MD mental health professional”). (Note: The receipt of mental health care item was derived from the National Comorbidity Replication Study and the original English wording asked about help for “emotions, nerves, use of drugs or alcohol, or any other mental health issue” (6). In the text above, we provide the version of the question when back translated from Khmer.) If respondents endorsed seeing a provider within the past five years, they were then asked follow-up questions regarding whether any visits were made in the past 12 months for help with mental health, the number of visits made in the past 12 months, and the average duration of visits. Respondents were also asked whether they had obtained a prescription for medication from their provider and, if so, the name of the medication and when they started the medication.

Minimally adequate care was defined as either having received pharmacotherapy (≥ 2 months of an antidepressant or anxiolytic medication and ≥ 4 visits to a psychiatrist or medical doctor) or psychotherapy (≥ 8 visits with a psychiatrist or other mental health specialty provider with an average treatment session ≥ 30 minutes) based upon available evidence-based guidelines and criteria used in prior studies (6, 12). Mode of communication was assessed for each provider type seen in the past 12 months with the following question, “How did you typically communicate with this [provider]?” Response options were: “You spoke in English,” “The [provider] spoke in Khmer,” “You used an interpreter provided by the [provider] or clinic,” or “You had a family member or friend interpret.”

Data Analysis

Analyses were weighted to account for complex sampling design effects and for attrition. The proportion of respondents with documented mental health need who had obtained mental health care in the past 12 months was computed separately across provider types. Correspondingly, the mean number of visits made in the past 12 months, the average duration of each visit, and mode of communication were estimated for each provider type seen. For all analyses, weighted percentages and unweighted sample sizes are provided.

Results

More than half of the Cambodian refugees who met criteria for PTSD and/or major depression (52%; N=127) obtained mental health services from at least one provider in the past 12 months. Thirty-nine percent (N=102) had seen a psychiatrist, 29% (N=66) a general medical doctor, and 4% (N=11) a non-MD mental health professional. Approximately half of Cambodian refugees who met criteria for PTSD and/or major depression (50%; N=124) reported taking a psychotropic medication in the past 12 months. Medication names were obtained either by recording information off of medication bottles provided by respondents (96.6%; N=119), by self-report (1.6%; N=3), or the source was missing (1.9%; N=2).

Table 1 provides a breakdown of mental health care obtained from each provider among those who had received services in the past 12 months. Of those who had sought care in the past 12 months, 80% (N=102) had seen a psychiatrist and 52% (N=66) had seen a general medical doctor. In contrast, only 9% (N=11) had seen a non-MD mental health professionals. Moreover, all of the respondents who obtained care from non-MD mental health professionals had also received treatment from psychiatrists or general medical doctors. Among those who had utilized mental health services in the past 12 months, 37% (N=48) had seen more than one type of provider. Overall, of the Cambodian refugees who had obtained any type of mental health care in the past 12 months, 45% (N=71) had received minimally adequate care. Approximately 37% (N=58) had received minimally adequate pharmacotherapy and an additional 8% (N=13) had received minimally adequate psychotherapy.

Table 1.

Provider type seen, mean number of visits, and mean visit duration for respondents who utilized mental health services in the past 12 months (N=127)^a

Provider type	Seen in the past 12 months b			Number of visits		Visit duration (minutes)
	N	%	SE	M	SE	M	SE
Psychiatrist	102	75	5.88	9.00	0.39	29.00	1.63
General medical	66	56	5.47	10.00	0.99	34.00	2.92
Other mental health specialty	11	7	2.25	8.00	2.10	45.00	6.24

^aRespondents had past 12 month PTSD and/or major depressive disorder

^bPercentages do not add up to 100 because some respondents saw more than one provider type.

Cambodian refugees who had seen psychiatrists had an average of 9.00 visits (SE=0.39) in the past 12 months with each session lasting an average of 28.00 minutes (SE=1.69). Similarly, among those who had seen general medical providers, an average of 10.00 visits (SE=0.99) was made with an average duration of 34.00 minutes (SE=2.97). For non-MD mental health professionals, an average of 8.00 visits (SE=2.10) was made with each session lasting an average of 46.00 minutes (SE=7.28).

Virtually all respondents who obtained mental health care from a psychiatrist (100%; N=102) or general medical doctor (97%; N=64) had been prescribed psychotropic medications. Of those who had been prescribed psychotropic medication, 55% (N=46) reported taking the medication for more than 5 years, while 26% (N=23) took the medication for more than a year but less than 5 years. The large majority of Cambodian refugees who had seen psychiatrists (95%; N=96) or non-MD mental health professionals (79%; N=8) had used interpreters supplied by the provider or clinic (see Table 2). In contrast, of those who had seen a general medical doctor, 63% (N=39) had used an interpreter and 32% (N = 22) had a provider who spoke in Khmer.

Table 2.

Mode of communication with providers

Provider type	Provider/clinic provided interpreter			Family/friend interpreted			Respondent spoke English			Provider spoke Khmer
	N	%	SE	N	%	SE	N	%	SE	N	%	SE
Psychiatrist	96	95	2.13	3	2	1.09	2	2	1.74	1	<1	0.62
General medical	39	63	7.48	1	1	1.04	4	4	2.43	22	32	7.13
Other mental health specialty	8	79	11.90	1	8	8.36	0	0	NA	2	12	8.97

Note. Sample sizes were not large enough to permit reliable estimates of differences between groups.

Discussion

The purpose of this study was to better understand the nature of mental health services provided to Cambodian refugees and to identify whether there are areas in which care might be improved. Although our findings indicate that Cambodian refugees are receiving minimally adequate treatment at rates comparable to diagnosable individuals in the U.S. general population (6), certain aspects of their care appear to be markedly different. First, Cambodian refugees are almost exclusively relying on psychiatrists and medical doctors for their care. Cambodian refugees are obtaining treatment from psychiatrists at almost double the rate of individuals with depression or PTSD in the general U.S. population (6). Moreover, Cambodian refugees’ pattern of mental health care also starkly contrasts those of other immigrant groups. For instance, Cambodian refugees are obtaining mental health treatment from psychiatrists at more than five times the rates of foreign-born Asian Americans with depressive and anxiety disorders (13). Similarly, Cambodian refugees’ are receiving care from general medical doctors at almost ten times the rate of foreign-born Asian Americans with a diagnosable mental disorder (14). Second, another distinctive feature of Cambodian refugees’ mental health care is their prevailing use of pharmacotherapy. Practically all who had obtained mental health treatment were on psychotropic medication. Cambodian refugees’ use of pharmacotherapy is nearly double that of White Americans and six times that of Asian Americans with depressive and anxiety disorders (15). Finally, Cambodian refugees’ experienced significant disparities with respect to the receipt of care from non-MD mental health professionals. Only 4% (N=11) of Cambodian refugees had obtained treatment from non-MD mental health professionals compared to 19% of White Americans and 14% of foreign-born Asian Americans with a diagnosable mental disorder (13).

Altogether, our findings suggest that Cambodian refugees’ mental health care consists primarily of pharmacotherapy and limited trauma-focused psychotherapy. Although our data do not allow us to determine definitively the extent to which trauma-focused psychotherapy is being delivered, the number and duration of visits with psychiatrists are of relatively low intensity if trauma-focused therapy is being provided. Cambodian refugees are seeing psychiatrists for an average of nine visits with a mean duration of 29 minutes. Given that care from psychiatrists almost always involved pharmacotherapy management and the use of interpreters, it seems unlikely that a half-hour visit would provide sufficient time for trauma-focused psychotherapy. If trauma-focused therapy is being delivered, it is occurring in a rather limited manner given that evidence-based trauma-focused psychotherapy typically consists of eight to twelve, 60 to 90 minute, sessions when there is provider and client language congruence (16).

These findings should be considered in light of treatment consensus guidelines for traumatized populations (17, 18). Although most PTSD practice guidelines acknowledge that pharmacotherapy can be beneficial, there is uniform support for the use of trauma-focused psychotherapy as the first-line of treatment (IOM, 2012). Moreover, a small but growing number of studies suggest that trauma-focused psychotherapy may be effective in treating PTSD specifically among refugee populations (19, 20). In fact, cognitive-behavior therapy yielded promising findings for Cambodian refugees who been undergoing long-term pharmacotherapy with treatment resistant PTSD (19). Given that the vast majority of Cambodian refugees with mental health needs are receiving pharmacotherapy, and most have been taking these medications for more than 5 years, efforts should be directed at wider dissemination of adjunctive psychotherapy.

The underutilization of evidence-based psychotherapy for PTSD is a broader issue that affects almost all traumatized groups (21), in spite of the fact that it is the recommended course of treatment for chronic PTSD (22). It is likely that just as the general U.S. population experiences barriers to accessing evidence-based trauma-focused psychotherapy (21), Cambodian refugees are encountering similar challenges that may be intensified by the lack of Khmer-speaking providers. This raises another potential challenge in providing refugees with effective PTSD treatments; namely, there has been insufficient study to determine how the use of interpreters impacts the quality and efficacy of mental health services (23). Little systematic research has been conducted to provide evidence-based guidelines for how to improve the quality of care for individuals with limited English proficiency. A recent meta-analytic review found that culturally-adapted mental health interventions were twice as effective when providers and clients were matched on language than when not, suggesting that provider and patient language congruence or lack thereof may affect the quality of mental health care (24).

One potential strategy for addressing this challenge may be through Narrative Exposure Therapy (NET), a short-term, trauma-focused therapy designed to be administered by trained refugees, in regions affected by war and disaster where mental health professionals may be scarce (25). A recent meta-analysis indicates NET is effective and its effectiveness is substantially greater when delivered by refugee lay counselors than by health care professionals (25), perhaps because this allows for more linguistically and culturally appropriate care. The success of NET suggests that trained lay providers may be able to provide high-quality psychotherapy among Cambodian refugees.

Certain limitations of this study should be noted. First, the standard definition of minimally adequate care may overestimate the quality of care in this population because the effective duration of visits may be reduced by the need for translation. Also, the construct of “minimally adequate care” is a crude measure of treatment engagement rather than of the quality of clinical care. Thus, more fine-grained research would clarify the extent to which Cambodian refugees are being provided with high-quality, evidence-based care. Moreover, this study does not shed light on the origins of the pattern we observed (in which few Cambodian refugees are receiving evidence-based psychotherapy even though it is considered a first line treatment for both PTSD and major depression). Although one can speculate that the finding arises from a combination of factors including a shortage of Khmer-speaking psychotherapy providers, proclivities toward pharmacotherapy because of somatic symptoms, and resettlement processes that may direct refugees to general medical doctors or psychiatrists rather than non-MD mental health professionals (e.g., medical screening for newly arrived refugees, disability evaluations), further study is needed to examine how this pattern of care developed.

Nonetheless, this is the first study to take a more comprehensive look at the nature of mental health care among a representative probability sample of refugees. To the extent that the patterns of care hold for other refugee groups residing in the United States, these findings have broad implications for the provision of first line recommended mental health treatments to refugee populations. Future research involving population-based samples rather than clinic or convenience samples is needed to determine whether significant disparities in the provision of trauma-focused psychotherapy are occurring in other refugee communities. Refugees are a heterogeneous group varying in socioeconomic backgrounds, trauma histories, and levels of integration in the United States, making it difficult to ascertain the generalizability of the experiences of one group of refugees to others. Our findings also highlight the need for further study of the longer-term integration of refugees into the mental health care system and access to effective and quality services when there is a limited supply of providers who can deliver care in the native language of refugees.

Conclusions

Almost thirty years after resettlement, the majority of Cambodian refugees continue to have substantial psychiatric problems despite relatively high utilization of mental health services. Cambodian refugees receive care almost entirely from psychiatrists and general medical doctors generally in the form of brief, relatively infrequent medication management visits delivered via an interpreter. Expansion of evidence-based trauma-focused psychotherapy, particularly if delivered in Khmer, may aid in further alleviating Cambodian refugees’ persistent trauma-related symptoms.