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Immigration in the U.S.: Is care for mental illness out of reach?

SAN FRANCISCO &

Omeed Popal's parents knew the young man wasn't well. He heard voices, believed people were trying to kill him, and once falsely confessed to his boss that he'd stabbed someone.

The family of Afghan refugees kept close watch over Popal for years, and got him emergency help when he seemed to need it. They even arranged a wedding, hoping marriage would prompt the 29-year-old Popal to settle down.

But Popal escaped their guard in August and swept through the streets of San Francisco in his black sport-utility vehicle, smashing into 18 people after killing one pedestrian in Fremont. He faces a variety of charges, including attempted murder and evading police, and is due back in court in two weeks.

Like many low-income immigrant families, whose difficulty getting health care is compounded by a language barrier and a deep cultural divide, Popal's relatives were at a loss when it came to finding a doctor who understood them.

Newcomers with radically different beliefs about mental health, such as Hmong refugees from Southeast Asia, have had to reconcile their different understanding of the causes of mental illness. What set Popal's case apart is the tragedy that ensued when he went untreated.

Doctors and others who work with immigrants say being in a new country, without the support of family and surrounded by a foreign culture can be a real psychological hardship.

The National Latino and Asian American Study, concluded by December 2003 with funding from the National Institute of Mental Health suggested that recent Hispanic and Asian immigrants had a lower incidence of mental disorders than Americans, but accessed help far less often.

Not speaking English or having health insurance presented the most obvious stumbling blocks, according to "Mental Health: Culture, Race, Ethnicity - Supplement," a report issued by the Office of the Surgeon General at the U.S. Department of Health and Human Services five years ago.

Studies reviewed in the report showed that 37 percent of Latinos are uninsured, and suggested that fewer than 1-in-20 Hispanics with mental disorders used the services of specialists.

Although insurance rates vary widely within the Asian-Pacific Islander population, taken as a whole the report found them far less likely than whites to seek care for a mental disorder, or even to mention their problems to friends and family.

Refugees like Popal's family, who fled during the Soviet invasion of Afghanistan in the 1980s, might arrive suffering post traumatic stress disorder, depression or anxiety. These are conditions that require long term care, and that can make it particularly difficult to meet new people and hold down a job &

the very things that might anchor lives in flux, Khalil Rahmany, a clinical psychologist who works primarily with Afghan immigrants.

"Very often, they've left their home, their hearts, their belongings," said Rahmany. "And often family members left without knowing if their relatives were even living or dead."

Many cultures also harbor time-honored biases about psychological problems.

"There are other ways of seeing things out there," said S. Reshma Yunus, director of SEMAH, a domestic violence prevention organization focusing on immigrant Muslim women. "If somebody comes in and they believe they're possessed, they need someone to help them get unpossessed.."

Such beliefs can keep people from seeking help even when they know it's available.

In Afghanistan, "it's seen as an emotional weakness, a deficit in personality," said Rahmany. "People with mental health problems were taken to the mullah or to holy sites, not to doctors."

Family members may even refrain from getting help for a relative because they don't want to shame them by exposing their illness to strangers, he said.

Popal's relatives tried to manage him as best they could, keeping watch and taking him to emergency rooms when he seemed out of control, said cousin Hamid Nekrawesh.

"If there was follow-up (to the emergency room visits) this whole situation could have been prevented," Nekrawesh said. "But the doctors didn't think he would be harmful to society."

Even for those open to Western-style counseling, finding a doctor who understands a patient's language and background and is willing to work with their belief system is difficult, said Sarita Kohli, director of mental health programs at Asian Americans for Community Involvement. The organization offers counseling for immigrants, refugees and torture survivors from dozens of mostly Asian countries, among them Cambodia, Vietnam, Laos, Thailand and China.

"There just aren't enough resources out there that are appropriate for our clients," Kohli said. "We can't refer them out because there isn't any place to refer them to."

The result is that many don't get the help they need, as suggested in the Surgeon General's report. The report called for increasing research, the geographic distribution of mental health providers, and the availability of treatments tailored to patient to remedy what it called "striking disparities in knowledge, access, utilization, and quality of mental health care for racial and ethnic minorities."

For most who go without treatment, the consequences are felt at home, among family, in a life stunted by a condition that might have been alleviated. Popal's bane was that without care, his mental problem led him to lash out, impacting the lives of dozens of others such as Susan Rajic, who became paralyzed from the neck down when struck by his car.

Nearly three months later, Rajic's struggling to regain some control of her arms with the hope of being able to feed herself again, said Debra Bogaards, her attorney.

Rajic understands the turmoil Popal's family is going through, but they had a responsibility to recognize the severity of his condition, seek treatment and not give him access to the car, which was registered in his name, Bogaards said.

"He seems to have a very strong Muslim community which is speaking out on his behalf," Bogaard said. "Where were they when he was going through these emergency room visits? They could have availed themselves of very good practitioners."

Now, Popal is being held on 18 counts of attempted murder and assault with a deadly weapon, plus single counts of battery on a peace officer and reckless evasion from police. He's also expected to face a murder charge in the death of a pedestrian who was run down in Fremont.

The shock has led his father, who had suffered from similar mental health problems but hadn't sought treatment, to start seeing a therapist that Popal's cousin Nekrawesh found for him.

In jail, Popal is under the constant supervision of doctors who are addressing his mental disorder with therapy and a drug regimen.

At his latest court hearing, Popal smiled and greeted family and friends in the gallery, and responded to the judge's questions without difficulty.

Now, with medical care, Popal is finally doing well &

well enough for court-appointed psychologists to declare him mentally fit to stand trial and take responsibility for his actions.

His arraignment is scheduled for Dec. 12.