In this cross-sectional study of refugee mothers relocated to San Diego, we found that Iraqi refugees were significantly more likely to have major depression, less likely to seek a mental health care provider, and more likely to suffer stigma of mental illness compared to Somali refugees. To our knowledge, this is the first study to directly compare two refugee communities who have access to comparable health care services within the same city yet engage in these services differently and suffer different levels of mental illness. Indeed, previous studies have demonstrated language and cultural competencies as major barriers to the utilization of mental health (Salami et al. 2019), but our study indicates that even within communities with these language and cultural challenges there are significant differences in mental illness prevalence and health care access—issues affected by a myriad of factors.
There are many possible explanations for these discrepancies found between the two refugee communities investigated in our study. While the two groups are comparable in many aspects (e.g., average age, marital status), the Somali refugees have been settled in the USA much longer than Iraqis, possibly enabling longer time to acculturate to life in the USA. This hypothesis is consistent with prior studies suggesting length of time resettled is associated with better assimilation and mental health (Porter and Haslam 2005; Salami et al. 2019), but at odds with others demonstrating longer time in resettlement is associated with worse mental health outcomes (Kirmayer et al. 2011; Uribe Guajardo et al. 2016). Somali respondents felt they had improved social and financial status in the USA compared to their prior country of origin, while Iraqis felt they had a drop in their social status, likely increasing their risk of worse post-migration outcomes. Unfortunately, both populations had a small proportion of respondents who felt they could meet their financial needs “very well”. Interestingly, the Somalis spent a longer total period in the transition countries before being resettled, while a greater proportion of Iraqi refugees went to more locations prior to resettlement in the USA. Perhaps the act of relocating more frequently exposes refugees to more factors affecting mental health, such as disruption of social support and networks, trauma, violence, harsh living conditions, and overall uncertainty (Kirmayer et al. 2011). A prior study did show that Somali mothers who had a history of trauma and torture were significantly more likely to suffer from depression and PTSD (East et al. 2018). Indeed, the association between trauma exposure and mental illness has been well documented (Steel et al. 2009), suggesting that this relationship would hold true for the Iraqi population in question.
Although Iraqi refugees were more educated, they still had a stigma against utilizing mental health care services in San Diego. Prior work has discussed how stigma associated with mental health disease in Iraq seems to be greater than in other parts of the world, and this stigma leads to reluctance to engage with treatment (Bolton 2013). Among the Iraqi refugee community, those who speak out about mental health can be considered ‘crazy’. Even if patients do want to seek care, they may not trust the health professionals and, particularly among women, they may be unable to seek care without family consent or a male chaperone to leave the home (Sadik et al. 2010). These barriers to care are concerning, especially since our study showed that refugees who had seen a mental health provider when needed had more favorable HSCL scores. Given this is a cross-sectional study, we cannot ascertain whether those who sought health care were less likely to be depressed because of the care they received or because their psychiatric disease was milder in the first place. Future studies optimally designed to investigate this question are needed.
The type of health care services also differed between the two populations. Somalis utilized a clinic setting whereas Iraqis utilized community-based services. This discrepancy can largely be attributed to the geographic location of Iraqis in El Cajon, an area of San Diego rich in community clinics, in addition to the Iraqi community’s dependence on refugee-specific services. Alternatively, Somalis are more established and live in a different location that does not have as high of a proportion of community clinics; thus, they have likely sought out additional health services beyond those only serving refugee communities. This finding might also reflect health insurance preferences by the two populations.
This study highlights an interesting difference in mental health utilization between the two groups, specifically that most Iraqis had not seen a mental health provider in the past year (as opposed to most Somalis who had sought care). Given Iraqis had worse mental health outcomes overall, this differential use of mental health services likely suggests that there is a large proportion of the Iraqi population who could benefit from seeing a mental health provider. Interestingly, most Iraqis who answered that they did not see a mental health provider reported that this was because they did not need to, revealing what is likely a misconception, denial, or fear of disclosing mental health illness among the Iraqi community. This discrepancy illuminates an opportunity to improve mental health education and care for the Iraqi refugee community, which prior research on resettled Iraqi refugees has shown can be accomplished through better provider knowledge of the Iraqi culture and community, effective communication, understanding of traditional beliefs, and backgrounds behind negative attitudes toward mental health disease (Guajardo et al. 2016). Surprisingly, Somalis reported more negative perceptions of health care providers, but still were more likely to utilize mental health services and demonstrated better mental health outcomes. One possible explanation is that providers may have implicit bias impacted by patient appearance and affecting how they interact with their patients, given most Iraqis (81%) were Christians who do not wear culturally identifying clothes as opposed to the Muslim Somalis (99.5%) who mostly wear hijabs (i.e., traditional Muslim headscarves). Or perhaps this negative perception of providers among Somalis could be related to their lower education status and/or language barriers. Racism may also have played a role given that Somalis generally have a darker complexion, as opposed to Iraqis.
Both groups, but particularly the Iraqis, had an inverse association between those who met criteria for major depression and those who actually saw a mental health provider. This could be perceived as evidence that interaction with mental health services has had a beneficial effect on respondent’s mental health. However, the fact that participants with higher levels of mental health were less likely to see a provider highlights an unmet need. To provide appropriate mental health services for these populations, we need new and culturally appropriate approaches. It is, however, encouraging that the few who are utilizing mental health services demonstrate a decreased likelihood of depression or emotional distress. Based on these results, more work is needed to identify barriers to accessing mental health care among refugees who would otherwise benefit from these services.
This study has some limitations. First, the cross-sectional study design precludes any assessments of causality or temporality—specifically we cannot ascertain whether participants accessed mental health before or after their diagnosis of a mental illness. However, given the chronic nature of depression and the fact that the disease is commonly precipitated by trauma (East et al. 2018), it is highly likely that mental illnesses were present before seeking mental health care clinic. This study also focused on refugee mothers specifically as opposed to fathers or other caregivers, so we cannot generalize our findings to men in the Iraqi and Somali refugee communities. Compared to women, men are generally less likely to admit to illnesses, especially mental illnesses (The World Health Report 2001). There were differences in the methods of data collection between the two study samples: the Iraqi population was sampled at random, while the Somali population was a convenient sample recruited by door-to-door search for qualified mothers. The Somali study group may therefore be a biased sample of unemployed or lower paid people given the community tends to congregate in City Heights and in certain apartment complexes until they get higher paying jobs elsewhere. Furthermore, missing data precluded the inclusion of time awaiting resettlement and time in resettlement in the USA in the multivariable analysis. Given significant differences between the two groups with regard to these measures, it should be noted that the results may have been confounded by this omission.
While the HSCL-25 has been shown to be useful in non-western refugee patients, prior investigations have varied in the robustness of using the standard cutoffs in Iraqi and Somali patients (Wind et al. 2017; Weiss 2015; Taylor et al 2014). Further work is needed to validate using these cutoffs (i.e., average total score > 1.75 or depression score > 1.45) to define psychiatric illness for the purposes of comparing two different populations, which is why in this study we also included results of HSCL-25 scores as a continuous variable. Lastly, there may be different interpretations of the word “disease” that varies by individual and possibly non-randomly between the two groups. Therefore, admission of having a “psychiatric disease” on the survey may depend on one’s impression of the implication of the word.