In the early 1990’s, tens of thousands of Nepali-speaking individuals fled Bhutan in order to avoid persecution and arrest . They were also forced to relinquish their citizenship in Bhutan . During 17 years of failed bilateral talks between the governments of Nepal and Bhutan, these individuals lived in refugee camps in eastern Nepal. They were prevented from returning to their homes in southern Bhutan and also barred from fully joining society in Nepal.
The condition of statelessness has had a significant impact on the overall mental health of these refugees. While in Nepal, 37.5% of adult refugees reported having symptoms consistent with major depression and 12.5% had experienced symptoms of psychosis . A similar study reported that of Bhutanese refugees who had survived torture, 14% had post-traumatic stress disorder (PTSD) . Other research has shown that both tortured and non-tortured Bhutanese refugees were equally likely to become psychologically unwell . However, torture survivors were more likely to have symptoms of PTSD, clinical anxiety, and clinical depression; non-tortured refugees were more likely to be diagnosed with pain disorders and specific phobias . Traumatic events and social adversities —such as witnessing accidents or violence, the death of a loved one, failure to meet expectations, unemployment, and poverty—are associated with PTSD among the Nepali-speaking Bhutanese population .
In 2006, Bhutanese refugees were given resettlement options in third countries, including the U.S. To date, approximately 78,000 Bhutanese refugees have resettled in the U.S. In 2012, the Centers for Disease Control and Prevention (CDC) investigated claims of a disproportionately high number of suicides within this community . The captured data substantiated these claims, showing that the reported rate of suicide among US-resettled Bhutanese refugees was 20.3 per 100,000 . This is higher than both the global rate of 11.4 per 100,000  and the US rate of 12.4 per 100,000 for suicide among the general population . Risk factors for suicidal ideation among this community included: not being able to provide for the family; having low perceived social support; screening positive for anxiety, depression, and distress; and increased family conflict after resettlement .
Help-seeking by individuals with mental health conditions or severe emotional distress is often limited. The Bhutanese community in the U.S., similar to other refugee communities [7,8], is believed to have limited mental health literacy and experiences language barriers when seeking out mainstream health services. An investigation conducted in the refugee community in Nepal in 2011 and in the U.S in 2012 found that Bhutanese refugees do not utilize a broad range of coping strategies and instead tend to deal with distress individually or with close family or friends [1,5]. None of the Bhutanese subjects listed existing mental health services as a coping mechanism , which further highlights the lack of adequate help-seeking behavior and the discordance in beliefs about treatment between this community and mental health professionals. Research among other immigrant communities has also shown that although a family member or close friend is often the first to recognize signs and behaviors that can be read as suicide warning signs, these individuals seldom have the tools and proficiency necessary to assist in suicide prevention [5,7,8].
Although data are not available for Bhutanese refugees, the perception that a person who seeks psychological treatment is undesirable or socially unacceptable [9,10] has been identified as a significant barrier to mental health care in other refugee communities [7,8,11]. Personal stigma refers to the stigmatizing attitudes and beliefs held by an individual, whereas perceived stigma refers to an individual’s beliefs about the views of others [12,13]. Many people hesitate to use mental health services because they do not want to be labeled a “mental patient” and want to avoid the negative consequences connected to stigma. In other populations with limited help-seeking, the most commonly reported reasons for not seeking treatment were a will to solve the problem on one’s own and a hope that the problem would get better by itself . Both forms of stigma serve as a burden to those suffering from mental illness and prevent access to adequate care by enforcing the notion that anyone seeking treatment for a mental illness is socially undesirable or flawed [12,13].
In order to combat the high rates of suicide and address other unmet mental health needs within the Bhutanese refugee community, there is a need for increased community awareness of mental illness and available mental health services . In other Asian immigrant communities, similar challenges have been addressed by providing mental health education to community leaders and the community at large. Studies done on the Chinese and Vietnamese communities in Australia have utilized Mental Health First Aid (MHFA) training to provide community members with the knowledge and skills needed to recognize common mental health disorders and assist with linkage to care [15,16].
Mental Health First Aid
Mental Health First Aid (MHFA) is widely used to train human service workers in the U.S. It was introduced in the U.S. in 2008 and, to date, more than 175,000 people from all 50 States have completed training. MHFA training is offered to a variety of audiences, including hospital staff, employers and business leaders, faith communities, and law enforcement . The goal of MHFA is to impart the knowledge necessary to provide support to people with mental illness . The program is intended to increase mental health literacy, decrease stigmatizing attitudes, and prepare community members to recognize and assist individuals who are in crisis. The 8-hour adult MHFA training course, performed in one full day, introduces participants to risk factors and warning signs, builds understanding of their impact, and reviews common treatments . More specifically, participants learn about depression, anxiety, trauma, psychosis, eating disorders, substance use disorders, self-injury and suicidal behaviors . They also learn a five-step action plan (known by the abbreviation ALGEE) to help people who may be developing a problem or who are already in a crisis: (1) Assess the risk of harm or suicide, (2) Listen non-judgmentally, (3) Give reassurance and information, (4) Encourage appropriate professional help, and (5) Encourage self-help and other support strategies [18-21].
Although outcomes data for immigrants with mental illness are limited, medium-term (6-month) evaluation studies conducted following MHFA training in Australia show that MHFA training results in consistent, positive changes among program participants. After completing MHFA training, individuals from Chinese and Vietnamese immigrant communities in Australia demonstrated improvements in mental health literacy, decreases in negative attitudes towards people with mental illness, and a broader knowledge of appropriate forms of assistance to give to community members suffering from mental illness [15,16]. However, MHFA has not yet been evaluated among the Bhutanese refugee community. Therefore, the aim of this study is to investigate the impact of MHFA training on Bhutanese refugee community leaders’ knowledge of appropriate first aid responses and stigmatizing attitudes towards people with mental illness.