The unweighted sample of 490 refugees was used for all analyses; however,
a sample size of 482 refugees was realized after weighting. *Strata
membership was determined by a community expert who judged if the house was
likely to contain a Cambodian based on features visible from the street (eg,
shoes on porch, Buddhist icons, and Southeast Asian plants). †A
household was eligible if it contained at least 1 individual aged 35 to 75
years who had lived in Cambodia during some portion of the Khmer Rouge regime
(April 1975 to January 1979).
Customize your JAMA Network experience by selecting one or more topics from the list below.
Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun C. Mental Health of Cambodian Refugees 2 Decades After Resettlement in
the United States. JAMA. 2005;294(5):571–579. doi:10.1001/jama.294.5.571
Context Little is known about the long-term mental health of trauma-exposed
refugees years after permanent resettlement in host countries.
Objective To assess the prevalence, comorbidity, and correlates of psychiatric
disorders in the US Cambodian refugee community.
Design, Setting, and Participants A cross-sectional, face-to-face interview conducted in Khmer language
on a random sample of households from the Cambodian community in Long Beach,
Calif, the largest such community in the United States, between October 2003
and February 2005. A total of 586 adults aged 35 to 75 years who lived in
Cambodia during the Khmer Rouge reign and immigrated to the United States
prior to 1993 were selected. One eligible individual was randomly sampled
from each household, with an overall response rate (eligibility screening
and interview) of 87% (n = 490).
Main Outcome Measures Exposure to trauma and violence before and after immigration (using
the Harvard Trauma Questionnaire and Survey of Exposure to Community Violence);
weighted past-year prevalence rates of posttraumatic stress disorder (PTSD)
and major depression (using the Composite International Diagnostic Interview
version 2.1); and alcohol use disorder (by the Alcohol Use Disorders Identification
Results All participants had been exposed to trauma before immigration. Ninety-nine
percent (n = 483) experienced near-death due to starvation and 90%
(n = 437) had a family member or friend murdered. Seventy percent
(n = 338) reported exposure to violence after settlement in the
United States. High rates of PTSD (62%, weighted), major depression (51%,
weighted), and low rates of alcohol use disorder were found (4%, weighted).
PTSD and major depression were highly comorbid in this population (n = 209;
42%, weighted) and each showed a strong dose-response relationship with measures
of traumatic exposure. In bivariate analyses, older age, having poor English-speaking
proficiency, unemployment, being retired or disabled, and living in poverty
were also associated with higher rates of PTSD and major depression. Following
multivariate analyses, premigration trauma remained associated with PTSD (odds
ratio [OR], 2.08; 95% CI, 1.37-3.16) and major depression (OR, 1.56; 95% CI,
1.24-1.97); postmigration trauma with PTSD (OR, 1.65; 95% CI, 1.21-2.26) and
major depression (OR, 1.45; 95% CI, 1.12-1.86); and older age with PTSD (OR,
1.76; 95% CI, 1.46-2.13) and major depression (OR, 1.47; 95% CI, 1.15-1.89).
Conclusion More than 2 decades have passed since the end of the Cambodian civil
war and the subsequent resettlement of refugees in the United States; however,
this population continues to have high rates of psychiatric disorders associated
Political instability, civil conflict, war, genocide, persecution, and
the attendant violations of human rights are increasingly recognized as paramount
public health concerns.1-3 According
to the United Nations High Commissioner on Refugees, there were approximately
19.2 million refugees, internally displaced persons, and asylum seekers worldwide
in 2004.4 Researchers studying these populations
have found high levels of violence exposure, often involving multiple traumas,
as well as significant mental health problems.5-10 Empirical
investigations generally conclude that depression and posttraumatic stress
disorder (PTSD) constitute the most common psychiatric disorders in refugee
populations. Inasmuch as depression is a key component of overall disease
burden11 and PTSD is a notable contributor
to disease burden, especially in countries wracked by violence,12 exposure
to mass trauma is a significant source of psychiatric disability worldwide.
Although there is agreement that refugee populations experience high
levels of psychiatric disability, most of the data for this conclusion come
from studies that may overestimate the magnitude of the problem. Much of this
research has focused on individuals seeking health or social services who
may have more severe problems than the general population of refugees.6,13,14Other studies have
assessed individuals petitioning for asylum who may be motivated to overreport
trauma exposure and related psychiatric symptoms.15,16
Additionally, research is frequently conducted while refugees are housed
in refugee camps or within a short time after resettlement in a host country.7,9,17-19 It
is difficult to determine if the psychiatric distress documented in these
studies represents an acute condition, which might resolve spontaneously or
with a change in circumstances, or whether it reflects a chronic condition
that will persist in the absence of a therapeutic intervention.
Similarly, there are few published community-based studies of refugee
populations after long-term resettlement in resource-rich countries like the
United States, although existing research has examined the long-term health
consequences for refugees resettled in resource-poor countries.20,21 Health
outcomes for refugees may vary as a function of the prosperity of the resettlement
country, with persons resettled in poorer countries experiencing continued
hardships that influence health. Finally, many studies of refugee mental health
have relied on symptom screening instruments to assess probable diagnoses.6,7,9,22,23 Although
these measures are correlated with clinical diagnoses and provide useful data,
they often fail to include the necessary information to make diagnostic assessments.
Consequently, they typically err on the side of high sensitivity rather than
high specificity and tend to overestimate prevalence.24,25
Cambodians constitute one of the largest refugee groups in the United
States, with approximately 150 000 refugees admitted since 1975.26 Although these refugees are now many years removed
from their tribulations, they were subjected to one of the most brutal and
traumatic periods of the past century. After a coup in 1970, a civil war began
that led to a Khmer Rouge takeover from 1975 to 1979. A Vietnamese invasion
in 1979 ended the Khmer Rouge reign, but civil war continued until United
Nations troops enforced a cease-fire in late 1991. Of an estimated population
of 7.1 million in 1975,27 as many as 2 million
Cambodians were killed during the 4-year Khmer Rouge reign. Approximately
1 million more were killed in the civil wars before and after this period.28 The period from 1978 to 1991 also produced more than
half a million refugees in Thailand refugee camps.
The goal of our study was to assess the population prevalence, comorbidity,
and correlates of psychiatric disorders in the US Cambodian refugee community
25 years after the Khmer Rouge era, using research methods that should provide
the most accurate available estimates. This knowledge should provide information
concerning the current health status of this community, guiding health-policy
decision makers to the needed services for this refugee community.
Our sample was designed to represent the population of Cambodian immigrants
residing in Long Beach, Calif. This city is home to the largest single concentration
of Cambodian refugees in the United States. The sample size was determined
by a desire to have relatively small confidence intervals (±5%) for
estimates of prevalence of psychiatric disorder when the true population prevalence
was 30% or 70%. This level of precision required an effective sample size
of 333. With an expected design effect of 1.5 due to weights (actual design
effect = 1.47), we aimed to interview 500 individuals.
Specifically, we derived our sample from a geographically contiguous
area composed of the 4 census tracts with the largest proportion of Cambodians
in Long Beach, Calif, containing approximately 15 000 total households.
We used a 3-stage random sample of individuals within households within blocks
(Figure). In the first stage, a simple
random sample of census blocks was selected. A community expert then surveyed
blocks with field staff and classified all 5555 households on selected blocks
as either likely (18%) or unlikely (82%) to be Cambodian households. The second
stage consisted of a stratified random sample of households (n = 2059)
in which we oversampled households judged by the community expert as likely
to contain Cambodian individuals. The community expert relied on common visual
signs, such as plants favored by the community growing in the lawn or placed
on the front porch (eg, lemon grass, bamboo), and Buddhist or other icons
on the front porch or visible in the window to select households likely to
contain Cambodian individuals. The likely/unlikely distinction was used to
create sampling strata so that we could then draw random samples of households
from within each of these subpopulations.
Selected households were then screened to determine whether they contained
at least 1 eligible individual. Screening was successfully completed for 2001
(97%) of the sampled households. Five hundred eighty-six households (29%)
contained 719 eligible Cambodians. In the third stage, a single eligible individual
was selected at random from each household. Of selected individuals, 527 (90%)
agreed to participate in the survey, resulting in an overall response rate
of 87%. Of these, 37 were not refugees and were excluded from the analytic
sample for this study, yielding an analytic sample of 490 participants. After
weighting participants to create a sample representative of the desired population
as described below, we had a weighted sample size of 482.
Individuals were determined to be eligible for interview if they were
aged between 35 and 75 years and had lived in Cambodia during some portion
of the Khmer Rouge regime (April 1975 to January 1979). In addition, our analyses
were restricted to 490 of those individuals interviewed who immigrated during
the years when the United States was accepting Cambodian refugees, which effectively
ended in 1992 when the United States adopted policies that favored repatriating
displaced Cambodians. All participants in our analytic sample left Cambodia
prior to the 1991 cease-fire and the subsequent deployment of a United Nations
peacekeeping force to Cambodia, and all respondents had spent time in a refugee
The interview team was composed of 5 bilingual lay interviewers. Interviewers
were themselves Cambodian refugees and were required to read, write, and speak
fluently in Khmer and English. Interviewers received extensive training before
conducting interviews and active supervision throughout data collection. Data
were obtained via face-to-face, fully structured interviews that took place
in participants’ homes. Interviews were conducted in Khmer and took
approximately 120 minutes to complete.
As part of the informed consent process, potential participants were
told that the purpose of the study was to learn about the life experiences
of people who had come from Cambodia as refugees and that the researchers
were interested in their current life situation, and their physical and emotional
health. Potential participants were informed that participation was completely
voluntary and that they were free to stop at any time. All persons were informed
of the specific topics to be covered in the interview and were expressly advised
that they would be reminded of traumatic incidents from the past, which may
cause them to become emotionally upset. Potential participants were also advised
that they might wish to talk with someone about these feelings or concerns
and were given contact information for 2 mental health clinics that provide
services to the Cambodian community. Both clinics were informed of the existence
of the study in advance of data collection. All informed consent materials
were read verbatim, questions were answered, and written informed consent
was obtained. Following the interview, participants received a nominal incentive
payment and were reminded that they had the option of availing themselves
of services provided at either of the 2 aforementioned clinics. Interviewers
also reviewed orally with participants a brochure containing the contact information
for local health, mental health, and social service agencies, before giving
them a copy of the brochure. The institutional review boards of RAND and the
California State University, Long Beach, approved the protocol.
All instruments were translated and back-translated following recommended
procedures to ensure content, technical, criterion, conceptual, and semantic
equivalence.29 Two bilingual, bicultural Khmer
translators translated all English measures into Khmer. The Khmer version
of the survey was then back-translated into English by a third bilingual,
bicultural Khmer translator to ensure equivalency and identify discrepancies
between the 2 English versions. A small number of discrepancies were reconciled
with the aid of the 3 original translators and 1 additional translator who
had not been involved in either of the initial translations.
Extensive development work preceded finalization of the instrument.
Focus groups were held with community experts to identify topics of potential
interest and to obtain feedback on initial versions of the instruments. The
comments of expert advisors were integrated into successive versions of the
interview in iterative fashion. The instruments were then pretested with multiple
respondents in both English and Khmer to identify areas of possible confusion.
Sociodemographic information, including age, marital status, education,
employment, self-assessed English-speaking proficiency (not at all, poor,
fair, or good), household size, and household income, was obtained. For analytic
purposes, income was expressed as a proportion of the federal poverty level.
Overseas trauma exposure was assessed by using a modified version of 17-item
Cambodian Harvard Trauma Questionnaire.30 Additional
trauma items were taken from the 46-item Bosnian version of the Harvard Trauma
Questionnaire.31 The Harvard Trauma Questionnaire
is the most widely used measure of its kind and has been translated into 35
languages.32 In total, respondents were asked
whether they had experienced each of 35 events before immigrating to the United
States. To assess exposure to violence in the United States, a modified version
of the Survey of Exposure to Community Violence33 was
used. Numerous studies document the reliability and validity of this instrument.34-36 Respondents indicated
whether they had witnessed or directly experienced each of 11 events since
arriving in the United States. For descriptive purposes, the total number
of endorsed trauma exposures is reported for both premigration and postmigration
Past 12-month diagnoses of PTSD and major depression were determined
by using the PTSD and depression modules of the Composite International Diagnostic
Interview (CIDI) version 2.1.37 This instrument
is keyed to the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV)38 criteria. The CIDI is intended to be administered
by lay interviewers and its cross-cultural applicability has been well established.20,39,40 The CIDI is designed
to assess all criteria required for a DSM-IV diagnosis,
including symptom profiles, severity, duration, and functional impairment,
and, in the case of PTSD, the required peritraumatic reactions. Several studies
attest to the reliability and validity of the CIDI.40-43 The
Alcohol Use Disorders Identification Test,44 developed
as part of an international World Health Organization collaborative project,
was used to screen for possible alcohol use disorders (AUDs). Perhaps the
most widely used and well-validated alcohol screener,45 this
instrument consists of 10 items. Responses to each question are scored from
0 to 4, with scores of 7 for women and 8 for men reflecting a probable AUD.46
Analyses used design weights and corrected for the design effects of
both weighting and clustering. Inverse-probability design weights accounted
for the underrepresentation of eligible persons in residences judged unlikely
to house Cambodians and for individuals from households with more than 1 eligible
resident. Nonresponse rates were low and there was no statistically significant
(P<.05) evidence that nonresponse was associated
with variables available for comparison (census tract, age, and sex). Thus,
nonresponse weights were not constructed. Throughout the text and tables,
we report weighted proportions as percentages and unweighted sample sizes.
All statistical analyses were performed by using SAS/STAT software version
9.1 (SAS Institute, Cary, NC).
Proportions and margins of error (computed as half of the exact binomial
95% confidence intervals) were calculated for dichotomous variables, whereas
means and SDs were calculated for continuous variables. Bivariate odds ratios
and their 95% confidence intervals were calculated predicting dichotomous
outcomes of major depression, PTSD, and probable AUD from age and year of
immigration (both of which were scaled as number of years divided by 10, and
treated as continuous), sex, the number of premigration and postmigration
trauma types experienced (expressed as the z score
of the sum of each type), English-speaking proficiency (good/fair vs not at
all/poor), marital status, high school completion, employment status, and
US federal poverty level (below poverty [<100%] vs above poverty level
[≥100%]). Age, sex, year of immigration, premigration and postmigration
trauma exposure were also included as independent variables in multivariate
logistic regressions predicting the same 3 outcomes.
On average, participants arrived in the United States in 1983 and were
aged 52 years at interview (Table 1).
Sixty-one percent of the respondents were women and 87% indicated Buddhism
as their religious affiliation. The majority of respondents were married and
low in socioeconomic status, with low levels of education, English-speaking
proficiency, and employment. Sixty-nine percent of the participants had household
incomes of less than 100% of the federal poverty level and 72% indicated currently
receiving government assistance.
Participants reported high rates of exposure to trauma and violence
before their arrival to the United States (Table
2). Participants reported experiencing a mean of 15 of 35 premigration
trauma types. For example, 99% of individuals (n = 483) reported
near-death due to starvation, 96% (n = 466) reported forced labor
(like animal or slave), 90% (n = 437) reported having a family member
or friend murdered, and 54% (n = 241) reported having been tortured.
Participants also reported exposure to violence in the United States, with
a mean 1.7 of 11 types of postmigration trauma exposure. For example, 34%
of individuals (n = 160) reported seeing a dead body in their neighborhood,
28% (n = 136) reported having been robbed, and 17% (n = 83)
reported having been threatened by a weapon and believing that they might
be seriously hurt or killed.
Consistent with this high level of traumatic exposure, 62% of respondents
(n = 301) met DSM-IV diagnostic criteria
for PTSD in the past year and 51% (n = 248) met diagnostic criteria
for major depression in the past year (Table 3). Comorbidity between these disorders was high. Seventy-one percent
of persons with PTSD also met criteria for major depression and 86% of those
with major depression met criteria for PTSD (φ = 0.50, P<.001). In contrast, low levels of probable AUD were
found (4%; n=14). Moreover, AUD was not significantly associated with either
PTSD (φ = 0.02, P = .81)
or major depression (φ = 0.01, P = .93).
Several demographic variables, in addition to aggregate premigration
and postmigration trauma exposure, showed bivariate associations with the
3 psychiatric disorders (Table 4). Specifically,
poor English-speaking skills, unemployment, being in retirement or disabled,
and living in poverty were associated with higher rates of PTSD and major
depression. Older respondents showed higher rates of PTSD and depression than
did younger participants. However, older respondents had lower rates of probable
AUD than did younger respondents. Women were less likely than men to have
either PTSD or AUD. PTSD and major depression were both associated with greater
exposure to premigration and postmigration trauma. In contrast, AUD was significantly
associated only with exposure to trauma after immigration to the United States.
The interpretation of the nonsignificant odds ratio predicting AUD is limited
by the large confidence intervals that result from the low prevalence of alcohol-related
problems in this sample.
We selected a subset of these variables for further analysis in multivariate
models aimed at predicting each of the 3 outcomes. We focused on constructs
that were likely to be antecedent to the development of the psychiatric disorders.
On this basis, age, sex, year of immigration, and premigration and postmigration
trauma exposure were selected as potential multivariate predictors. We omitted
several variables included as bivariate predictors due to concerns about direction
The odds ratios of these predictors, adjusted for age, sex, year of
immigration, and premigration and postmigration trauma exposure, show a similar
pattern across PTSD and major depression (Table
5). Participant age and the 2 trauma exposure variables were positively
associated with these psychiatric disorders. Alcohol use disorder was negatively
associated with age and positively related to extent of trauma exposure since
arriving in the United States. The bivariate association between sex and psychiatric
disorders was no longer significant after adjusting for the extent of trauma
exposure. Overall, these multivariate models produced high concordances between
actual and predicted disorder (c statistics of 0.77,
0.71, and 0.77 for PTSD, major depression, and AUD, respectively).
Our study examined the trauma exposure and mental health of a stratified
random sample of Cambodian refugees residing in the largest single Cambodian
community in the United States. Although on average more than 2 decades had
elapsed since arriving in the United States, our sample revealed high rates
of past-year PTSD (62%) and depression (51%). In comparison with epidemiological
studies of the general US population, these rates are extremely elevated.47,48 At the same time, rates of AUDs in
our sample were much lower than those reported in the general US population.48 The concern that motivated this research is that
certain features of previous studies of refugee samples may render them likely
to overestimate the magnitude of mental health problems. We found evidence
of pronounced mental health problems in previously traumatized refugees. Indeed,
only approximately 30% of the sample was free of any of the 3 disorders assessed.
These results indicate that members of refugee communities can have substantial
need for mental health services even years removed from their tribulations.
These data also demonstrate a dose-response relationship between trauma
exposure (both premigration and postmigration) and the likelihood of a current
psychiatric disorder. Specifically, degree of exposure to each broad class
of trauma is uniquely associated with both PTSD and major depression. This
finding of a possible dose-response relationship involving both PTSD and depression
has been found in related refugee research.8 However,
the relationship of trauma to depression has perhaps not been as widely appreciated.
Many refugee studies focus solely on PTSD to the exclusion of major depression
and other conditions likely to result from trauma exposure.20,23 Moreover,
in both bivariate and multivariate models, these findings identify a similar
pattern of predictors for both depression and PTSD. This comparability in
risk factors, along with the high comorbidity between PTSD and major depression
following trauma exposure, raise questions as to whether PTSD and depression
are empirically differentiable disorders or manifestations of a single continuum
of posttraumatic distress.49
This study found low rates of probable AUD in Cambodian refugees. Although
previous research using convenience samples has suggested that Cambodian refugees
are at high risk for alcohol abuse,50,51 to
our knowledge, this study is the first to assess this in a representative
community sample. These findings are consistent with other research indicating
that Asian-American subgroups differ substantially in their drinking patterns,
with some groups showing relatively high abstinence.52 The
absence of a relationship between PTSD and alcohol abuse is particularly striking
inasmuch as numerous studies of US samples report high comorbidity between
the 2 disorders,53 with many theorists positing
a causal link between PTSD and alcohol abuse.54 Our
findings suggest that researchers looking for biomedical explanations for
the association between alcohol abuse and PTSD should pay attention to the
cultural context in which drinking occurs, as this factor may moderate the
Unlike studies conducted on general US populations, we found that women
were no more likely than men to develop PTSD47 or
depression.55 One possible explanation is that
the frequency or severity of the traumas differed for men and women in ways
not captured by our trauma measure. It is also noteworthy that whereas these
results differ from typical findings in western populations, they are consistent
with research on sex differences in the prevalence of depression in Asian
immigrants in the United States56 as well as
in developing countries.55 Scant attention
has been devoted to sex differences in the mental health of refugee samples,
and available data have yielded mixed findings.20,57 Thus,
additional research is required.
In interpreting these findings, certain limitations of our study design
should be considered. Our study relied on cross-sectional data, restricting
our ability to infer the causal directions underlying the observed associations.
For example, the associations between socioeconomic status measures and psychiatric
diagnosis may represent the economic burden of these diseases or it may reflect
the impact of socioeconomic status on trauma recovery. Research using longitudinal
methods is needed to assess these hypotheses. In addition, as is the case
with most psychiatric epidemiology, the research design required retrospective
recall of both trauma exposure and symptoms. Such recall may be vulnerable
to bias.58,59 Because our sample
resided in a single Cambodian refugee community, it may not be representative
of the broader population of Cambodian refugees in the United States. Nonetheless,
it was a representative sample of the largest Cambodian community in the United
States, and achieved a high response rate, factors that minimize the biases
often found in research on refugee and immigrant populations.
Limitations may also exist with respect to the instruments used. Some
researchers have expressed concern that the CIDI may overestimate prevalence
relative to other lay-administered diagnostic tools.60 However,
research on the reporting of sensitive information suggests that individuals
often underreport symptoms in epidemiological surveys.61 Available
data indicate that the CIDI produces prevalence estimates very similar to
those derived from clinician-administered diagnostic assessments.62 Although additional research into the use of the
CIDI with Cambodians is clearly warranted, at present the CIDI constitutes
the de facto standard for conducting large-scale psychiatric epidemiology
research across languages and cultural settings. More generally, further investigation
is needed to establish the reliability and validity of other instruments used
in this study for use with Khmer-speaking Cambodians.
This study did not collect information on the extent to which participants
were being treated for mental health conditions or other health concerns.
Future research is required to determine the degree to which high rates of
PTSD and depression observed in this community are due to low service utilization
or ineffective treatments.
Despite arriving in the United States approximately 2 decades ago, Cambodian
refugees were beset by high rates of psychiatric disorders. The pervasiveness
of these disorders raises questions about the adequacy of existing mental
health resources in this community. Addressing this high level of need may
require additional research to identify barriers to seeking services as well
as efforts at improving treatment for this population. On a larger public
policy level, these findings raise questions about governmental policies concerning
The lives of Cambodian refugees—and perhaps those of refugees
from other developing countries—are fraught with difficulties for which
they may have been inadequately prepared. In the case of Cambodian refugees,
many were uneducated farmers, illiterate even in their native language,63 who entered the United States with no marketable
skills and significant mental health problems.64 Even
after 2 decades, the majority of this community speak little or no English,
are at income levels below poverty, and rely on public assistance. Asylum
policies for future refugees need to be evaluated not only with respect to
their ability to remove vulnerable populations from life-threatening danger
but also their capacity to promote the long-term health and well-being of
the refugees. Our findings suggest that the US response to Cambodian refugees
has not succeeded in this latter goal.
Corresponding Author: Grant N. Marshall,
PhD, RAND, 1776 Main St, PO Box 2138, Santa Monica, CA 90407 (email@example.com).
Author Contributions: Dr Marshall had full
access to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis.
Study concept and design: Marshall, Schell,
Elliott, Berthold, Chun.
Acquisition of data: Marshall, Berthold, Chun.
Analysis and interpretation of data: Marshall,
Schell, Elliott, Berthold, Chun.
Drafting of the manuscript: Marshall, Schell,
Elliott, Berthold, Chun.
Critical revision of the manuscript for important
intellectual content: Marshall, Schell, Elliott.
Statistical analysis: Schell, Elliott.
Obtained funding: Marshall, Schell, Elliott,
Administrative, technical, or material support:
Marshall, Berthold, Chun.
Study supervision: Marshall, Chun.
Financial Disclosures: None reported.
Funding/Support: This study was supported by
grants R01MH059555 from the National Institute of Mental Health and R01AA013818
from the National Institute on Alcohol Abuse and Alcoholism (Dr Marshall).
Role of the Sponsors: The National Institute
of Mental Health and the National Institute of Alcohol Abuse and Alcoholism
did not participate in the design or conduct of the study, in the collection,
management, analysis, or interpretation of the data, or in the preparation,
review, or approval of the manuscript.
Disclaimer: The views expressed in this article
are those of the authors and do not necessarily reflect the opinions of the
National Institute of Mental Health, the National Institute of Alcohol Abuse
and Alcoholism, or the institutions with which the authors are affiliated.
Acknowledgment: We thank the RAND Survey Research
team: Judy Perlman, MA, Can Du, MA, and Crystal Kollross, MS, for their assistance
with data collection and Katrin Hambarsoomians, MS, (RAND), for her help with
data analysis. We thank Bradley Stein, MD, (RAND), and David Takeuchi, PhD,
(University of Washington, Seattle), for their insightful comments on the
manuscript. We gratefully acknowledge the contribution of our interviewers
and community advisors to the success of this research. We particularly thank
Bryant Ben, who served as both community advisor and lead interviewer, for
his wise counsel and steadfast effort. Mss Du, Hambarsoomians, Kollross, and
Perlman, and Mr Ben were supported by grants R01MH5955 and R01AA13818. We
are also indebted to the research participants without whom this study would
not have been possible.