Depression among Afghan Refugees in The West

David Sahar, MD
San Francisco, CA
June, 1998
Afghan Mosaic Magazine

The Former Soviet Union invasion of Afghanistan in 1979 and the subsequent war that followed, had left millions of Afghans wandering throughout the world.  The migration of this heterogeneous group of people, has left them with a variety of stressors outside their native country.  Though physical threat may have been virtually eliminated to many of these refugees in the Western Countries,  loss of  country, culture, kinship ties as well as traumatic experiences during  or before their escape has manifested itself in several forms of mental and emotional scars. Of these, major depression appears to be a prevalent problem in this refugee population

Major depression is a serious and often disabling psychiatric disorder, with a higher prevalence in women than men.  Common symptoms of this disorder include sadness, loss of interest in activities that were previously pleasurable to the individual.  These patients may also feel discouraged, defeated, helpless, hopeless, and have difficulty carrying out day-to-day activities.  Disturbance in appetite, sleep cycle, motor, energy level, libido, concentration, memory and thinking are common.  The symptom may finally end tragically with suicide, as it does in 15 - 30% of  patients with major depression(4). In general, while  women tend to attempt suicide more often, men complete the act at a greater rate.  It has been proposed that the difference is attributed to the method of suicide, e.g. pill overdose vs. gun shot to the head.

In 1987, Brown and Harris(1) conducted studies on the relationship between life stress  to the onset of depression in United Kingdom.  Their findings indicate that six experiences were important predictors of depression in their patient populations.  These experiences which involve loss included 1. death, 2. separation, 3. loss of employment, 4. loss of material possessions, 5. loss of physical health and 6. loss of cherished ideas. These losses combined with sense of commitment to what is lost has been associated with depression. 

One can readily appreciate that many Afghan refugees have experienced all of the six losses described by Brown and Harris, and much more.  In fact, the two decades of war has caused Afghans to become one of the most traumatized people in the world, physically and mentally.  It is beyond the scope of this article to discuss the condition of Afghans within the native country, or to discuss the inarticulate disbelief of what humans are capable of doing to one another.

In a study conducted by Lipson and Omidian(2) in 1992-93, which was based on a telephone survey, community meetings and a 196-family survey in the San Francisco Bay Area, it was noted that 48% of Afghan families lost members and 25% had a family member who had been imprisoned and/or tortured. Separation from environment appeared to be a stress factor, although 61% reported “mostly satisfied” and 12% “mostly disappointed” when asked about satisfaction with life in United States. Problems relating to employment was reported in 42% of this population. 58% reported loss of property as a source of stress. Illness in family as  a current family stressor was reported in 38%.  And finally loss of status and culture as a source of stressor was reported in 48 and 70% respectively. 

Symptoms of the above mentioned stressors were described as sleep disturbances, memory problems, headaches, constant worry, flashbacks of bad memories, depression, dizziness, and anger.  These symptoms may fulfill the criteria for axis I of Diagnostic and Statistical Manual of Mental Disorder (DSM) IV for Major Depressive Disorder although Adjustment Disorder with Depressed Mood,  Somatization Disorder and Posttraumatic Stress Disorder may also be present among these patients.  However, the above study did not evaluate the severity, duration and combination of symptoms during a single time interval.  Further work is needed to determine these factors and make a more accurate assessment of depression among this Afghan population.

It is worth reiterating that the above study was conducted in 1992-93 and geographically is confined to San Francisco Bay Area.  Although a high concentration of Afghans in the Bay Area may support such research in Western Hemisphere, it may not reflect the status of Afghan refugees in other regions of the United States, or for that matter, the world.  Northern California has a relatively temperate weather, compared to, for example, Minneapolis, where the climate is drastically different from the native Afghanistan.  Also, families that are in Northern California may form a social network in the area, where as such support may be impossible, if not difficult, for families living in South Dakota or Iowa due to distance. On the other hand some Afghans prefer to be isolated from the large Afghan communities for variety of personal reasons.

A similar study conducted on 404 Southeast Asian refugees seen at a Minneapolis (MN) community clinic by Kroll et al (3) reports three-quarters of patients met DSM-III criteria for major depressive episode.  Interestingly somatization was a common form of expressing distress in this patient population.  Many would come in for their pain, and only later spoke of their sadness, losses, and anger.  Although numerous differences exist between the Southeast Asian refugees and the Afghan refugees, notably language and culture, there are parallels that can be drawn between the two groups.   Many Afghans may recall a relative who complained of variety of bodily pain, who later was diagnosed with no specific etiology due to lack of physical evidence.  This contributes to further frustration of these patients and dissatisfaction with western medicine.  

Treatment of depression will largely depend on the exact diagnosis, patients preferences and type of medical insurance the patient has.  Patients with major depression are often treated with drugs.  It should be remembered that these drugs, e.g. Prozac and Zoloft, will not work overnight, rather a lag time of three to four weeks maybe seen before a true mood-elevating effect is seen. On the other hand, patients with mild depressions or depression secondary  to environmental “stress” or interpersonal conflicts are best  treated with counseling or psychotherapy.

What are the major manifestations of depression? Signs and symptoms of this disorder include depressed mood, inability to experience pleasure, appetite disturbance, sleep disturbance, psychomotor disturbance, fatigue or loss of energy, feelings of worthlessness or excessive inappropriate guilt, diminished ability to concentrate or indecisiveness and recurrent thoughts of death or suicidal ideation for a period of at least two weeks. Not all of the above symptoms are necessarily present at one time.  It should be noted that depression may also be secondary to other physical problems, e.g. hypothyroidism.

Major depression is a serious medical problem. Physical and mental manifestation of this disorder is not only debilitating to the individual, but it can negatively affect the loved ones around the depressed individual. Since this disorder is usually treatable, it is important for patients with this disorder to seek professional help. Recent Afghan refugees who are depressed may not be able to voice their problems due to language barrier and lack of knowledge about the subject or may not know that they have a problem.  Thus it is important for Afghans to recognize symptoms of this problem and to seek help for the family member who is suffering from this treatable disorder.


1.       Brown GW, Bifulco A, Harris TO: Life events, vulnerability, and onset of depression: some refinements. Br J Psychiatry 1987; 150:30-42.

2.       Lipson J, and Omidian PA: Health among San Francisco Bay Area Afghans: A Community Assessment. The Afghanistan Studies Journal, Volume 4 1993; 71-86.

3.       Kroll J, Habenicht M, Mackenzie T: Depression and Posttraumatic Stress Disorder in Southeast Asian Refugees. American Journal of Psychiatry 146:12, December 1989.

4.   Gold PW, Goodwin FK, Chrousos GP: Clinical and biochemical manifestation of depression, part II: relation to neurobiology  of stress. New England Journal of Medicine 319(6):348-535, 1988a.