Health & Medicine

UC Davis psychiatrist discusses mental health stigma among immigrants

About one in 25 people worldwide suffer from depression, but many cultures refuse to acknowledge the problem because of the social stigma of mental illness, said Dr. Russell Lim, director of diversity education and training for the UC Davis Department of Psychiatry and Behavioral Sciences.

Lim, 53, trains future doctors to help Sacramento’s growing refugee population overcome that stigma. His clinical focus on transcultural and community psychiatry helps immigrants get treatment for depression, anxiety, agitation, bi-polar and psychotic disorders, and post-traumatic stress. Last month, Lim received the Kun-Po Soo Award from the American Psychiatric Association “for his contributions to understanding the importance of understanding culture in mental health issues,” said UC Davis Medical Center spokeswoman Phyllis Brown.

Lim’s work is critical to the region’s mental health, as about 29,000 refugees fleeing war, persecution, gang violence and natural disasters have resettled over the last 20 years in Sacramento County, which has taken in more refugees per capita than almost any area in the nation. Over the past five years alone, 1,200 Iraqi refugees have settled in Sacramento County.

In 2014-15, the U.S. government issued 1,400 special immigrant visas to Afghanis and Iraqis in Sacramento County who worked for the U.S. military during recent wars. Lim, editor of the 2015 Clinical Manual of Cultural Psychiatry, discussed the challenges of bridging cultures to save lives.

Q: What kind of psychiatric cases are we now dealing with in the region?

A: I probably see 200 to 250 patients a year who speak at least eight different languages. We see people from Iraq, Afghanistan, Armenia, Russia, Ukraine, Laos, Vietnam, China, Cambodia and South Asia. Every culture has some stigma about having a mental illness. What makes the illnesses different in different countries is the language they use to tell you how they hurt. In China, emotions that can signal mental illness are often conveyed through metaphors – “heartache” means sadness, while “fatigue” usually means hurt and despair. The Hmong associate the liver with various symptoms, including sadness, and Cambodian patients say they have a “weak heart” when they’re depressed.

A typical case would be a 35-year-old Iraqi who fled in 2012 because he’d worked for the U.S. Embassy as an interpreter. He was always worried he’d be kidnapped and shot. He can’t sleep due to repeated nightmares about the drone attacks he witnessed, or about one of his friends whom he saw shot and killed. He cries daily. He has flashbacks during the day that come with no provocation. He avoids going out in public. He’s unable to clean his home or prepare his own meals. He thinks about suicide frequently, but won’t hurt himself, because the Quran forbids suicide.

Q: How can people help immigrants who appear to be struggling with mental health problems?

A: You can call Sacramento County Mental Health at (916) 875-1055 or 888-881-4881 after hours. They have interpreters available and screen patients for mental disorders. Those eligible for treatment will be referred to a county clinic for evaluation and scheduled with a psychiatrist who can prescribe medications. The county will take patients without private insurance and cover those suffering from PTSD. We have new medications we didn’t have 10 years ago, but the basic job is still listening to people and helping them feel better.

Q: How can communities get past the stigma associated with seeking mental health services?

A: Often immigrants and refugees turn to herbal medicine, acupuncture and religious leaders, delaying sending a loved one to a psychiatrist who can diagnose the illness and prescribe proper treatment. Grigoriy Bukhantsov (a Ukrainian refugee charged at age 19 with killing his sister-in-law, her 3-year-old daughter and 2-year-old son in 2012 in Rancho Cordova) had been having issues for several years prior to the murders. He’d been receiving counseling from his community.

His refusal to see a mental health professional was likely cultural. Someone who needs mental health treatment may try to manage the illness without the use of a psychiatrist or substance abuse specialists. While support from one’s ethnic and religious communities can be helpful, it works best when combined with medications from a psychiatrist or family doctor, and counseling from certified substance abuse therapists. You can destigmatize mental illness with public service announcements and booths at health fairs targeting particular communities, making it more likely they will seek treatment. In the former Soviet Union, calling somebody crazy was a way to get rid of people by locking them up.

His family did call law enforcement several times, but he wasn’t taken away. Often law enforcement is not comfortable with mental illness. Many police departments receive 0 to 40 hours of mental health training per officer. The only thing relatives or friends can do is insist the patient has threatened their lives and that he or she be brought to an emergency room for an evaluation to determine whether they are a 5150 – gravely disabled or a danger to themselves and others.

Q: What have we learned from our large number of Southeast Asian refugees?

A: History provides insight into a patient’s experience. We see many Hmong that helped the U.S. in the Vietnam War. When the U.S. pulled out in April of 1975, the North Vietnamese took over and methodically killed all those who had helped the Americans. Some Hmong and Vietnamese hid in the jungle, staying one step ahead of the Viet Cong. Many died in the villages from gunshot wounds, mortar fire or being burned in their houses. Those who survived living in the jungle would often cross the Mekong River to Thailand. Many drowned; those who made it spent years in Thai refugee camps. It’s not surprising that many suffer from depression and PTSD. Some still have flashbacks about the trauma that they had witnessed.

Psychiatric medications such as Citalopram and Prazosin can help with nightmares and flashbacks and depression. I believe there are many more refugees with symptoms who do not come to see a psychiatrist. Having linkages to the community would improve access to the clinics, but non-Hmong practitioners would also benefit from training in culturally appropriate assessment to uncover otherwise hidden depression. We know there are a certain number of people who get better if we don’t do anything but we can’t predict who those people are. Most people would benefit from treatment – medications and therapy will help people get better sooner than if you don’t do anything at all.

Stephen Magagnini: (916) 321-1072, @StephenMagagnini