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Depression among vietnamese refugees in a primary care clinic
Depression among Vietnamese Refugees in a Primary Care Clinic
ELIZABETH
HIOK-BOON
LIN,
M.D.,
M.P.H. LOREN
J.
LAURIE
TAZUMA,
IHLE,
Seattle,
Washington
B.A. M.D.
From the Department of Family Medicine, UniversityofWashingtonSchoolofMsdicine,andthe lnternstional District Community Health Center, Seattle, Washington. Dr. Lin was a Robert Woad Johnson Faculty Development Fellow in Family Medicine at the time of this study. Requests for reprints should be addressed to Dr. Elizabeth Hiok-Soon Lin. Department of Health Services, X-37, Unlverslty of Washington School of Public Health and Community Medicine, Seattle, Washington, 98195. Manuscript accepted July 8, 1984.
Refugees are at high risk for mental disorders and manlfest cultural Influences In their health behavior. The Vietnamese Depression Scale was admlnlstered to Vietnamese patients at a community clinic to assess the underlying prevalence of depresslon. The rate of accurate dlagnosls and the manlfestatlons of depression were also examined. A hlgh prevalence of depresslon (52 percent) and a hlgh level of underdlagnosls (56 percent) by primary care physlclans were found. Nlnety-flve percent of these patlents presented with physkal symptoms. Compared wlth patlents who had negative depresslon scores, those who had poeltlve depresslon scores were morellkelytobedderandsougMcareatthedkdcmore~equentty. These flndlngs underscoretheknportanceofdepreselonasanurgent health problem among Vletnamese refugees In primary care. Accuracy In dlagnosls can be Improved by using the Vletnamese Depression Scale and constltutes the first step toward effective treatment. . More than 600,000 refugees from Vietnam, Laos, and Cambodii have resettled in the United States since 1975. The harrowing experience surrounding forced migration, the unfamiliar so&cultural environment of the host country, and the self-selection of migrants in whom mental disorders may be more likely to develop have been cited as responsible for an observed association between migration and increased mental disorders [ 1,2]. Most of the research on the health problems of Southeast Asian refugees has focused on physical illnesses such as infectious disease and hernatologlc disorders [3,4] or on adjustment difficulties and dysfunctions [ 5-71. Even though earlier diagnostic surveys reported relatively low prevalence of depression in the primary care setting for the Indochinese populations, several investigators predicted that there may be a delayed appearance of psychiatric disorders [7-g]. A high prevalence of depression (40 percent [lo]) had been reported for Vietnamese patients in the psychiatric setting. Our clinical experience with Indochinese refugees suggested that a large proportion of the depressed patients presented with physical symptoms and that many of these may be misdiagnosed. The association of somatization and depression has been reported by Kleinman [l l] for Chinese patients and by Goldberg and Blackwell [12] for Briiish patients. Underdiignosis occurs when patients focus on somatic symptoms and the physicians rely solely on the biomedical model. We screened Vietnamese patients In a primary care setting to assess the underlying prevalence of depression, the rate of detection, the frequency of clinic utilization, the mode of presentation, and patient characteristics related to depression.
January
1985
The American
Journal
of Medlclna
Volume
78
41
DEPRESSION
IN VIETNAMESE
REFUGEES-LIN
ET AL
PATIENTS AND METHODS
RESULTS
This study was conducted at the International District Community Health Center, a nonprofit, community-based clinic primarily serving the Asian/Pacific Islander population of Seattle, Washington, and surrounding King County. Ninety-five percent of the patients are of Chinese, Filipino, Vietnamese, Laotian, Khmer, Korean, and Samoan descent. Sixty percent are refugees, and the majority are low-income patients who do not speak English. The health care staff members are multicultural and provide care in 12 different languages and dialects. Between March 15 and May 151983, Vietnamese patients over 18 years of age who sought medical care at the clinic were asked to complete the Vietnamese Depression Scale in the waiting room before seeing the clinician. The Vietnamese Depression Scale, developed by Kinzie et al [ 131, is an l&item, self-report questionnaire in Vietnamese resembling English-language instruments such as the Beck Depression Inventory [14] and the Zung Self-Rating Depression Scale [ 151. With special attention to the crosscultural differences in the expression of depression, the authors based the scale on depressive symptoms characteristic of Vietnamese perceptions. The Vietnamese Depression Scale has been validated on the basis of DSM Ill criteria with a sensitivity of 91 percent and a specificity of 95 percent [131. lnfcrtned consent was obtained after the nature of the study and the Vietnamese Depression Scale were fully explained to the patients in Vietnamese. No eligible subjects refused to participate. When the clinic was busy, however, some patients did not receive the questionnaire. Of 130 potential responses, 80 completed questionnaires were obtained initially. In order to determine whether the “overlocked” patients were comparable to the sample group, half of the patients whc had inadvertently been omitted were contactad by phone and asked to come to the clinic to complete the questionnaire. Almost 50 percent of those contacted agreed to return to tha clinic to complete the questionnaire. An additional 12 responses were obtained in this way, yielding a total of 92 responses or 70 percent of eligible subjects. Clinical recognition of depression was determined by chart review. Whenever tha diagnosis of depression was manticned in tha progress notes or problem list for the two-month paricd under study, a clinical confirmation was recorded. For each clinic visit, the patient’s presenting complaints, diagnoses, and laboratory results were recorded by the clinician on an encounter form. Social and demographic information, including age, sex, duration of residence in United States, residence status, English-language proficiency, marital status, family composition, patient’s arnployrnant, and enrollment in schools, was obtained from the patient’s
The initial sample and the “resample” were similar with respect to the demographic characteristics (such as age, sex, income, and so on) and the depression scores. Therefore, these two groups were combined in the subsequent analysis. Demographic Characteristics. This relatively young group of refugees (mean age 39 years) had been in the United States for about three and a half years. The majority of them were limited in English proficiency and needed translation (82.1 percent). Even though their educational background was diverse, ranging from elementary school through professional training, only 8.3 percent were employed and 7.1 percent were enrolled in school. More than half were female (58.3 percent), and 82.7 percent were married. For an average household size of 3.5 persons, the monthly income was $575. Depression Scores. Soores above 13 were considered positive and indicative of depression. The mean score was 13.8, with a minimum of 0 and maximum of 34 and a standard deviation of 8.8. The prevalence of positive scores for depression in this sample was 50 percent. An estimate of the prevalence of depression in this population was obtained by correcting the frequency of positive scores to account for characteristics of the screening test [ 181. This yielded an estimated prevalence of 52 percent. This high rate of positive scores on the depression scale led to concern about potential false-positive scores. Subsequently, subjects with positive depression scores were stratified into quartiles, and two patients were randomly picked from each quartile. The last subject was chosen randomly from one of the four quartiles. These nine subjects constituted 19.8 percent of all patients with positive depression scores and were evaluated by a psychiatrist (L.T.) using a modified SADS (Schedule of Affective Disorders and Schizophrenia) interview [ 171. This interview assessed the presence of psychiatric symptoms and categorized the symptoms according to DSM Ill criteria for affective, anxiety, and schizophrenic disorders. Seven of the nine patients evaluated by SADS interview still showed major depression when they were interviewed four to six months after the Vietnamese Depression Scale was administered. In another, major depression was diagnosed three months before the interview and was treated successfully with antidepressants. She could not recall her symptoms prior to treatment. Review of her chart revealed that she most likely had major depression. The other subject had severe mental retardation that was accompanied by depression and psychotic symptoms. Thus, eight of the nine subjects interviewed, or 88.9 percent, were con-
Chart.
The chief complaints, patient characteristics, diagnoses, and depression scores were recorded. Statisticalsignificance was tested by &&square tests, McNernar’s tests, and multiple regression analysis to assess the relationship between the independent variables (social and demographic characteristics and chief complaints) and the dependent variable (depression score).
42
January
1985
The American
Journal
of Medicine
Volume
78
DEPRESSlON
firmed to have major depression. The other had a combination of depression and mixed organic brain syndrome. Comparison of Depression Scores wlth Clinic Records. Clinical notation of the diagnosis or treatment of depression was compared with depression score (Table I). It is evident that the prevalence of recorded diagnoses of depression in the subjects’ charts (23 percent) was much lower than the prevalence of depression as measured by the depression scale. Nearly all of the discordant pairs had a positive diagnosis by the questionnaire but were missed in the clinic setting (p
January
TABLE I
IN VIETNAMESE
REFUGEES-LIN
ET AL
Comparison of Depression Scores wlIh Cllnlcal Records Dspressknl Diagnoals Incharl
TCF Positive Negative Total
YeS
No
20 1 21(23%)
26 45 71(77%)
Total 46 (50%) 46 (50%) 92 (100%)
Continuous variables such as age were divided into quartiles. Because of the number of chi-square tests performed on this sample, a conservative p value (p
1995
The American
Journal
ol Medlclne
Volume
79
43
DEPRESSION
IN VIETNAMESE
REFUGEES-LIN
ET AL
The reported under-utilization of psychiatric services by mentally ill Indochinese refugees patients [19] mirrors the high prevalence of depression in primary care. This under-utilization of psychiatric services and underdiagnosis of depression in primary care create a double-edged phenomenon and illustrate the cultural shaping of the expression of depression and the pattern of health care utilization. In cultures in which psychologization is stigmatized, the acceptable copying style will result in the suppression and denial of the psychological components of distress and the expression of physiologic aspects of distress [I 11. Thus, patients with emotional disorders can be expected to avoid psychiatric facilities and articulate their distress through a physical idiom in a primary care setting. It is uncertain how well our findings can be generalized outside of the community clinic setting as these patients were poor, unemployed, and limited in English proficiency. A larger and more diverse sample followed up for a longer period of time would provide more generalizable findings. Nevertheless, the high prevalence of depression, the low rate of clinical detection, and the high clinic utilization by depressed patients who
1. 2. 3. 4.
0: Emigration and insanity: a study of mental diseases among the Norwegm populatbn of Minnesota. Acta Psychiatr Stand 1932; 4 (suppl): 1-206. Hull D: Ml@ion, adaptagon and illness: a review. Sot Scl Med 1979; 13A: 25-36. Health status of lndochlnese refugees: malaria and hepatitis B. Morbid Mortal Weeklv Reo 1979: 28: 463-470 Cantanzaro A, Mozer R: Health’status of refugees from Vietnam, Laos, and Cambodia. JAMA 1982; 247: 1303-
present with somatic symptoms all emphasize the urgency of this important health problem in primary care. The Vietnamese Depression Scale provides a simple and effective diagnostic tool to improve the detection of depression. Our findings suggest that this instrument should become a routine assessment tooi in clinics with significant numbers of Vietnamese patients and should be used to evaluate any Vietnamese patient in primary care whose physical complaints and utilization are not well explained and in whom somatization is suspected. Research findings documenting the efficacy of therapy for depression [20] further underscore the importance of these findings as treatment of depression is associated with a reduction in the somatic symptoms, an improvement in depression, and a decrease in clinic utilization for depression. ACKNOWLEDGMENT
We are indebted to the staff at the International District Community Health Center, Seattle, for their assistance. Drs. ‘Wayne Katon, William Carter, Al Berg, Marjorie Muecke, David Kinzie, and Arthur Kleinman provided invaluable suggestions.
Odegaard
13.
1308. 5.
Ngyen
SD: Psychiatric
Southeast
Asian
and psy chosomatlc
refugees.
Psychiatr
problems
J Univ Ottawa
among
14.
1982;
7: 163-172. 6. 7.
a. 9.
10.
Sutherland JE, Avant RF, Franz WB Ill, Monzon CM, Stark NM: Indochinese refugee health assessment and treatment. J Fam Pratt 1983; 16: 61-67. Muecke MA: In search of healers: Southeast Asian refugees in the American health care system. West J Med 1983; 139: 835-641. Lin KM, Tazuma L, Minoru M: Adaptational problems of Vletnamese refugees I. Health and mental health status. Arch Gen Psychiatry 1979; 36: 955-961. Ed&son RV, Ho&g GN: Health problems among Indochinese refuoees. Am J Public Health 1980; 70: 1003-1006. Kinzie jD, Tran AK, Breckenridge A, Bloom JD: An Indochinese refugee psychiatric clinic: culturally accepted treatment approaches. Am J Psychiatry 1960; 137: 1429-
15. 16. 17.
ia. 19.
20.
1432.
44
January 1965
The American Journal of Medlclne
Volume 76
Klelnman AM: Neurasthenia and depression: a study of so matizatlon and cutture in China. Cult Med Psychlaby 1982; 6: 117-190. Goldberg DP, Blackwell B: Psychiatric illness in general practice. A detailed study using a new method of case Mentiflcatlon. Br Med J 1970; 2: 439-443. Kinzle JD, Manson SM, Vlnh DT, Nguyen TT, Anh B. Pho TN: Development and valkfatlon of a Vietnamese-languege depression rating scale. Am J Psychiatry 1982; 139: 1276-1261. BeckAT.BeamesderferA:Anesseasmentofdspressbn.The mgm. Mcd Probl1974; Zu&JW:nseif~deprassionscsle.ArchGsnPsych&y 196% 12: 63-70. Rogan W, Gladen B: Estknatlng prevalence from the results of a screening test. Am J Epklemiol1978; 107: 71-76. Endicott J, Spltzer RL: Dlagnostlc interview. The schedule for affective disorders and schizophrenia-life-time version. Arch Ben Psychiatry 1978; 35: 837-644. Katon W: Depresslon: somatic symptoms and medical dlsorders in primary care. Compr Psychiatry 1982; 23: 274-286. Miller B, Chambem EB, Coleman CM: Indochinese refugees: natlonelmentalhealthneedsessessment. Mlqatkx~ Today 1981; 9: 26-31. Widmer RB, Cadoret RJ: Depression: the great imltator in family practice. J Fam Pratt 19e3; II: 465-505.
ELIZABETH
HIOK-BOON
LIN,
M.D.,
M.P.H. LOREN
J.
LAURIE
TAZUMA,
IHLE,
Seattle,
Washington
B.A. M.D.
From the Department of Family Medicine, UniversityofWashingtonSchoolofMsdicine,andthe lnternstional District Community Health Center, Seattle, Washington. Dr. Lin was a Robert Woad Johnson Faculty Development Fellow in Family Medicine at the time of this study. Requests for reprints should be addressed to Dr. Elizabeth Hiok-Soon Lin. Department of Health Services, X-37, Unlverslty of Washington School of Public Health and Community Medicine, Seattle, Washington, 98195. Manuscript accepted July 8, 1984.
Refugees are at high risk for mental disorders and manlfest cultural Influences In their health behavior. The Vietnamese Depression Scale was admlnlstered to Vietnamese patients at a community clinic to assess the underlying prevalence of depresslon. The rate of accurate dlagnosls and the manlfestatlons of depression were also examined. A hlgh prevalence of depresslon (52 percent) and a hlgh level of underdlagnosls (56 percent) by primary care physlclans were found. Nlnety-flve percent of these patlents presented with physkal symptoms. Compared wlth patlents who had negative depresslon scores, those who had poeltlve depresslon scores were morellkelytobedderandsougMcareatthedkdcmore~equentty. These flndlngs underscoretheknportanceofdepreselonasanurgent health problem among Vletnamese refugees In primary care. Accuracy In dlagnosls can be Improved by using the Vletnamese Depression Scale and constltutes the first step toward effective treatment. . More than 600,000 refugees from Vietnam, Laos, and Cambodii have resettled in the United States since 1975. The harrowing experience surrounding forced migration, the unfamiliar so&cultural environment of the host country, and the self-selection of migrants in whom mental disorders may be more likely to develop have been cited as responsible for an observed association between migration and increased mental disorders [ 1,2]. Most of the research on the health problems of Southeast Asian refugees has focused on physical illnesses such as infectious disease and hernatologlc disorders [3,4] or on adjustment difficulties and dysfunctions [ 5-71. Even though earlier diagnostic surveys reported relatively low prevalence of depression in the primary care setting for the Indochinese populations, several investigators predicted that there may be a delayed appearance of psychiatric disorders [7-g]. A high prevalence of depression (40 percent [lo]) had been reported for Vietnamese patients in the psychiatric setting. Our clinical experience with Indochinese refugees suggested that a large proportion of the depressed patients presented with physical symptoms and that many of these may be misdiagnosed. The association of somatization and depression has been reported by Kleinman [l l] for Chinese patients and by Goldberg and Blackwell [12] for Briiish patients. Underdiignosis occurs when patients focus on somatic symptoms and the physicians rely solely on the biomedical model. We screened Vietnamese patients In a primary care setting to assess the underlying prevalence of depression, the rate of detection, the frequency of clinic utilization, the mode of presentation, and patient characteristics related to depression.
January
1985
The American
Journal
of Medlclna
Volume
78
41
DEPRESSION
IN VIETNAMESE
REFUGEES-LIN
ET AL
PATIENTS AND METHODS
RESULTS
This study was conducted at the International District Community Health Center, a nonprofit, community-based clinic primarily serving the Asian/Pacific Islander population of Seattle, Washington, and surrounding King County. Ninety-five percent of the patients are of Chinese, Filipino, Vietnamese, Laotian, Khmer, Korean, and Samoan descent. Sixty percent are refugees, and the majority are low-income patients who do not speak English. The health care staff members are multicultural and provide care in 12 different languages and dialects. Between March 15 and May 151983, Vietnamese patients over 18 years of age who sought medical care at the clinic were asked to complete the Vietnamese Depression Scale in the waiting room before seeing the clinician. The Vietnamese Depression Scale, developed by Kinzie et al [ 131, is an l&item, self-report questionnaire in Vietnamese resembling English-language instruments such as the Beck Depression Inventory [14] and the Zung Self-Rating Depression Scale [ 151. With special attention to the crosscultural differences in the expression of depression, the authors based the scale on depressive symptoms characteristic of Vietnamese perceptions. The Vietnamese Depression Scale has been validated on the basis of DSM Ill criteria with a sensitivity of 91 percent and a specificity of 95 percent [131. lnfcrtned consent was obtained after the nature of the study and the Vietnamese Depression Scale were fully explained to the patients in Vietnamese. No eligible subjects refused to participate. When the clinic was busy, however, some patients did not receive the questionnaire. Of 130 potential responses, 80 completed questionnaires were obtained initially. In order to determine whether the “overlocked” patients were comparable to the sample group, half of the patients whc had inadvertently been omitted were contactad by phone and asked to come to the clinic to complete the questionnaire. Almost 50 percent of those contacted agreed to return to tha clinic to complete the questionnaire. An additional 12 responses were obtained in this way, yielding a total of 92 responses or 70 percent of eligible subjects. Clinical recognition of depression was determined by chart review. Whenever tha diagnosis of depression was manticned in tha progress notes or problem list for the two-month paricd under study, a clinical confirmation was recorded. For each clinic visit, the patient’s presenting complaints, diagnoses, and laboratory results were recorded by the clinician on an encounter form. Social and demographic information, including age, sex, duration of residence in United States, residence status, English-language proficiency, marital status, family composition, patient’s arnployrnant, and enrollment in schools, was obtained from the patient’s
The initial sample and the “resample” were similar with respect to the demographic characteristics (such as age, sex, income, and so on) and the depression scores. Therefore, these two groups were combined in the subsequent analysis. Demographic Characteristics. This relatively young group of refugees (mean age 39 years) had been in the United States for about three and a half years. The majority of them were limited in English proficiency and needed translation (82.1 percent). Even though their educational background was diverse, ranging from elementary school through professional training, only 8.3 percent were employed and 7.1 percent were enrolled in school. More than half were female (58.3 percent), and 82.7 percent were married. For an average household size of 3.5 persons, the monthly income was $575. Depression Scores. Soores above 13 were considered positive and indicative of depression. The mean score was 13.8, with a minimum of 0 and maximum of 34 and a standard deviation of 8.8. The prevalence of positive scores for depression in this sample was 50 percent. An estimate of the prevalence of depression in this population was obtained by correcting the frequency of positive scores to account for characteristics of the screening test [ 181. This yielded an estimated prevalence of 52 percent. This high rate of positive scores on the depression scale led to concern about potential false-positive scores. Subsequently, subjects with positive depression scores were stratified into quartiles, and two patients were randomly picked from each quartile. The last subject was chosen randomly from one of the four quartiles. These nine subjects constituted 19.8 percent of all patients with positive depression scores and were evaluated by a psychiatrist (L.T.) using a modified SADS (Schedule of Affective Disorders and Schizophrenia) interview [ 171. This interview assessed the presence of psychiatric symptoms and categorized the symptoms according to DSM Ill criteria for affective, anxiety, and schizophrenic disorders. Seven of the nine patients evaluated by SADS interview still showed major depression when they were interviewed four to six months after the Vietnamese Depression Scale was administered. In another, major depression was diagnosed three months before the interview and was treated successfully with antidepressants. She could not recall her symptoms prior to treatment. Review of her chart revealed that she most likely had major depression. The other subject had severe mental retardation that was accompanied by depression and psychotic symptoms. Thus, eight of the nine subjects interviewed, or 88.9 percent, were con-
Chart.
The chief complaints, patient characteristics, diagnoses, and depression scores were recorded. Statisticalsignificance was tested by &&square tests, McNernar’s tests, and multiple regression analysis to assess the relationship between the independent variables (social and demographic characteristics and chief complaints) and the dependent variable (depression score).
42
January
1985
The American
Journal
of Medicine
Volume
78
DEPRESSlON
firmed to have major depression. The other had a combination of depression and mixed organic brain syndrome. Comparison of Depression Scores wlth Clinic Records. Clinical notation of the diagnosis or treatment of depression was compared with depression score (Table I). It is evident that the prevalence of recorded diagnoses of depression in the subjects’ charts (23 percent) was much lower than the prevalence of depression as measured by the depression scale. Nearly all of the discordant pairs had a positive diagnosis by the questionnaire but were missed in the clinic setting (p
January
TABLE I
IN VIETNAMESE
REFUGEES-LIN
ET AL
Comparison of Depression Scores wlIh Cllnlcal Records Dspressknl Diagnoals Incharl
TCF Positive Negative Total
YeS
No
20 1 21(23%)
26 45 71(77%)
Total 46 (50%) 46 (50%) 92 (100%)
Continuous variables such as age were divided into quartiles. Because of the number of chi-square tests performed on this sample, a conservative p value (p
1995
The American
Journal
ol Medlclne
Volume
79
43
DEPRESSION
IN VIETNAMESE
REFUGEES-LIN
ET AL
The reported under-utilization of psychiatric services by mentally ill Indochinese refugees patients [19] mirrors the high prevalence of depression in primary care. This under-utilization of psychiatric services and underdiagnosis of depression in primary care create a double-edged phenomenon and illustrate the cultural shaping of the expression of depression and the pattern of health care utilization. In cultures in which psychologization is stigmatized, the acceptable copying style will result in the suppression and denial of the psychological components of distress and the expression of physiologic aspects of distress [I 11. Thus, patients with emotional disorders can be expected to avoid psychiatric facilities and articulate their distress through a physical idiom in a primary care setting. It is uncertain how well our findings can be generalized outside of the community clinic setting as these patients were poor, unemployed, and limited in English proficiency. A larger and more diverse sample followed up for a longer period of time would provide more generalizable findings. Nevertheless, the high prevalence of depression, the low rate of clinical detection, and the high clinic utilization by depressed patients who
1. 2. 3. 4.
0: Emigration and insanity: a study of mental diseases among the Norwegm populatbn of Minnesota. Acta Psychiatr Stand 1932; 4 (suppl): 1-206. Hull D: Ml@ion, adaptagon and illness: a review. Sot Scl Med 1979; 13A: 25-36. Health status of lndochlnese refugees: malaria and hepatitis B. Morbid Mortal Weeklv Reo 1979: 28: 463-470 Cantanzaro A, Mozer R: Health’status of refugees from Vietnam, Laos, and Cambodia. JAMA 1982; 247: 1303-
present with somatic symptoms all emphasize the urgency of this important health problem in primary care. The Vietnamese Depression Scale provides a simple and effective diagnostic tool to improve the detection of depression. Our findings suggest that this instrument should become a routine assessment tooi in clinics with significant numbers of Vietnamese patients and should be used to evaluate any Vietnamese patient in primary care whose physical complaints and utilization are not well explained and in whom somatization is suspected. Research findings documenting the efficacy of therapy for depression [20] further underscore the importance of these findings as treatment of depression is associated with a reduction in the somatic symptoms, an improvement in depression, and a decrease in clinic utilization for depression. ACKNOWLEDGMENT
We are indebted to the staff at the International District Community Health Center, Seattle, for their assistance. Drs. ‘Wayne Katon, William Carter, Al Berg, Marjorie Muecke, David Kinzie, and Arthur Kleinman provided invaluable suggestions.
Odegaard
13.
1308. 5.
Ngyen
SD: Psychiatric
Southeast
Asian
and psy chosomatlc
refugees.
Psychiatr
problems
J Univ Ottawa
among
14.
1982;
7: 163-172. 6. 7.
a. 9.
10.
Sutherland JE, Avant RF, Franz WB Ill, Monzon CM, Stark NM: Indochinese refugee health assessment and treatment. J Fam Pratt 1983; 16: 61-67. Muecke MA: In search of healers: Southeast Asian refugees in the American health care system. West J Med 1983; 139: 835-641. Lin KM, Tazuma L, Minoru M: Adaptational problems of Vletnamese refugees I. Health and mental health status. Arch Gen Psychiatry 1979; 36: 955-961. Ed&son RV, Ho&g GN: Health problems among Indochinese refuoees. Am J Public Health 1980; 70: 1003-1006. Kinzie jD, Tran AK, Breckenridge A, Bloom JD: An Indochinese refugee psychiatric clinic: culturally accepted treatment approaches. Am J Psychiatry 1960; 137: 1429-
15. 16. 17.
ia. 19.
20.
1432.
44
January 1965
The American Journal of Medlclne
Volume 76
Klelnman AM: Neurasthenia and depression: a study of so matizatlon and cutture in China. Cult Med Psychlaby 1982; 6: 117-190. Goldberg DP, Blackwell B: Psychiatric illness in general practice. A detailed study using a new method of case Mentiflcatlon. Br Med J 1970; 2: 439-443. Kinzle JD, Manson SM, Vlnh DT, Nguyen TT, Anh B. Pho TN: Development and valkfatlon of a Vietnamese-languege depression rating scale. Am J Psychiatry 1982; 139: 1276-1261. BeckAT.BeamesderferA:Anesseasmentofdspressbn.The mgm. Mcd Probl1974; Zu&JW:nseif~deprassionscsle.ArchGsnPsych&y 196% 12: 63-70. Rogan W, Gladen B: Estknatlng prevalence from the results of a screening test. Am J Epklemiol1978; 107: 71-76. Endicott J, Spltzer RL: Dlagnostlc interview. The schedule for affective disorders and schizophrenia-life-time version. Arch Ben Psychiatry 1978; 35: 837-644. Katon W: Depresslon: somatic symptoms and medical dlsorders in primary care. Compr Psychiatry 1982; 23: 274-286. Miller B, Chambem EB, Coleman CM: Indochinese refugees: natlonelmentalhealthneedsessessment. Mlqatkx~ Today 1981; 9: 26-31. Widmer RB, Cadoret RJ: Depression: the great imltator in family practice. J Fam Pratt 19e3; II: 465-505.