PSYCHIATRIC MORBIDITY AMONG AFGHAN REFUGEES IN PESHAWAR, PAKISTAN

Farooq Naeem, Khalid A Mufti* ,  Mohammad Ayub** , Asad Haroon# ,Farida Saifi# , Saima Mahmood Qureshi# , Ali Ihsan#, Haroon Rasheed Chaudry^,

Saif ur Rehman Dagarwal+, David Kingdon*

Department of Psychiatry, Royal South Hants Hospital, Southampton, SO143ED, *Department of Psychiatry, Khyber Medical College, Peshawar, Pakistan, **Prudoe Hospital, Durham, Midlands, UK, # Horizon, EE 32 Nishterabad Peshawar Pakistan, ^Fatima Jinnah Medical College, Lahore, Pakistan, +Village Daigam, Distt. Kama City Ningarhar, Afghanistan

Background: A review of the literature shows that refugees in different parts of the world have high rates of psychological and emotional problems. However, psychiatric morbidity among afghan refugees in Pakistan has been poorly studied. Most of the studies of psychiatric disorders come from western countries. However, these studies may not be representative of the afghan refugees in Pakistan. This study was carried out to measure psychiatric morbidity among a group of Afghan refugees attending a psychiatric clinic in Peshawar, Pakistan. Methods: This is a cross sectional study, to measure prevalence of psychiatric morbidity among the residents of Afghan refugee camps in Peshawar, Pakistan, who attended a psychiatric clinic between November 2003 and February 2004. Data were collected using Mini International neuropsychiatry Interview Schedule (MINI), and a form specifically developed for the study. Results: Nearly 80% of our patients had a diagnosis of Post Traumatic Stress Disorder. Nearly half, (47.9%) reported family history of mental illness, while almost a quarter 923.3%) had a physical disability or long term illness. Only 13.7% (106) had contacted health services prior to seeking help for their psychiatric illness. Conclusions: A high number of patients presenting with PTSD is not an unusual finding when one considers the traumatic experiences faced by the general population of Afghanistan. Only a small number of the patients had been in contact with the health services prior to their contact with the psychiatric service. This study highlights the importance of  health education among afghan refugees and to establish the mental health services for them.

Keywords: Psychiatric, Morbidity, Refugees

INTRODUCTION

Pakistan has received Afghan refugees since 1980s. In the recent years there has been an increase in the refugees again after the American invasion of Afghanistan. This is however, a poorly studied and supported group, compared with their counterparts in Europe and America, mainly due to financial and medical problems of Pakistan. The burden of care of this refugee group lies mainly with Pakistani, Non Governmental Organisations (NGOs), along with a small number of western NGOs.

Pakistani health system has merely coped with this big population of refugees. Pakistan has faced ongoing economic problems, drug and organised violence and terrorism, lack of democracy and ongoing conflicts with her neighbours. It is understandable that the country never had a chance to develop a health system. It is therefore hardly surprising that in spite of some international funding Pakistan could hardly meet the health requirements of the refugees.

Refugees are a at high risk of developing mental health problems for a variety of reasons; traumatic experiences in and escapes from their countries of origin, difficult camp or transit experiences, culture conflicts and adjustment problems in the country of resettlement, and multiple losses; family members, country, and way of life.

Many studies in the West have found high rates of psychiatric disorder among refugees.2 Wide variations in the rates of these disorders can be attributed to differing cultures and experiences in the groups sampled. Although the concept PTSD has been questioned 3 , and it has been suggested that the rates of Post Traumatic Stress Disorder may have been exaggerated, 4  the rates of Post Traumatic Stress Disorders have been estimated to be as high as 90% in psychiatric clinic populations.5

In a community study of the Afghan refugees, in Holland, the prevalence of PTSD was found to be 35%.6 Similarly, an American study examined the psychological effects of the war in Afghanistan on two groups of young Afghan refugees currently residing. They found the rates of mental health problems to be higher among pushto speaking population compared with Tajik population.7 In another American study thirty-eight refugees between 12 and 24 years of age were interviewed with the Structured Clinical Interview for DSM-III-R. Five subjects met DSM-III-R criteria for PTSD, 11 subjects met the criteria for major depression, and 13 had either PTSD or major depression or both.8

However, people in the west may not be representative of the afghan refuges. The study of mental health problems among Afghan refugees in Pakistan therefore provides us with an opportunity to study mental health problems in this population. This study was carried out to investigate the rates of PTSD among Afghan refugees attending a clinic in Peshawar, Pakistan. The primary objectives of the study are to measure prevalence of psychiatric morbidity among Afghan refugees. The secondary objectives include measurements of clinical and demographic details.

MATERIAL AND METHODS

This is a cross sectional study. Information was collected from Afghan refugees, attending a psychiatric service, between November, 2003 and February 2004. 

All the refugees attending a psychiatric service in Peshawar, who fulfilled our inclusion criteria, were approached. All those approached, consented and were therefore included in our study. 

We gathered data from the 1035 patients who attended the service between the specified periods.   

The inclusion criteria included, (a) being an Afghan refugee, (b) between the ages of 15 and 65, (c) attending the psychiatric service and (d) with a diagnosis of a functional psychiatric illness. Those with a diagnosis of (a) learning disability, (b) dementia and (c) organic brain disorder were excluded from the study.

Measurement of psychopathology

Psychopathology was measured by Mini International neuropsychiatry Interview Schedule (MINI).9 A form to record experiences of trauma was specially designed based on qualitative experiences with ten refugees.   

Analyses were carried out using SPSS 10.  Both parametric and non parametric tests were conducted. 15 cases were removed from our initial analyses due to missing data.

RESULTS

Information was available was available for 1020 patients who attended the psychiatric service, during the study period. The mean age of the sample was 33 years (range=15-64), other characteristics of the sample are shown in table 1.

47.9% (372) reported family history of mental illness, 23.3% (181) had a physical disability or long term illness. Only 13.7% (106) had contacted health services prior to seeking help for their psychiatric illness. Most of the refugees were pashtun, 741 (95.5%), other ethnic groups included; Uzbek= 15 (1.9%), Tajik = 7 (0.9%), Hazara =3 (0.4%), Turkman =1 (0.1%), Baluch= 2 (0.3%) and Kizilbash= 7 (0.9%). Table 2 shows the prevalence of psychiatric disorders. 

Table-1: Demographic and other data

 

Number

%

Gender

                            Male

                            Female

 

436

340

 

  56.2

  43.8

Marital status of the respondent

                            Single

                            Married

                            Widowed

                            Widower

 

      92

649

      26

        8

 

  11.9

  83.6

    3.4

    1.0

Level of Education

                            Primary

                            Matric

                            Uneducated

          

     111

         6

     659

 

  14.3

    0.8

  84.9

Employment Status

                            Self Employed

                            Employed

                            Unemployed

 

     232

     115

     429

 

  29.9

  14.8

  55.3

Children

                            Up to 2 yrs

                            3-5 yrs

                            6 yrs or more

 

     207

     302

     267

        

  26.7

  38.9

  34.4

Migration Period in years

                            1 year

                            2 yrs.

                            3 yrs.

 

     122

     615

       39

 

  15.7

  79.3

    5.0

Table 2, psychiatric morbidity among afghan refugees

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnoses

Frequency

%

No diagnosis

10

    1.0
Major depressive episode lifetime

        44

    4.3
Major depressive episode current

        14

    1.4
manic episode current

          2

      .2
Hypomania episode past

          1

      .1
Panic disorder current

          1

      .1
Obsessive compulsive disorder

          2

      .2
Post traumatic stress disorder

      776

  76.1
Substance dependence (non alcohol)

      101

    9.9
Substance abuse (non alcohol)

          2

      .2
Psychotic disorder lifetime

43

    4.2
Psychotic disorder current

          1

      .1
Generalized anxiety disorder

23

    2.3
Total

    1020

100.0
Patients were referred by different sources; camp commander =72  (9.3%), maulvi (local priests) / faith healer= 48 (6.2%), Camp Dispensary= 467 (60.2%), lady health worker= 66 (8.5%), welfare organisation= 39 (5.0%), un-registered health practitioners= 48 (6.2%) and others (e.g; teachers, family and friends and people who had benefited from psychiatric treatment) = 36(4.6%). Nearly 58% (448/1020) of the sample had a co morbid disorder.  Table 3, shows prevalence of co morbid mental illness in this group.

Table-3:Co morbid disorders

 

 

 

 

 

 

 

 

 

 

 

 

Co morbid diagnoses

Frequency

%

Nil

          401

       39.3
Maj dep episode current

          146

       14.3
Maj dep episode lifetime

          171

       16.8
Manic episode current

            19

         1.9
Manic episode past

              5

           .5
Panic disorder current

            25

         2.5
Social phobia

              2

           .2
Substance dependence

            26

         2.5
Substance abuse

            53

         5.2
Psychotic disorder lifetime

              6

           .6
Psychotic disorder current

            55

         5.4
Generalized anxiety disorder

          111

       10.9
DISCUSSION

There was no gender difference in our sample. Our finding that most of the patients were uneducated and unemployed was consistent with the past findings. However, most of our patients were married, and had 3 or more children.

We found the rates of depression and anxiety disorders as low in the sample. However, this could be due to the fact that most of these patients had a diagnosis of PTSD. We have therefore also described the rates of the co morbid disorders. It appears that the rates of depression and anxiety are very common as a co morbid diagnosis. However, the rates of drug and alcohol disorders were low. This could be partly explainable due to social stigma and cultural values attached to the use of these substances in the Muslim societies.

Our patients reported a variety of trauma. While men reported, mainly torture and assault, women were affected by the direct experience of bombardment. This is possible due to the fact that men were more likely to be directly involved in the war, while women could possibly be exposed to trauma due to the experiences while at home.

Majority of our patients were Pashtu speaking. There is at least one study conducted in the USA, in which the investigators found the rates of psychiatric disorders and the war related experiences of those from different regions to be different. 

These patients were being seen in a Psychiatric facility run by an NGO, and only a selective type of patients might be attending this service. However, this study points out high rates of PTSD among clinical populations of Afghan refugees. It is also possible that people with PTSD seek more help than those with affective or psychotic disorders. There is a need to repeat this work.

REFERENCES

1.        De jong, J., Scholte, W., Koeter, M., et al (2000) The prevalence of mental health problems in Rwandan and Burundese refugee camps. Acta Psychiatrica Scandinavica, 102, 171-177

2.        Summerfield, D. (2001) Asylum seekers, refugees and mental health services in the UK. Psychiatric Bulletin, 25, 161-16

3.        Watters, C. (2001). Emerging paradigms in the mental health care of refugees. Social Science and Medicine, 52, 1709-1718.

4.        Silove, D. (1999) The psychosocial effects of torture, mass human rights violations, and refugee trauma. Journal of Nervous and Mental Disease, 187(4), 200-207.

5.        Gernaat HB, Malwand AD, Laban CJ, Komproe I, De Jong J. (2002) Many psychiatric disorders in Afghan refugees with residential status in Drenthe, especially depressive disorder and post-traumatic stress disorder. Ned Tijdschr Geneeskd. Jun 15;146(24):1127-31. 

6.        Mghir R, Raskin A. (1999) The psychological effects of the war in Afghanistan on young Afghan refugees from different ethnic backgrounds. Int J Soc Psychiatry. Spring;45 (1):29-36; discussion 36-40

7.        Mghir R, Freed W, Raskin A, Katon W. (1995) Depression and posttraumatic stress disorder among a community sample of adolescent and young adult Afghan refugees. J Nerv Ment Dis. 1995 Jan;183(1):24-30. 

8.        Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC. (1998) Mini International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 59 Suppl 20:22-33;quiz 34-57. Review.

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Address For Correspondence:

Prof. Khalid A. Mufti, Horizon, EE 32 Nishterabad Peshawar Pakistan. Tel: 92-91-270779

Email: kamufti2001@yahoo.com