Many Tibetan refugees flee Tibet in order to escape physical and mental hardships, and to access the freedoms to practice their culture and religion. We aimed to determine the prevalence of mental illnesses within the refugee population and determine the prevalence of previous torture reported within this population.

We performed a systematic literature search of 10 electronic databases from inception to May 2005. In addition, we searched the internet, contacted all authors of located studies, and contacted the Tibetan Government-in-exile, to locate unpublished studies. We included any study reporting on prevalence of mental illness within the Tibetan refugee populations. We determined study quality according to validation, translation, and interview administration. We calculated proportions with exact confidence intervals.

Five studies that met our inclusion criteria (total n = 410). All studies were conducted in North India and 4 were specifically in adult populations. Four studies provided details on the prevalence of torture and previous imprisonment within the populations. The prevalence of post-traumatic stress disorder ranged from 11–23%, anxiety ranged from 25–77%, and major depression ranged from 11.5–57%.

Our review indicates that the prevalence of serious mental health disorders within this population is elevated. The reported incidence of torture and imprisonment is a possible contributor to the illnesses. Non-government organizations and international communities should be aware of the human rights abuses being levied upon this vulnerable population and the mental health outcomes that may be associated with it.

In 1950, China began its occupation of Tibet. Since then, many Tibetans have fled to Nepal and India. More than 50 years of occupation have been accompanied by forced population displacements, widespread hunger, restrictions on cultural and religious freedoms, well-documented political violence against specific cultural groups, mass arrests, imprisonment of political prisoners and execution. Human rights groups have documented at least 60 deaths of peaceful demonstrators since 1987. [1] The current Tibetan population of Tibet is estimated at 6 million, with an undetermined number of Chinese occupants. This repression against Tibetans has resulted in large refugee populations in neighboring countries. It is estimated that more than 150,000 Tibetan refugees reside in the neighboring countries of Bhutan, Nepal, and India;[1] a generous token from such poor countries.

Due to political oppression, cultural oppression, and a desire to practice their religion, a growing number of Tibetans seek to escape to Tibetan settlements in India, the seat of the Tibetan Government-in-exile. The most common route is through Nepal. Depending on the point of departure and the type of transport used, the journey from Tibet to Nepal can take several days to months1. Most refugees cross the high mountains along commonly used escape routes to access Nepal. The Tibetan Refugee Transit Centre (TRTC), established by the United Nations High Commissioner for Refugees (UNHCR) in Katmandu, Nepal estimate that an average of 2,500 Tibetan refugees arrive into Nepal every year, with an equal number unsuccessful in their journey due to death or captivity. The TRTC assists refugees with their onward journey to India. The social background of those Tibetans who manage to flee has remained fairly constant over the past few decades, with a majority proportion of new arrivals being minors, monks and nuns. Nomads, farmers, and unemployed persons make up the remaining proportion. The number of attempted Tibetan refugee flights increases or decreases depending on the vigilance of Chinese border patrols.

Globally, at the start of 2004, there are an estimated 9.7 million refugees, included in a total of just over 17 million listed as ’persons of concern’ for the UNHCR (including asylum seekers, internally displaced persons, returned refugees still being monitored, stateless persons, and refugees)[2]. Mental disorders are often overlooked in refugee populations. A recent analysis of mental illnesses within refugees residing in developed countries found that the prevalence of post-traumatic stress disorder (PTSD) was roughly 1 in 10, and major depressive disorder was roughly 1 in 20[3]. We previously examined the experiences of recent refugees in the flight from Tibet to Nepal and discovered that those interviewed were at a greater susceptibility for mental health issues than expected, due to traumatic events, torture, and unfamiliarity with their new surroundings[4]. The goal of this analysis was to review the prevalence of mental illnesses reported amongst the Tibetan refugee populations, and secondarily examine the reported incidences of torture by the Tibetan refugees. To determine this, we conducted a systematic review of the available literature.

Eligible studies assessed the prevalence of mental health disorders among Tibetan refugees in Nepal and India, and repatriated refugees in Tibet. Studies had to report original communications on the assessment of mental health outcomes using a measurement tool. We excluded qualitative studies, case reports and studies addressing the political experiences of participants. We additionally excluded studies assessing the mental health of Chinese nationals residing in Tibet.

With the aid of an information specialist, we searched the following 10 data bases (from inception to May 2005): AMED, CINAHL, Cochrane CENTRAL and the Cochrane library, EMBASE, ERIC, MedLine via PubMed, HEALTHSTAR, Psych-info, Sociological abstracts, and Web of Science. We additionally searched the internet using Google as well as bibliographies of relevant papers. Where appropriate we searched using the single term Tibet* as the yield was manageable. We contacted the authors of all studies for clarification of study outcomes, garnering a response rate of 100%. The Tibetan Government in Exile was contacted to determine if they were aware of unpublished research.

We used the definition of torture as stated in the United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment and Punishment (UN Torture Convention)[5]. Torture, according to this convention, is defined as any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity[5].

Two reviewers worked independently and in duplicate, to review the abstracts and full text versions of identified reports and to adjudicate their inclusion.

Two reviewers, working independently extracted data from the included studies using a standardized form. We specifically abstracted information on the following: population; duration of time outside of Tibet; number of children, clergy, elderly, and women; access to mental health services; and mental health outcomes (PTSD, anxiety and depression) identified using standardized measurement tools. We additionally extracted information on the number reporting imprisonment and torture.

In order to determine the validity of the interventions used to assess mental health status, we examined if these measurement tools had been translated and validated in the Tibetan language. We additionally assessed whether the tool was provided by interviewer administration or self-administered. We assessed whether reliability had been assessed and whether authors evaluated construct validity.

We determined the diagnostic criteria of the screening tools, where available, as follows: Harvard Trauma Questionnaire, scores above 2.5 are considered strongly suspicious of PTSD;[6] Hopkins Symptom Checklist-25, scores above 1.75 on the individual (anxiety and depression) of the HSCL-25 is consistent with significant emotional distress and correlates with the presence of diagnosable psychiatric morbidity. [7]

Where proportions of populations were provided, we calculated the exact confidence intervals around the proportions. We did not pool results due to the heterogeneity of populations and methodologies employed. We tested interrater reliability using the K statistic. All statistics were performed using StatsDirect (Manchester, 2003).

Our systematic searches yielded 21 relevant abstracts. Thirteen were excluded as review articles. Of the remainder, 8 were selected for further examination and 4 were excluded as they were either qualitative or examined physical health outcomes. Four studies were included from academic publications[1,8-10]. One additional study was included from the non-government Organization (NGO) Physicians for Human Rights[11]. K for inclusion was ≥ 1, indicating perfect agreement. Table ​Table11 describes the study populations. All studies were conducted in North India and all studies met the requirements of reporting specific methodological issues.

Tibetan refugees and exiles numbered at least 150,000 in 2009. Edward J. Mills, Sonal Singh, Timothy H Holtz, Robert M Chase, Sonam Dolma, Joanna Santa-Barbara, and James J Orbinski, “Prevalence of mental disorders and torture among Tibetan refugees: A systematic review,” BMC International Health and Human Rights, Vol. 5, No. 7 (2005), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308816/.

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