Last rites in Syracuse

His hand over his mouth, the stunned funeral director shook his head. In front of Prem Regmi's open casket, where chairs were normally lined up for a Christian service, mourners huddled around a makeshift shrine on the floor, the centrepiece a lit pile of oiled wicks. The older and more grief-stricken sat in chairs along the outer perimeter of the carpeted room, the men on one side wearing topis, the women on the other wearing blank stares.

As the priest and Prem's father prayed, they lit more wicks to add to the burning pile. A wick fell out of the tray and its tiny flame danced on the floor. "Pick it up, quickly!" men shouted in Nepali. The funeral director had tried to stop this part of the rites, but had been convinced to allow it. As he stood in the corner, an old man in a yellow winter hat and a suit jacket too large for his shrunken frame approached him. He cupped his hands in front of his face in prayer and bowed his head, then mimed a few words and nodded affirmatively. "It's okay," the director told him.

Despite visions of broken fire codes, the director may have extended the extra cross-cultural compassion knowing this was a particularly difficult funeral. Suicide is one of those most wrenching of family tragedies, unfairly leaving loved ones wondering what they should have or could have done differently.

It was under these circumstances that Hem Regmi said his final goodbye to his son at a cemetery in Syracuse, New York on 7 June 2013. At the crematorium, bodies pressed close to one another to watch, the whir of machines replacing the sensations more familiar to those used to attending cremations in Nepal or Bhutan. After the prayers ended, wailing women and girls emerged first, supporting one another. Then came Hem. Stoic till now, his eyes brimmed with tears, his chin crumpled. He held his hands out limply like a child, and two men walked him away.

Prem Regmi became the second loss to suicide in the small but growing Bhutanese refugee community near the centre of New York state. Three years earlier, 20-year-old Mitra Mishra had taken his own life in a city park. Across the country, suicides had sprung up in the cities the Lhotsampas (Bhutanese of Nepali origin) now called home. A 2012 study by the Centers for Disease Control and Prevention (CDC) and the Refugee Health Technical Assistance Center of the Massachusetts Department of Public Health revealed the rate of suicide among US-resettled Bhutanese to be 20.3 per 100,000 – higher than both the rate for the general US population (12.4) and the global suicide rate (16), and higher than the rates among other refugee groups. Suicide rates are calculated per 100,000 people, so these figures do not represent percentages (a mistake that dangerously exaggerated the rates in some reporting on the suicides).

By July 2014, the federal Office of Refugee Resettlement (ORR) put the official count of confirmed suicides at 40. Bhutanese refugee activist and former editor T P Mishra of the Bhutan News Service, a news agency founded by Bhutanese refugees in Nepal, estimates the real number is somewhere between 42 and 50. Mishra knew of at least one suicide incorrectly reported by ORR so he suspects the list is not completely accurate.

Understanding a sensitive issue

Deeply personal pain that had been setting in across different communities had now become a national issue. Once the magnitude of the problem had sunken in, the natural question was why? The refugee experience itself is an obvious first thought. On top of traumatic events experienced during the conflict itself, the trauma of forced exile, statelessness and languishing in refugee camps may have taken its toll. Also, the Bhutanese first began to arrive in the US in 2008, in the midst of the deepest economic recession since the 1930s. In the years since, finding a job has felt like a Sisyphean task for educated, English-speaking Americans and nearly impossible for the many refugees possessing few English words and a class one or two education.

"People have been promised a lot," Mishra says, citing his own family as an example. Unlike the highly educated editor, when resettlement started, his two brothers spoke no English and had never been to school. "They were of the opinion that we shouldn't come to the US. But then people like me convinced them that we should." Mishra says he has held up his promise to his family, but knows the burden is too great for a lot of families. In his current job as case manager, Mishra sometimes hits a wall. "It's too much pain," he says, "The more I try to help people, the more they expect."

Religion too has been cited. Brandon Kohrt, a medical anthropologist and psychiatrist working in Nepal since 1996 and with the Bhutanese in the US, noted that is difficult to consider religion itself as a metric for suicide risk, particularly given the wide variability in practise of a religion like Hinduism. Mishra suggested it as a cause, citing the lack of suicides among Christian Bhutanese, but he explains this less as a comment on the religions themselves than on how they are practised in the US. "They have a place where they can go every week where someone can teach them about the value of life," Mishra says of Christian adherents. "When it comes to Hinduism, I don't see that happening. I see that there are bigger cultural events, there are religious events being organised, but I don't see Hindu people going to a place where people are telling them about the value of life."

The caste system does seem to be a factor in risk profiles. In rural northwestern Nepal where he works, Kohrt sees much higher rates among lower castes, likely explained by lower socioeconomic and educational resources and higher levels of stress and trauma due to caste discrimination. In the US, religious conversion increases stress, not necessarily for those who have converted, but for their families, Kohrt says. When adult children adopt Christianity, they may prevent their parents from practising Hinduism and engaging in rituals – this was the case with an older woman he knew of who attempted suicide.

But Kohrt also cautioned against taking the rates revealed by the CDC study to mean more than they do. The study was a first important step in identifying a problem, he says, but now the research community must follow the problem over time to see how serious it really is. Because suicide is such a rare event and the study population necessarily small, the occurrence may look higher than it really is.

And suicide rates are actually quite high in Nepal as well. The rate among refugees in the camps in Nepal was 20.7 (the International Organization of Migration recorded 67 suicides between 2004 and 2010) and 2012 data from the World Health Organization puts the rate for Nepal's general population at a staggering 24.9 (Bhutan's is 17.8). Suicide was the leading cause of death for Nepali women between the ages of 15-49 according to the Maternal Mortality and Morbidity Study of 2008-2009. It had ranked third in the same study a decade earlier. This could mean the suicides have less to do with being a refugee than with a set of ideas that can develop around mental health and shape individual responses.

Against this background, the reasons individuals take their lives are as varied and personal as the lives themselves, but are reasons you might expect from any group: undiagnosed psychiatric disorders, alcohol and drug abuse, domestic and relationship problems.

Prem's story

"Whenever he got a problem, he kept it with him. He never shared, always smiled as if he had no problems," Lok Regmi says of his late brother Prem. Lok is telling me his brother's story across a table at the Red Dragon, a recently opened Bhutanese-Nepali restaurant in Syracuse, New York. The third of four brothers, Prem generally stayed out of trouble, Lok says. "He was an aware guy." At 26, Prem even led the Regmi family to the US, arriving in Syracuse alone in 2010 before the rest of the family resettled in stages.

Prem wandered around the states a little bit looking for work, and eventually moved to Colorado with his wife whom he had met in Syracuse. "We used to hear sometimes that he was drunk," Lok says, but the family didn't hear much else. The couple wouldn't often answer the phone, with Prem working late at his meat processing job. So it was a surprise when Prem called from jail, arrested for domestic violence, Lok says. He and his brothers pooled their meagre resources to pay the USD 1500 bail, and Prem drove across the country back to Syracuse.

"I forgot the month, but it was snowy time," Lok says. Prem wasn't a very experienced driver and was driving an old car he adds, the elder brother in him showing concern even now. Prem didn't want to return to Colorado, citing the money and domestic problems back home, but the family and a local caseworker, Jai Subedi, convinced him to go. His father came out to Colorado a few weeks later and found Prem drunk. But he reported back to the family that Prem "never misbehaved".

Prem settled into a pattern of work and attending classes on domestic violence when he called a second time from jail, again on a domestic violence charge. Lok is fuzzy on the exact details – Prem kept them quiet – but Prem claimed that though the accusations were false, he plead guilty because he didn't have money for a lawyer. Prem came back to Syracuse again, now estranged from his wife and enmeshed in a maze of probation and financial responsibilities for child support, which he didn't seem to fully understand. The problems took their toll and Lok noticed Prem growing depressed.

On the day Prem killed himself, he brought his mother several bags of rice and gallons of oil telling her she'd need it in a couple of days. He also complained of chest pain, but refused Lok's entreaties to go to the hospital because of his mounting financial worries. That evening, Prem told their father he was going out for a cigarette. After an hour passed and he hadn't returned, the family worried he might have gone drinking. Prem's phone was out of service and friends they called didn't know where he was. Lok and his brother Netra drove to the hospital thinking Prem's chest pain might have become serious. On the way, Lok's wife Sabitra called. "Come back home as soon as possible. Our house is surrounded by police officers," she said. "I'm very scared."

Prem had been found hanging in a nearby children's playground. He was now in the hospital, alive, but in critical condition. Lok and his siblings couldn't tell their parents how serious he was and initially told them he'd be okay. "We didn't have any answers to give our parents," Lok says. "We were scared to tell them the truth." The truth was Prem was brain-dead. After a few days on a ventilator, they made the difficult decision to take him off.

Lok concludes his story with his regret over not forcing Prem to go to the hospital. Lok thinks Prem didn't realise he was experiencing a psychological condition. "If he understood something about that, I think he would not have done it," he says.

Developing an appropriate response

Few Bhutanese have the vocabulary or cultural familiarity to discuss mental health says Dr Chhabi Lall Sharma, an outpatient psychiatrist in St Paul, Minnesota. Currently the only Bhutanese psychiatrist in the US, Sharma came to the country for political asylum in 2003. Sharma sees many refugees in his practise, including a large number of Bhutanese, for whom it remains taboo to talk about mental health problems. "It's more often couched in the language of physical pain," he explains. "It doesn't make sense, and you can't figure out which system it is affecting."

After so many years working with the Bhutanese, and his shared cultural background, Sharma knows to keep gently prodding, but Western medical providers unused to Bhutanese cultural norms may get tripped up by a patient who describes no emotional symptoms. "A regular American patient is more likely to say, I'm depressed," Dr Sharma explains. "They know the symptoms, they know how to talk about the symptomatology, they know the language. In Nepali, dukha laaghca (I feel sad), runa manalaagcha (I feel like crying), it's not exactly depression, but those are the symptoms."

But until there's a phalanx of Bhutanese psychiatrists, more creative approaches are required to deal with the situation. One strategy is to increase the mental health literacy of the community itself. In this vein, ORR supported community members in running the first community conference on suicide awareness and prevention on 28 and 29 June 2014.

"We had a great brainstorming session during the first day," says Ashok Gurung, one of the conference co-leaders and a master's student in biology at the University of Pittsburgh. Attendees were asked which issues they thought most affected suicidal thinking in the community, and completed a survey modelled after research with a Chinese immigrant community in Australia. Language was a common response, as was family separation. The second day involved training in Mental Health First Aid, which aims to give regular people the skills to assist in a mental health emergency.

Also in Pittsburgh, grant money allowed Gurung and other non-professional volunteers to get training to work with the community. "We never say that we are mental health counsellors. If we say so then they will just avoid talking to us," Gurung says. "They feel 'I'm a mental health patient now.'" Gurung saw first-hand how effective a trained community member can be. When a woman who came to see him wouldn't open up, he mentioned that he knew her cousins in Australia. "I know your brothers and they're my friends. I can be your brother," he recalled telling the woman, who then admitted she had been contemplating suicide. "It's not always a mental health thing that makes them decide to take their own life. Sometimes it is very impulsive," he says.

Better understanding of the issues allows for simple thoughtful changes, like in the way the suicides have been reported by the Bhutan News Service (BNS), the Bhutanese refugee news outlet which has reported the most on individual cases. Mishra, the former editor, started researching guidelines for reporting on suicide after US-based friends told him about suicide contagion and suggested the website tone down its detailed reporting on methods. BNS also started putting hotline information at the end of suicide-related articles and ran banners on preventive measures. Mishra said some on the team suggested they stop reporting on suicides altogether, which he rejected, insisting people need to know what's going on in the community.

The focus on cultural appropriateness and the tendency of the Bhutanese to describe physical symptoms more often than psychological ones led one American physician to look towards a physical intervention with roots in Southasia. According to an article for the Heartland Health Monitor, Dr Joe LeMaster found that yoga practise not only reduced the pain his psychiatric patients complained of, it also seemed to improve symptoms of anxiety and depression and help with acculturation. LeMaster is still trying to figure out why yoga helped, but thinks it may simply be because the practise matches well with a Hindu worldview.

Back in northwest Nepal, researcher Brandon Kohrt and his team are testing a decidedly psychological intervention that he believes may fit better with the Nepali cultural landscape and offer logical applications for the Bhutanese refugee population in the US given the cultural similarities. A major parallel for the situation in Nepal and for the refugees in the US is access to care, says Kohrt. The challenge now is to figure out how to better reach out to Bhutanese communities in the US. Kohrt thinks this means increasing the number of trained people, providing therapy in a non-stigmatising way, and integrating mental health into other aspects of refugee life, like physical health and literacy classes. The key seems to be both creating psychologically strong, culturally appropriate interventions, and increasing understanding of mental health issues throughout the population.

At their field site in Jumla, the team is piloting a cultural adaptation of dialectical behavioural therapy (DBT). Developed by American psychologist Marsha Linehan, DBT has strong roots in Buddhist meditative tradition. Through mindfulness practise, participants recognise and accept the sensations and thoughts they are experiencing, without struggling against what they cannot change. The therapy is intended to help people stop self-harmful behaviours, like suicidal thinking, by teaching them to be more aware of what triggers those thoughts and how to cope with the underlying distress.

"It's the gold standard rate for suicide prevention in America," Ramaiya says of DBT. But the researchers had to modify the model so much for cultural and logistical reasons that Kohrt says their version is not really DBT so much as a simplified version based on the concepts. DBT requires a fairly high rate of literacy, explained Ramaiya, and uses a lot of technical terms. She immediately noticed that these elements had to be drastically modified for the low-literacy participants in Jumla, only two of whom could read. "It's as if even holding a pen is kind of foreign to them," she said.

One famous idea in DBT is to distract yourself with a strong sensation – in the US, therapists advise their patients to hold an ice cube so the overwhelming cold will distract them from distressing feelings. But there are, of course, no icemakers in Jumla. Ramaiya and colleagues told the women to take a very cold bath. At the same time, some of the concepts that form the core of DBT, like mindfulness, can be difficult and take some time for Americans to wrap their minds around. Ramaiya says the Jumla women understood mindfulness right away. While the project is ongoing and Kohrt says the results won't be ready for some time, if it proves effective there are likely to be lessons that can be beneficial in other contexts.

Additionally, Kohrt considers schools fertile ground for public health-style mental health interventions. Not only are adolescents at high risk for psychological problems, offering mental health education as part of the regular school day reduces the stigma, he explains. Bhutanese refugee youth in the US often find themselves in the strange position of being cultural brokers for their parents too, both increasing their stress and placing them as information bearers. His team is also trying this approach out in Jumla through a newly created NGO called Heart Mind International. Their next project is a training programme for teachers in mental health literacy.

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I had first met Lok Regmi, not because of the tragedy of his brother's suicide, but because of the triumph of his wife's mental health. I interviewed him in 2012 for an earlier article about the community suicides during which he described Sabitra's struggles with depression and paranoid delusions while in the camp. A couple of times Sabitra ran away. She said people were trying to kill her parents and she had to save them. She also twice told Lok she wanted to die. Lok credits his training as a community mental health worker in the camps with allowing him to get Sabitra the help she needed. He calls her improved health, "my great happiness."

Sabitra now regularly sees a therapist and psychiatrist and Lok makes sure she doesn't forget to take her medications. When I ask him what he thinks was different about his wife's and his brother's situations, he doesn't hesitate. "She shared with me."