Patients of immigrant origin in inpatient psychiatric facilities. A representative national survey by the Psychiatry and Migration Working Group of the German Federal Conference of Psychiatric Hospital Directors

EPA guidance on cultural competence training

The stress of migration as well as social factors and changes related to the receiving society may lead to the manifestation of psychiatric disorders in vulnerable individuals after migration. The diversity of cultures, ethnicities, races and reasons for migration poses a challenge for those seeking to understand how illness is experienced by immigrants whose backgrounds differ significantly from their clinicians. Cultural competence represents good clinical practice and can be defined as such that a clinician regards each patient in the context of the patient's own culture as well as from the perspective of the clinician's cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. It points out that cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment. To reach these aims, both individual and organizational competence are needed, as well as teaching competence in terms of educational leadership. The WPA Guidance on Mental Health and Mental Health Care for Migrants and the EPA Guidance on Mental Health Care for Migrants list a series of recommendations for policy makers, service providers and clinicians; these are aimed at improving mental health care for immigrants. The authors of this paper would like to underline these recommendations and, focusing on cultural competency and training, believe that they will be of positive value.

Risk of Psychosis Among Refugees: A Systematic Review and Meta-analysis

IMPORTANCE

This systematic review and meta-analysis is, to date, the first and most comprehensive to focus on the incidence of nonaffective psychoses among refugees.

OBJECTIVE

To assess the relative risk (RR) of incidence of nonaffective psychosis in refugees compared with the RR in the native population and nonrefugee migrants.

DATA SOURCES

PubMed, PsycINFO, and Embase databases were searched for studies from January 1, 1977, to March 8, 2018, with no language restrictions (PROSPERO registration No. CRD42018106740).

STUDY SELECTION

Studies conducted in Denmark, Sweden, Norway, and Canada were selected by multiple independent reviewers. Inclusion criteria were (1) observation of refugee history in participants, (2) assessment of effect size and spread, (3) adjustment for sex, (4) definition of nonaffective psychosis according to standardized operationalized criteria, and (5) comparators were either nonrefugee migrants or the native population. Studies observing ethnic background only, with no explicit definition of refugee status, were excluded.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed for extracting data and assessing data quality and validity as well as risk of bias of included studies. A random-effects model was created to pool the effect sizes of included studies.

MAIN OUTCOMES AND MEASURES

The primary outcome, formulated before data collection, was the pooled RR in refugees compared with the nonrefugee population.

RESULTS

Of the 4358 screened articles, 9 studies (0.2%) involving 540 000 refugees in Denmark, Sweden, Norway, and Canada were included in the analyses. The RR for nonaffective psychoses in refugees was 1.43 (95% CI, 1.00-2.05; I2 = 96.3%) compared with nonrefugee migrants. Analyses that were restricted to studies with low risk of bias had an RR of 1.39 (95% CI, 1.23-1.58; I2 = 0.0%) for refugees compared with nonrefugee migrants, 2.41 (95% CI, 1.51-3.85; I2 = 96.3%) for refugees compared with the native population, and 1.92 (95% CI, 1.02-3.62; I2 = 97.0%) for nonrefugee migrants compared with the native group. Exclusion of studies that defined refugee status not individually but only by country of origin resulted in an RR of 2.24 (95% CI, 1.12-4.49; I2 = 96.8%) for refugees compared with nonrefugee migrants and an RR of 3.26 (95% CI, 1.87-5.70; I2 = 97.6%) for refugees compared with the native group. In general, the RR of nonaffective psychosis was increased in refugees and nonrefugee migrants compared with the native population.

CONCLUSIONS AND RELEVANCE

Refugee experience appeared to be an independent risk factor in developing nonaffective psychosis among refugees in Denmark, Sweden, Norway, and Canada. These findings suggest that applying the conclusions to non-Scandinavian countries should include a consideration of the characteristics of the native society and its specific interaction with the refugee population.

Assessment of Perceived Stress Related to Migration and Acculturation in Patients with Psychiatric Disorders (MIGSTR10)-Development, Reliability, and Dimensionality of a Brief Instrument

Assessment of stressors related to migration and acculturation in patients with psychiatric disorder and migration background could help improve culturally sensitive concepts of psychiatry and psychotherapy for diagnosis and treatment. The present overview delineates development and psychometric properties of an instrument (MIGSTR10) for assessment of stressors related to migration and acculturation, particularly for application in patients with psychiatric disorders. Ten migration-related stressors were derived from a qualitative content analysis of case histories of patients with psychiatric disorder and migration background and put into a suitable interview and questionnaire format (MIGSTR10; 10 questions, answer format: categorical yes/no, and dimensional 0-10) for self-assessment and observer ratings in several languages. Reliability (interrater agreement, internal consistency) and dimensionality (multi-dimensional scaling, MDS) were investigated in n = 235 patients with migration background and n = 612 indigenous German patients. Interrater agreement (ICC) for MIGSTR10 single items and sum scores (categorical and dimensional) was sufficiently high (≥.58); internal consistency (Cronbach's α) reached medium to high values (.56-.73). MDS revealed a two-dimensional solution with two item clusters (A: communication, migration history, forced marriage, homesickness, discrimination, other stressors; B: family conflicts, loss of status, feelings of shame, guilt feelings). The MIGSTR10 is a rationally developed, straightforward 10-item screening instrument with satisfactory psychometric properties for the assessment of individual and specific stressors related to migration and acculturation.

Sex-Dependent Association of Perigenual Anterior Cingulate Cortex Volume and Migration Background, an Environmental Risk Factor for Schizophrenia

Migration status is one of the best-established risk factors for schizophrenia. An increase in risk is observed in both first- and second-generation immigrants, with a varying magnitude depending on the ethnic background of the individuals. The underlying mechanisms for the increased risk are only recently coming into focus. A causal role for social stress has been widely proposed, and recent work indicated altered neural stress processing in the perigenual anterior cingulate cortex (pACC) in migrants. Since previous work shows that social stress may lead to enduring changes in the gray matter volume of vulnerable brain regions, we investigated the impact of migration background on brain structure. We studied healthy young adults (N = 124), native Germans and second-generation migrants, using whole-brain structural magnetic resonance imaging. Groups were matched for a broad range of sociodemographic characteristics including age, gender, urban exposure, and education. We found a significant group by sex interaction effect in pACC gray matter volume, which was reduced in males with migration background only. This mirrors previous findings in urban upbringing, another risk factor for schizophrenia. Our results provide convergent evidence for an impact of environmental risk factors linked to schizophrenia on gray matter volume and extend prior data by highlighting the possibility that the pACC structure may be particularly sensitive to the convergent risk factors linked to schizophrenia.

Risk of psychosis in refugees: a literature review

Conflicts and precarious living conditions resulted in the arrival of large numbers of refugees in Europe and especially in Germany. Evidence suggests that immigrant populations are at elevated risk of psychotic disorders. Considering the traumatic pre- and post-migratory adversities refugees may have encountered, people granted refugee status may even be more susceptible to psychosis than non-refugee migrants. The aim of this literature review is to summarise and interpret recent research on the incidence or prevalence of psychotic disorders in refugees, additionally focusing on the aspects of gender and Middle Eastern provenance. A systematic search in PubMed was performed in the time from 20 to 28 May 2016. Relevant literature was limited to articles describing cohort studies conducted in Western industrialised countries. Articles published between 1 June 2006 and 28 May 2016 were analysed. Content relating to psychotic disorders in refugees was reviewed and summarised. The selected studies showed an increased risk of psychotic disorders in refugees compared with both the indigenous population and non-refugee. migrants. The elevated risk was more pronounced in refugee men. A particularly high risk in refugees of Middle Eastern origin could not be inferred. The higher susceptibility to psychotic disorders in refugees emphasises the need for the development and implementation of adequate prevention strategies. Clinicians and people working in a refugee setting should be aware of early signs and symptoms of psychosis. Further research is required to evaluate post-migratory experiences and investigate the population of refugees affected by the current humanitarian crisis.

[Mental disorders of immigrants in Germany]

Currently the majority of data regarding indicators of psychiatric morbidity of migrant and minority groups in Germany is derived from studies on help-seeking behavior, mental health service use, or data from population studies, which were not specifically aimed at including migrants. Such data are only available for certain groups, for example, population-based studies on psychiatric disorders and suicidal behavior among Turkish migrants have been conducted, while, comprehensive data on the psychiatric morbidity among major migrant groups in Germany are still rather limited. Barriers to recruiting migrants for health studies, difficulties in assessing psychiatric morbidity in multi-cultural samples, observed as feasibility problems, are among the factors that interfere with population-based studies.

From Kraepelin to a modern and integrative scientific discipline: the development of transcultural psychiatry in Germany

The roots of transcultural psychiatry in Germany can be traced back to Emil Kraepelin, who made the first culturally comparative observations on mental disorders in Southeast Asia at the start of the 20th century. Since the beginning of the 1970s, contributors to the literature of transcultural psychiatry in Germany have been predominantly concerned with the mental health of migrant workers from Mediterranean countries, particularly the practical difficulties and therapeutic implications of inpatient psychiatric treatment of these migrant groups. The inauguration of the Section on Transcultural Psychiatry of the German Association for Psychiatry and Psychotherapy 20 years ago reflected an increasing scientific interest in this topic. In addition to the psychic impact of migration, research into transcultural care is currently focused on disparities in the utilization of health care and conjectured barriers to access to health and mental health care among migrants. Furthermore, studies based on epidemiological approaches have been carried out in order to resolve the question of whether migrants are as affected by mental disorders as the ethnic German population, and which issues contribute to the so-called "healthy migrant" effect. Other topics that have been explored in the last 10 years are the particular psychosocial situation of asylum seekers and refugees in Germany, and the effects of inadequate integration and discrimination on their mental health. In summary, after a short historical and theoretical overview, this article reviews the current major themes in transcultural research in German contemporary psychiatry, and concludes with an overview of future developments in this field.

How to express mental health problems: Turkish immigrants in Berlin compared to native Germans in Berlin and Turks in Istanbul

The paper explores expressions used by Turkish immigrants in Berlin to delineate psychiatric illnesses and psychological problems. These are compared to expressions used by native Germans in Berlin and Turks in Istanbul to assess possible cultural differences in articulating mental disorders. For this purpose, results of a Free Listing carried out with the three above mentioned groups are presented. The data suggest that relevant items which are connected to mental health issues vary between the groups as well as within the groups, thus showing dependency on factors such as education. For the group of Turkish immigrants the data further suggest that this group connects psychic stress to family problems. Concerning help seeking, Turkish immigrants, like members of the other groups, mention professional psychological/psychiatric help as useful for solving mental health problems.

[Patients of immigrant origin in inpatient psychiatric facilities. Differences between first and second generation: nationwide questionnaire of the Psychiatry and Migration Working Group of the German Federal Conference of Psychiatric Hospital Directors]

In a representative nationwide survey, the Psychiatry and Migration Working Group of the German Federal Conference of Psychiatric Hospital Directors examined the use of inpatient psychiatric and psychotherapeutic services in Germany by patients of immigrant origin. Questionnaires were sent to a total of 350 general hospital psychiatric clinics throughout Germany and 131 responded by the specified deadline (19 July 2006). In our study, persons of immigrant origin comprised 17% of patients in the responding facilities, which confirmed the results of the pilot study in 2004 of 17.4%. This indicates that the percentage of inpatient psychiatric services used by patients of immigrant origin is almost proportionate to these patients' percentage of the general population (18.6%, Microcensus 2005). In this main study patients of immigrant origin were significantly more likely to receive an ICD-10 F2 diagnosis, and it was precisely patients with this diagnosis who were observed to experience difficulties in communication with caregivers. With reference to the F2 diagnoses there were no noticeable differences between first generation of inpatients with migration history and second generation of inpatients with migration history. There were however more first generation of inpatients with migration history diagnosed with affective disorders whereas more second generation of inpatients with migration history were diagnosed with personality and behavioural disorders. Such differences were not found in the group of patients without immigrant origin. Whilst first generation of inpatients with migration history demonstrated higher educational levels, second generation of inpatients with migration history showed fewer linguistic difficulties.

The level of non-Western immigrants' use of acute psychiatric care compared with ethnic Norwegians over an 8-year period

Immigrants are assumed by many to have more mental health problems than the population in the countries they have emigrated to, and clinicians have the impression that an increasing number of non-Western immigrants are referred to acute psychiatric care. Patients referred over an 8-year period to an acute care facility, responsible for a catchment area of close to 100,000 inhabitants in Oslo, Norway, were scrutinized to study the latter assumption. In total 792 men and 701 women (47.0%) were referred. There were 168 men and 59 women among the non-Western immigrants, i.e. 26.0% of the non-Western immigrants were women, whereas 50.2% or 611 out of 1217 ethnic Norwegians were women. Non-Western immigrants were referred twice as often in 2007, n=40, as in 2000, n=19. Non-Western immigrants as a percentage of the other referred patients increased from 15.2% to 16.0% in 2006, which was lower than the representation in the general population. Mean age was lower for non-Western immigrants, 34.6 (standard deviation, s=14.7) than for ethnic Norwegians 39.5 (s=11.6). Mean length of stay was lower for ethnic Norwegians. If the prevalence of mental disorders is the same or higher in immigrants than in the original population, this study indicates that they are under-represented among referred patients from the catchment area population. This seems to be the case especially for women.