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Symptomatology Among Bhutanese Refugees in Nepal

Nirakar Man Shrestha, MD, DAB; Bhogendra Sharma, MBBS; Mark Van Ommeren, MA; Shyam Regmi, MBBS; Ramesh Makaju, MBBS; Ivan Komproe, PhD; Ganesh B. Shrestha, MBBS; Joop T. V. M. de Jong, MD, PhD

JAMA. 1998;280:443-448.

Context.— Most of the world's refugees are displaced within the developing world. The impact of torture on such refugees is unknown.

Objective.— To examine the impact of torture on Bhutanese refugees in Nepal.

Design.— Case-control survey. Interviews were conducted by local physicians and included demographics, questions related to the torture experienced, a checklist of 40 medical complaints, and measures of posttraumatic stress disorder (PTSD), anxiety, and depression.

Setting.— Bhutanese refugee community in the United Nations refugee camps in the Terai in eastern Nepal.

Participants.— A random sample of 526 tortured refugees and a control group of 526 nontortured refugees matched for age and sex.

Main Outcome Measures.— The Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for PTSD and the Hopkins Symptom Checklist-25 (HSCL-25) for depression and anxiety.

Results.— The 2 groups were similar on most demographic variables. The tortured refugees, as a group, suffered more on 15 of 17 DSM-III-R PTSD symptoms (P<.005) and had higher HSCL-25 anxiety and depression scores (P<.001) than nontortured refugees. Logistic regression analysis showed that history of torture predicted PTSD symptoms (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.7-8.0), depression symptoms (OR, 1.9; 95% CI, 1.4-2.6), and anxiety symptoms (OR, 1.5; 95% CI, 1.1-1.9). Torture survivors who were Buddhist were less likely to be depressed (OR, 0.5; 95% CI, 0.3-0.9) or anxious (OR, 0.7; 95% CI, 0.4-1.0). Those who were male were less likely to experience anxiety (OR, 0.66; 95% CI, 0.44-1.00). Tortured refugees also presented more musculoskeletal system– and respiratory system–related complaints (P<.001 for both).

Conclusion.— Torture plays a significant role in the development of PTSD, depression, and anxiety symptoms among refugees from Bhutan living in the developing world.

From the Center for Victims of Torture, Kathmandu, Nepal (Drs N. Shrestha, Sharma, Regmi, Makaju, and G. Shrestha and Mr Van Ommeren); and the Free University (Drs Sharma, Komproe, and de Jong and Mr Van Ommeren) and the Transcultural Psychosocial Organization (Mr Van Ommeren and Drs Komproe and de Jong), Amsterdam, the Netherlands.

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