This study represents the first attempt to evaluate the prevalence of depressive symptoms and their underlying factors among resettled older Bhutanese adults residing in Ohio, USA. The study's results revealed a notably high incidence of depressive symptoms in this population and revealed several key contributing factors. These factors include self-reported health, chronic health conditions, social support, life satisfaction, and resilience, underscoring the complex and multifaceted nature of the issue.
The findings regarding the high prevalence of depressive symptoms among older Bhutanese individuals align with the findings of previous studies on depression among refugee populations [17, 45, 46]. For example, a study focused on Hmong refugees aged 55 and above, one of the least privileged Asian American groups originating from highland Laos, reported that more than 72% of older Hmong individuals exhibited depressive symptoms [47]. Another study involving Bhutanese refugees in the USA aged 18 and above revealed that older individuals were more likely to experience depressive symptoms [21]. Several potential factors may explain these observed findings. First, it is plausible that the older Bhutanese adults in our study may still have experienced the enduring stress and trauma of their forceful displacement from Bhutan in the 1990s [6]. During the extended refugee stage in Nepal's refugee camps, refugees lived in dire conditions with limited resources and faced significant daily life stressors. Additional stressors were introduced during resettlement and integration into US culture and society. Throughout this challenging journey, they likely encounter numerous stressors attributed to language barriers, religious and cultural differences, acculturation stress, discrimination, transportation limitations, unemployment, etc. [23]. In accordance with the life course approach to aging [48], the cumulative stressors experienced throughout their lives may have played a substantial role in contributing to the higher prevalence of depression among older Bhutanese adults.
Among the correlates, better self-reported health, the absence of chronic disease, high social support, satisfaction with life, and high resilience were associated with lower odds of depressive symptoms. Both subjective health and chronic morbidity exhibited significant associations with depression in both bivariate and regression analyses, with poor health ratings and the presence of chronic morbidities being linked to higher depression scores. In line with our findings, a previous study centered on depression among Bhutanese refugees in the USA also documented a connection between better health and depression [22]. The relationship between physical health or morbidity and mental health has garnered support from numerous studies, all indicating a heightened risk of depression among individuals with both single and multiple chronic conditions [49, 50]. An extensive study on depression and multimorbidity in late life has shed light on the bidirectional connection between these two conditions, likely linked to accelerated aging processes [49, 51]. An additional underlying mechanism that can elucidate how chronic diseases contribute to or worsen depression lies in the burden of coping with chronic morbidity itself. Following a diagnosis, individuals often contend with feelings of uncertainty, anxiety, and a profound sense of health-related loss, significantly affecting their quality of life and heightening their vulnerability to depressive symptoms [52, 53]. Furthermore, chronic conditions, compounded by factors such as physical deterioration, reduced physical activity levels, social stigma, and increasing social isolation [52, 53], can impede one's sense of self, self-esteem, and control over one’s life, shaping one’s identity and subjecting one to social stigma, isolation, and poorer mental health [52]. Recognizing and understanding these factors is crucial for providing comprehensive care and managing the potential exacerbation of depression. A holistic healthcare approach that considers both physical and mental health and addresses the psychosocial burden of chronic conditions could significantly benefit the well-being of older adults.
Consistent with previous research, social support was identified as a protective factor against depression in older refugees [21, 54, 55]. It is well established that social support is crucial for maintaining both physical and psychological well-being [56]. Coping strategies used by individuals when they are stressed can also be extended to help those in distress as a form of assistance [57]. Studies have demonstrated that robust social support can enhance resilience against poor mental health outcomes associated with stress and trauma [56]. More specifically, social support achieves this by reducing risky behaviors and providing external coping mechanisms during stressful situations [56]. Hence, group belongingness, social identity, and social support have been recognized as protective factors benefiting the mental health of refugees [58]. Specifically, among our participants, the majority of whom lacked formal education and English language proficiency, heavily relied on and received strong support from their families during their transition to a new society [23]. This underscores that older Bhutanese individuals may indeed have access to the resources provided by robust social support against depression.
Higher life satisfaction predicts lower depression risk, consistent with prior studies [59–61]. This relationship holds true even among internally displaced individuals, where increased life satisfaction is linked to reduced mental health issues, including anxiety and depression [61]. In studies examining life satisfaction and depression, Asian cultures, including the Nepali-Bhutanese culture, have focused on family structure and relationships, recognizing them as protective elements [60, 62]. This emphasis on shared family values, which are consistent across Asian cultures, underscores the importance of filial duty and family support for older parents [62, 63]. Residing in an extended family setting and benefiting from moral support and informal caregiving provided by their children could have contributed to a sense of contentment among our participants. These cultural norms are linked to higher life satisfaction and a decrease in depressive symptoms among older adults [62]. Mental health interventions may benefit from including a component of personal fulfillment to empower individuals to take proactive steps to improve their life satisfaction.
Resilience is frequently linked to mental health, explaining its protective function against conditions such as depression, stress, or trauma [21, 64–66]. This study further supports this connection. Previous research indicates that resilience strengthens an individual's ability to navigate difficult life circumstances, emphasizing its role as a personal coping mechanism [64, 65]. Moreover, within the framework of the social ecology of resilience theory, it is crucial to recognize that resilience does not depend solely on individual efforts to access resources [67]. Instead, it represents a shared characteristic between individuals and their social environment, with the social context playing a pivotal role in promoting enduring well-being and recovery among populations facing adversity [67, 68]. Resilient individuals typically employ positive coping strategies, such as maintaining a positive mindset, seeking support from others, and engaging in problem solving [64]. These factors empower them to effectively manage challenges that might otherwise contribute to adverse mental health outcomes. Resilience training that includes but is not limited to education, awareness, and resilience-building activities such as mindfulness exercises or support groups can contribute to improved mental health.
Strengths and Limitations of the Study
This study has several notable strengths. It included four major cities with substantial resettled Bhutanese populations in Ohio (Columbus, Cleveland, Cincinnati, and Akron). This study's emphasis on the population aged 55 years and above allowed for a targeted exploration of a demographic often underrepresented in research. The findings obtained offer valuable insights into the unique challenges, needs, and potentials within this age segment among the resettled Bhutanese people, shedding light on critical factors that influence their mental health. Conducting interviews in the Nepali language likely facilitated effective communication and ensured accurate interpretation of responses. Additionally, the interviewers shared similar sociocultural and linguistic backgrounds with the participants and possessed graduate-level training in survey design and research methodology, enhancing the reliability of the data collection. Moreover, the survey utilized validated Nepali assessment tools for depression, social support, life satisfaction, and resilience scales, thereby bolstering the validity of the measures employed in the study.
Nonetheless, it is important to acknowledge certain limitations of this study. The cross-sectional nature of the study restricts the ability to draw causal inferences. Furthermore, while random sampling was the preferred method, the absence of a suitable sampling frame necessitated the use of snowball sampling, potentially introducing selection bias. Nevertheless, snowball sampling is a frequently employed method for recruiting hard-to-reach populations, such as the resettled Bhutanese community in the USA [24]. Additionally, the reliance on self-reported data may have introduced recall and social desirability biases into the study.