Psychoses, PTSD, and depression in Somali refugees in Minnesota

Original Paper



Initial clinical observation of Somali patients seen at a busy inner-city community clinic (CUHCC) suggested that, in addition to the expected pictures of Posttraumatic Stress Disorder (PTSD) and depression previously seen in the clinic’s Southeast Asian refugee population from 1980 to 2000, there was an unusually high number of young Somali men presenting with acute psychotic disturbances.


The aim of this study of health care utilization of Somali refugees (N = 600) seen in the mental health unit of the clinic from 2001 to 2009 was to investigate the major patterns of psychiatric disorders in this outpatient population and compare these findings with a cohort of non-Somali patients (N = 3,009) seen at the same outpatient clinic during the years 2007–2009. If the results supported the initial clinical observations that the rate of psychoses was higher among young Somali men than non-Somali men attending CUHCC clinic, then several areas of further research would recommend itself. First, since this study was not a study of prevalence of mental illness in the Somali community, the next step would be to undertake a study of community prevalence of mental illness among different age and gender cohorts. Second, further research should look into likely causative and contributory risk factors to explain the development of psychoses among Somali young men.


Somali and non-Somali patients were diagnosed according to DSM-IV-R criteria. Main outcome measures (diagnoses, age cohort, sex) were analyzed by Chi-square tests. Patterns of illness and adjustment varied significantly by age and gender cohorts, reflecting the relevance of age and gender at time of trauma on different trauma and loss experiences and cultural and religious shaping of subsequent adjustment and symptoms.


The study confirmed that almost half of the Somali male patients are under age 30, 80% of whom presented with psychoses, compared with the rate of psychosis (13.7%) in the non-Somali control group of same-aged males at the clinic. The older male, and the majority of Somali female patients, show predominantly depressive and PTSD symptomatology.


War trauma experienced in childhood, early malnutrition from famines, head trauma, and excess Khat use in male adolescents provide partial explanations for the large number of young psychotic Somali men seen in the clinic from 2001 to 2009.


Somali refugees Psychoses PTSD Khat Refugee mental health 


  1. 1.
    Population Notes, Minnesota State Demographics Center, June 2004. Accessed 23 December 2009
  2. 2.
    Lewis IM (2002) A modern history of the Somali, 4th edn. Ohio University Press, AthensGoogle Scholar
  3. 3.
    Besteman C (1999) Unraveling Somalia: race, violence and the legacy of slavery. University of Pennsylvania Press, PhiladelphiaGoogle Scholar
  4. 4.
    Feyissa AM, Kelly JP (2008) A review of the neuropharmacological properties of khat. Prog Neuropsychopharmacol Biol Psychiatry 32:1147–1166PubMedCrossRefGoogle Scholar
  5. 5.
    Al-Motarreb A, Baker K, Broadley KJ (2002) Khat: pharmacological and medical aspects and its social use in Yemen. Phytother Res 16:403–413PubMedCrossRefGoogle Scholar
  6. 6.
    Cox G, Rampes H (2003) Adverse effects of khat: a review. Adv Psychiatr Treat 9:456–463CrossRefGoogle Scholar
  7. 7.
    Anthony C (2009) Africa’s displaced peoples: State-building realpolitik and stunted globalization. Harvard Int Rev 31(3):50–54Google Scholar
  8. 8.
    The 2009 HHS Poverty Guidelines. Federal Register Notice, 23 Jan 2009. Accessed 11 November 2009
  9. 9.
    Al-Saffar S, Borga P, Edman G, Hallstrom T (2003) The aetiology of posttraumatic stress disorder in four ethnic groups in outpatient psychiatry. Soc Psychiatry Psychiatr Epidemiol 38:456–462PubMedCrossRefGoogle Scholar
  10. 10.
    Yeomans PD, Herbert JD, Forman EM (2008) Symptom comparison across multiple solicitation methods among Burundians with traumatic event histories. J Trauma Stress 21:231–234PubMedCrossRefGoogle Scholar
  11. 11.
    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
  12. 12.
    Bhui K, Abdi A, Abdi M, Pereira S, Dualeh M, Robertson D, Sathyamoorthy G, Ismail H (2003) Traumatic events, migration characteristics and psychiatric symptoms among Somali refugees. Soc Psychiatry Psychiatr Epidemiol 38:35–43PubMedCrossRefGoogle Scholar
  13. 13.
    Kroll J (2003) Posttraumatic symptoms and the complexity of responses to trauma. JAMA 290:667–670PubMedCrossRefGoogle Scholar
  14. 14.
    Briggs L, Macleod AD (2006) Demoralisation—a useful conceptualization of non-specific psychological distress among refugees attending mental health services. Int J Soc Psychiatry 52:512–524PubMedCrossRefGoogle Scholar
  15. 15.
    Scuglik DL, Alarcon RD, Lapeyre AC, Williams MD, Logan KM (2007) When the poetry no longer rhymes: mental health issues among Somali immigrants in the USA. Transcult Psychiatry 44:581–595PubMedCrossRefGoogle Scholar
  16. 16.
    Kroll J, Habenicht M, Mackenzie T, Yang M, Chan S, Vang T, Nguyen T, Ly M, Phommasouvanh B, Nguyen H, Vang Y, Cabugao R (1989) Depression and post-traumatic stress disorder in Southeast Asian refugees. Am J Psychiatry 146:1592–1597PubMedGoogle Scholar
  17. 17.
    Ellis BH, MacDonald HZ, Lincoln AK, Cabral HJ (2008) Mental health of Somali adolescent refugees: the role of trauma, stress, and perceived discrimination. J Consult Clin Psychol 76:184–193PubMedCrossRefGoogle Scholar
  18. 18.
    Odenwald M, Schauer M, Neuner F, Lingenfelder B, Horn R, Catani C, Klaschik C, Elbert T (2002) War trauma, Khat abuse and psychosis: mental health in the demobilization and reintegration program Somaliland. Final Report of the vivo mission 2 within the EC/GTZ, Sept–Nov. Accessed 27 August 2006
  19. 19.
    Bhui K, Warfa N (2007) Drug consumption in conflict zones in Somalia. PLoS Med 4(12):e354. doi:10.1371/journal.pmed.0040354 PubMedCrossRefGoogle Scholar
  20. 20.
    Odenwald M, Hinkle H, Schauer E, Neuner F, Schauer M, Elbert TR, Rockstroh B (2007) The consumption of Khat and other drugs in Somali combatants: a cross-sectional study. PLoS Med 4(12):e341. doi:10.1371/journal.pmed.0040341 PubMedCrossRefGoogle Scholar
  21. 21.
    Odenwald M, Hinkle H, Schauer E, Schauer M, Elbert TR, Neuner F, Rockstroh B (2009) Use of khat and posttraumatic stress disorder as risk factors for psychotic symptoms: a study of Somali combatants. Soc Sci Med 69:1040–1048PubMedCrossRefGoogle Scholar
  22. 22.
    Bhui K, Craig T, Mohamud S, Warfa N, Standfeld SA, Thornicroft G, Curtis S, McCrone P (2006) Mental disorders among Somali refugees: developing culturally appropriate measures and assessing socio-cultural risk factors. Soc Psychiatry Psychiatr Epidemiol 41:400–408PubMedCrossRefGoogle Scholar
  23. 23.
    Mavreas V, Bebbington P (1989) Does the act of immigration provoke psychiatric breakdown? A study of Greek Cypriote immigrants. Acta Psychiatrica Scand 80:469–473CrossRefGoogle Scholar
  24. 24.
    Selten JP, Sijben N (1994) First admission rates for schizophrenia in immigrants to the Netherlands: the Dutch National Registrar. Soc Psychiatry Psychiatr Epidemiol 29:71–77PubMedGoogle Scholar
  25. 25.
    Cantor-Graae E, Pedersen CB, McNeil TF, Mortensen PB (2003) Migration as a risk factor for schizophrenia: a Danish population based cohort study. Br J Psychiatry 182:117–122PubMedCrossRefGoogle Scholar
  26. 26.
    Leao TS, Sundquist J, Frank G, Johansson L-M, Johansson E-S, Sundquist K (2006) Incidence of schizophrenia or other psychoses in first-and second-generation immigrants, a national cohort study. J Nerv Ment Dis 194:27–33PubMedCrossRefGoogle Scholar
  27. 27.
    Coid JW, Kirkbride JB, Barker D, Cowden F, Stamps R, Yang M, Jones PB (2008) Raised incidence rates of all psychoses among migrant groups. Arch Gen Psychiatry 65:1250–1258PubMedCrossRefGoogle Scholar
  28. 28.
    Lataster T, Van Os J, Drukker M, Henquet C, Feron F, Gunther N, Myin-Germeys I (2006) Childhood victimization and developmental expression of non-clinical delusional ideation and hallucinatory experiences: victimization and non-clinical psychotic experiences. Social Psychiatry Psychiatr Epidemiol 41:423–428CrossRefGoogle Scholar
  29. 29.
    Kilcommons AM, Morrison AP (2005) Relationships between trauma and psychosis: an exploration of cognitive and dissociative factors. Acta Psychiatr Scand 112:351–359PubMedCrossRefGoogle Scholar
  30. 30.
    Shevlin M, Dorahy MJ, Adamson G (2007) Trauma and psychosis: an analysis of the National Comorbidity Study. Am J Psychiatry 164:166–169PubMedCrossRefGoogle Scholar
  31. 31.
    Moore THM, Zammit S, Lingford-Hughes A, Barnes TRE, Jones PB, Burke M, Lewis G (2007) Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet 370:319–328PubMedCrossRefGoogle Scholar
  32. 32.
    Degenhardt L, Hall W (2006) Is cannabis use a contributory cause of psychosis? Can J Psychiatry 51:556–565PubMedGoogle Scholar
  33. 33.
    Degenhardt L, Tennant C, Gilmour S, Schofield D, Nash L, Hall W, McKay D (2007) The temporal dynamics of relationships between cannabis, psychosis and depression among young adults with psychotic disorders: findings from a 10-month prospective study. Psychol Med 37:927–934PubMedCrossRefGoogle Scholar
  34. 34.
    Henquet C, Krabbendam L, Spauwen J, Kaplan C, Lieb R, Wittchen H-U, van Os J (2005) Prospective cohort study of cannabis use, predisposition for psychosis, and psychotic symptoms in young people. Br Med J 330:11–14CrossRefGoogle Scholar
  35. 35.
    Schweinsburg AD, Brown SA, Tapert SF (2008) The influence of marijuana use on neurocognitive functioning in adolescents. Curr Drug Abuse Rev 1:99–111PubMedGoogle Scholar
  36. 36.
    Warfa N, Klein A, Bhui K, Leavey G, Craig T, Stansfeld A (2007) Khat use and mental illness: a critical review. Soc Sci Med 65:309–318PubMedCrossRefGoogle Scholar
  37. 37.
    Odenwald M (2007) Chronic khat use and psychotic disorder: a review of the literature and future prospects. Sucht 53:9–22Google Scholar
  38. 38.
    Randall T (1993) Khat abuse fuels Somali conflict, drains economy. JAMA 269:12–13PubMedCrossRefGoogle Scholar
  39. 39.
    Susser E, Neugebauer R, Hoek HW, Brown AS, Lin S, Labovitz D, Gorman JM (1996) Schizophrenia after prenatal famine. Arch Gen Psychiatry 53:25–31PubMedGoogle Scholar
  40. 40.
    St. Clair D, Xu M, Wang P, Yu Y, Fang Y, Zhang F, Zheng X, Gu N, Feng G, Sham P, He L (2005) Rates of adult schizophrenia following prenatal exposure to the Chinese famine of 1959–61. JAMA 294:557–562PubMedCrossRefGoogle Scholar
  41. 41.
    McClennan JM, Susser E, King M-C (2006) Maternal famine, de novo mutations, and schizophrenia. JAMA 296:582–584CrossRefGoogle Scholar
  42. 42.
    Internal Displacement Monitoring Centre (iDMC): Somalia: Window of opportunity for addressing one of the world’s worst internal displacement crises. 10 January 2006, Accessed 23 August 2006
  43. 43.
    Sargent J, Michael K (2005) The need for a digital aid framework in humanitarian relief. The 9th World Multi-Conference on Systematics, Cybernetics and Informatics, Orlando, FL, 10–13 July 2005. Accessed 26 August 2006
  44. 44.
    IRINnews: Somalia. All-out war catastrophic for southern Somalia––famine watchdog. 12 January 2007. Accessed 12 January 2007
  45. 45.
    Patman RG (1997) Disarming Somalia: the contrasting fortunes of US and Australian peacekeepers during UN intervention 1992–93. Afr Aff 96:509–533Google Scholar
  46. 46.
    Moore PS, Marfin AA, Quenemoen LE, Gessner BD, Ayub YS, Miller DS, Sullivan KM, Toole MJ (1993) Mortality rates in displaced and resident populations of central Somalia during 1992 famine. Lancet 341:935–938PubMedCrossRefGoogle Scholar
  47. 47.
    Seal AJ, Creeke PI, Mirghani Z, Abdalla F, McBurney RP, Pratt LS, Brookes D, Ruth LJ, Marchand E (2005) Iron and vitamin A deficiency in long-term African refugees. J Nutr 135:808–813PubMedGoogle Scholar
  48. 48.
    Collins S, Myatt M (2000) Short-term prognosis in severe adult and adolescent malnutrition during famine. JAMA 284:621–626PubMedCrossRefGoogle Scholar
  49. 49.
    McGrath J (1999) Hypothesis: is low prenatal vitamin D a risk-modifying factor for schizophrenia? Schizophrenia Res 40:173–177CrossRefGoogle Scholar
  50. 50.
    Dealburto MJ (2007) Why are immigrants at increased risk for psychosis? Vitamin D insufficiency, epigenetic mechanisms, or both? Med Hypotheses 68:259–267CrossRefGoogle Scholar
  51. 51.
    Insel BJ, Schaefer CA, McKeague IW, Susser ES, Brown AS (2008) Maternal iron deficiency and the risk of schizophrenia in offspring. Arch Gen Psychiatry 65:1136–1144PubMedCrossRefGoogle Scholar
  52. 52.
    Onyut LP, Neuner F, Ertl V, Schauer E, Odenwald M, Elbert T (2009) Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement––an epidemiological study. Confl Health 3. doi:10.1186/1752-1505-3-6 (electronic version)
  53. 53.
    Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC (1998) The mini-international neuropsychiatric interview (MINI): the development and validation of a structured diagnostic interview for DSM-IV and ICD-10. J Clin Psychiatry 59(20):22–33PubMedGoogle Scholar
  54. 54.
    Gerritsen AAM, Bramsen I, Deville W, van Willigen LHM, Hovens JE, vander Ploeg HM (2006) Physical and mental health of Afghan, Iranian, and Somali asylum seekers and refugees living in the Netherlands. Soc Psychiatry Psychiatr Epidemiol 41:18–26PubMedCrossRefGoogle Scholar
  55. 55.
    Silove D, Steel Z, Bauman A, Chey T, McFarlane A (2007) Trauma, PTSD and the longer-term mental health burden amongst Vietnamese refugees. Soc Psychiatry Psychiatr Epidemiol 42:467–476PubMedCrossRefGoogle Scholar
  56. 56.
    Al-Saffar S, Borga P, Hallstrom T (2002) Long-term consequences of unrecognized PTSD in general outpatient psychiatry. Soc Psychiatry Psychiatr Epidemiol 37:580–585PubMedCrossRefGoogle Scholar
  57. 57.
    Cougnard A, Marcelis M, Myin-Germeys I, De Graaf R, Vollebergh W, Krabbendam L, Lieb R, Wittchen HU, Henquet C, Spauwen J, Van Os J (2007) Does normal developmental expression of psychosis combine with environmental risk to cause persistence of psychosis? A psychosis proneness-persistence model. Psychol Med 37:513–527PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Jerome Kroll
    • 1
  • Ahmed Ismail Yusuf
    • 1
  • Koji Fujiwara
    • 2
  1. 1.Community-University Health Care Clinic, University of Minnesota Medical SchoolMinneapolisUSA
  2. 2.Duluth Medical Research InstituteUniversity of Minnesota Medical SchoolDuluthUSA

Personalised recommendations