Shattered Shangri-la: differences in depressive and anxiety symptoms in students born in Tibet compared to Tibetan students born in exile

  • Dabney Evans
  • David C. Buxton
  • Andrey Borisov
  • Amita K. Manatunga
  • Dawa Ngodup
  • Charles L. RaisonEmail author



As a result of ongoing political tensions within Tibetan regions of the People’s Republic of China, several thousand Tibetans escape across the Himalayas every year to seek refuge in India and Nepal. Prior studies have found a high prevalence of depressive and anxiety symptoms in these refugees, many of whom are young and have been exposed to significant trauma. However, it is not known whether depressive and anxiety symptoms are more prevalent in these refugees than in ethnic Tibetans born and raised in the relative political and social stability of exile communities in North India and Nepal.


We conducted a cross-sectional survey of a convenience sample of 319 students attending school at the Tibetan Children’s Villages in Northern India to test the a priori hypothesis that adolescents and young adults who escaped from Tibet to India would demonstrate increased depressive and anxiety symptoms when compared to ethnic Tibetans born and raised in exile. The Hopkins Symptom Checklist-25 (HSCL-25) was used to measure depressive and anxiety symptoms. In addition, demographic information on age, sex, country of birth and frequency of family contact was collected.


Students born in Tibet had higher mean HSCL-25 depressive and anxiety symptom scores than did ethnic Tibetans born in exile. Female students demonstrated higher depressive and anxiety scores, as did those with limited contact with immediate family. After adjusting for sex, age and frequency of family contact, being born in Tibet was associated with increased HSCL-25 depressive and anxiety symptom scores (depression: F[2, 316] = 29.96, P < 0.0001; anxiety: F[4, 316] = 43.57, P < 0.0001).


The experience of being raised in Tibet and escaping to India appears to be a risk factor for increased depressive and anxiety symptoms when compared to being born and raised within an exile community in India or Nepal.

Key words

refugees exile Tibet trauma depression anxiety 



Dabney Evans contributed to study design, data collection and management and manuscript preparation. David C. Buxton contributed to study design and data collection and management. Andrey S. Borisov contributed to data interpretation and manuscript preparation. Amita K. Manatunga contributed to study design and data interpretation. Dawa Ngodup contributed to data collection. Charles L. Raison contributed to study design, data interpretation and manuscript preparation. All authors had full access to the data and reviewed the manuscript. Charles L. Raison had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dabney Evans, David C. Buxton, Andrey S. Borisov, Amita Manatunga and Dawa Ngodup have no conflicts of interest to disclose. Charles L. Raison has served as a consultant/advisory board member for Wyeth, Lilly and Schering Plough and serves on the speakers’ bureau for Wyeth and Lilly. The authors would like to thank Mrs. Jetsun Pema, major-general Sushil K. Nanda (retired), and Nitin Nanda, M.D., for aiding with the logistics of conducting this study in Dharamsala, India. This work was supported by a Vernacular Modernities Undergraduate Foreign Project Summer Scholarship and a Patrick Stewart Human Rights Scholarship to D.C.B. C.L.R. received support from the Emory Tibet Science Initiative. Funding to D.C.B. and C.L.R. allowed collection of data in Dharamsala, India.


  1. 1.
    Avedon JF (1984) Exile from the land of snows. Knopf, New YorkGoogle Scholar
  2. 2.
    Bolton P (2001) Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. J Nerv Ment Dis 189:238–242PubMedCrossRefGoogle Scholar
  3. 3.
    Brislin RW, Lonner WJ, Thorndike RM (1973) Cross-cultural research methods. In: Holt RT, Turner JE (eds) Comparative studies in behavioral sciences. Wiley, New York, pp 32–58Google Scholar
  4. 4.
    Cheung P, Spears G (1995) Psychiatric morbidity among New Zealand Cambodians: the role of psychosocial factors. Soc Psychiatry Psychiatr Epidemiol 30:92–97PubMedCrossRefGoogle Scholar
  5. 5.
    Council P (1994) Tibetan refugee community integrated development plan II 1995–2000. Central Tibetan Administration of H.H. the Dalai Lama, Dharamsala, Himachal Pradesh, IndiaGoogle Scholar
  6. 6.
    Crescenzi A, Ketzer E, Van Ommeren M, Phuntsok K, Komproe I, de Jong JT (2002) Effect of political imprisonment and trauma history on recent Tibetan refugees in India. J Traum Stress 15:369–375CrossRefGoogle Scholar
  7. 7.
    Democracy TCfHRa. Accessed February 1, 2006
  8. 8.
    Dolma S, Singh S, Lohfeld L, Orbinski JJ, Mills EJ (2006) Dangerous journey: documenting the experience of Tibetan refugees. Am J Pub Health 96:2061–2064PubMedCrossRefGoogle Scholar
  9. 9.
    Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Wintrob R, Richman JA, Birz S (1988) Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis 176:257–263PubMedGoogle Scholar
  10. 10.
    Fox SH, Tang SS (2000) The Sierra Leonean refugee experience: traumatic events and psychiatric sequelae. J Nerv Ment Dis 188:490–495PubMedCrossRefGoogle Scholar
  11. 11.
    Halepota AA, Wasif SA (2001) Hopkins symptoms checklist 25(HSCL-25) Urdu translation: an instrument for detecting anxiety and depression in torture and trauma victims. JPMA J Pak Med Assoc 51:255–257PubMedGoogle Scholar
  12. 12.
    Hermansson AC, Timpka T, Thyberg M (2002) The mental health of war-wounded refugees: an 8-year follow-up. J Nerv Ment Dis 190:374–380PubMedCrossRefGoogle Scholar
  13. 13.
    Hesbacher PT, Rickels K, Morris RJ, Newman H, Rosenfeld H (1980) Psychiatric illness in family practice. J Clin Psychiatry 41:6–10PubMedGoogle Scholar
  14. 14.
    Holtz TH (1998) Refugee trauma versus torture trauma: a retrospective controlled cohort study of Tibetan refugees. J Nerv Ment Dis 186:24–34PubMedCrossRefGoogle Scholar
  15. 15.
    Ichikawa M, Nakahara S, Wakai S (2006) Cross-cultural use of the predetermined scale cutoff points in refugee mental health research. Soc Psychiatry Psychiatr Epidemiol 41:248–250PubMedCrossRefGoogle Scholar
  16. 16.
    Jones L (2002) Adolescent understandings of political violence and psychological well-being: a qualitative study from Bosnia Herzegovina. Soc Sci Med 55:1351–1371PubMedCrossRefGoogle Scholar
  17. 17.
    Keller A, Lhewa D, Rosenfeld B, Sachs E, Aladjem A, Cohen I, Smith H, Porterfield K (2006) Traumatic experiences and psychological distress in an urban refugee population seeking treatment services. J Nerv Ment Dis 194:188–194PubMedCrossRefGoogle Scholar
  18. 18.
    Kleijn WC, Hovens JE, Rodenburg JJ (2001) Posttraumatic stress symptoms in refugees: assessments with the Harvard Trauma Questionnaire and the Hopkins symptom Checklist-25 in different languages. Psychol Rep 88:527–532PubMedCrossRefGoogle Scholar
  19. 19.
    Mahmoudi KM (1992) Refugee cross-cultural adjustment: Tibetans in India. Int J Intercult Relat 16:17–32CrossRefGoogle Scholar
  20. 20.
    Mills EJ, Singh S, Holtz TH, Chase RM, Dolma S, Santa-Barbara J, Orbinski JJ (2005) Prevalence of mental disorders and torture among Tibetan refugees: a systematic review. BMC Int Health Hum Rights 5:1–8CrossRefGoogle Scholar
  21. 21.
    Mollica RF, McInnes K, Sarajlic N, Lavelle J, Sarajlic I, Massagli MP (1999) Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. JAMA 282:433–439PubMedCrossRefGoogle Scholar
  22. 22.
    Mollica RF, Sarajlic N, Chernoff M, Lavelle J, Vukovic IS, Massagli MP (2001) Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. JAMA 286:546–554PubMedCrossRefGoogle Scholar
  23. 23.
    Mollica RF, Wyshak G, de Marneffe D, Khuon F, Lavelle J (1987) Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry 144:497–500PubMedGoogle Scholar
  24. 24.
    Rasekh Z, Bauer HM, Manos MM, Iacopino V (1998) Women’s health and human rights in Afghanistan. JAMA 280:449–455PubMedCrossRefGoogle Scholar
  25. 25.
    Sack WH, Clarke G, Him C, Dickason D, Goff B, Lanham K, Kinzie JD (1993) A 6-year follow-up study of Cambodian refugee adolescents traumatized as children. J Am Child Adolesc Psychiatry 32:431–437CrossRefGoogle Scholar
  26. 26.
    Sandanger I, Moum T, Ingebrigtsen G, Dalgard OS, Sorensen T, Bruusgaard D (1998) Concordance between symptom screening and diagnostic procedure: the Hopkins Symptom Checklist-25 and the composite international diagnostic interview I. Soc Psychiatry Psychiatr Epidemiol 33:345–354PubMedCrossRefGoogle Scholar
  27. 27.
    Servan-Schreiber D, Le Lin B, Birmaher B (1998) Prevalence of posttraumatic stress disorder and major depressive disorder in Tibetan refugee children. J Am Child Adolesc Psychiatry 37:874–879CrossRefGoogle Scholar
  28. 28.
    Shrestha NM, Sharma B, Van Ommeren M, Regmi S, Makaju R, Komproe I, Shrestha GB, de Jong JT (1998) Impact of torture on refugees displaced within the developing world: symptomatology among Bhutanese refugees in Nepal. JAMA 280:443–448PubMedCrossRefGoogle Scholar
  29. 29.
    Silove D, Steel Z, Bauman A, Chey T, McFarlane A (2007) Trauma, PTSD and the longer-term mental health burden amongst Vietnamese refugees : a comparison with the Australian-born population. Soc Psychiatry Psychiatr Epidemiol 42:467–476PubMedCrossRefGoogle Scholar
  30. 30.
    Tang SS, Fox SH (2001) Traumatic experiences and the mental health of Senegalese refugees. J Nerv Ment Dis 189:507–512PubMedCrossRefGoogle Scholar
  31. 31.
    Terheggen MA, Stroebe MS, Kleber RJ (2001) Western conceptualizations and Eastern experience: a cross-cultural study of traumatic stress reactions among Tibetan refugees in India. J Traum Stress 14:391–403CrossRefGoogle Scholar
  32. 32.
    Thapa SB, Hauff E (2005) Psychological distress among displaced persons during an armed conflict in Nepal. Soc Psychiatry Psychiatr Epidemiol 40:672–679PubMedCrossRefGoogle Scholar
  33. 33.
    Yehuda R, Halligan SL, Bierer LM (2001) Relationship of parental trauma exposure and PTSD to PTSD, depressive and anxiety disorders in offspring. J Psychiatr Res 35:261–270PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Dabney Evans
    • 1
  • David C. Buxton
    • 2
  • Andrey Borisov
    • 3
  • Amita K. Manatunga
    • 4
  • Dawa Ngodup
    • 5
  • Charles L. Raison
    • 3
    Email author
  1. 1.Institute of Human RightsEmory UniversityAtlantaUSA
  2. 2.VCU School of MedicineVirginia Commonwealth UniversityRichmondUSA
  3. 3.Dept. of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlantaUSA
  4. 4.Dept. of Biostatistics, Rollins School of Public HealthEmory UniversityAtlantaUSA
  5. 5.Tibetan Children’s VillagesKangraIndia

Personalised recommendations