[Health care utilisation of migrants with mental disorders compared with Germans]

[Current Outpatient Psychotherapeutic Care for People with Migration and Refugee Experience in Germany - An Overview]

Although mental health is a human right, even in a country with a well-developed healthcare system like Germany, it is not possible to ensure non-discriminatory access to mental health care for all people, regardless of their origin. For individuals with a history of flight or migration it is particularly difficult to gain access to adequate psychotherapeutic care. This review addresses key barriers contributing to the lack of outpatient care for people with a history of flight or migration. Lack of knowledge about the treatment system, fear of stigma, structural barriers, language barriers, lack of networking of healthcare providers, lack of knowledge of mental health practitioners, as well as stereotypes, discrimination, and racism towards people with a refugee or migration history were identified as the most important barriers with sufficient evidence. Innovative concepts such as peer support can enable non-discriminatory treatment access. In addition, there is an urgent need to train the profession of psychotherapists in racism- and discrimination-sensitive work and to integrate these aspects into psychotherapeutic education and training.

Barriers and facilitators to seeking and accessing mental health support in primary care and the community among female migrants in Europe: a "feminisms" systematic review

BACKGROUND

Recent years have seen record levels of migration to Europe. Female migrants are at heightened risk of developing mental health disorders, yet they face barriers to accessing mental health services in their host countries. This systematic review aims to summarise the barriers and facilitators to accessing mental health support for female migrants in Europe.

METHODS

The review follows PRISMA guidelines, and the protocol was pre-published on PROSPERO. Six electronic databases were searched: CINAHL, Global Health Database, Medline, PsycARTICLES, PsycINFO and Web of Science. Thematic analysis was undertaken on the identified studies. A feminist quality appraisal tool was applied.

RESULTS

Eight qualitative, six quantitative and five mixed methods studies were identified. Barriers included a lack of information, stigma, religious and cultural practices and beliefs, and a lack of consideration of gender-specific needs within the health system. Gender-sensitive services, supportive general practitioners and religious leaders facilitated access.

CONCLUSIONS

The design of mental health research, services, policies, and commissioning of support for migrants must consider female migrant needs. Mental health support services must be culturally aware and gender sensitive.

REGISTRATION

The review protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO, registration number CRD42021235571.

Health Care Services Utilization of Persons with Direct, Indirect and without Migration Background in Germany: A Longitudinal Study Based on the German Socio-Economic Panel (SOEP)

There is ambiguous evidence with regard to the inequalities in health care services utilization (HCSU) among migrants and non-migrants in Germany. The aim of this study was to analyze the utilization of doctors and hospitalization of persons with direct and indirect migration background as well as those without in Germany. This study was based on data of the German Socio-Economic Panel using the adult sample of the years 2013 to 2019. HCSU was measured by self-reported utilization of doctors and hospitalization. Associations between HCSU and migration background were examined using multilevel mixed-effects logistic regression and zero-truncated multilevel mixed-effects generalized linear models. The odds ratios of utilization of doctors and hospitalization for persons with direct migration background compared with persons without migration background were 0.73 (p < 0.001) and 0.79 (p = 0.002), respectively. A direct migration background was associated with a 6% lower number of doctoral visits within three months compared with no migration background (p = 0.023). Persons with direct migration background still have a lower HCSU than persons without migration background in Germany. Access to health care needs to be ensured and health policy-makers are called upon to keep focus on the issue of inequalities in HCSU between migrants and non-migrants in Germany.

Effectiveness of Inpatient Psychotherapy for Patients With and Without Migratory Background: Do They Benefit Equally?

BACKGROUND

Research on the effectiveness of inpatient psychotherapy for migrant patients predominantly concludes that they have greater symptom severity at admission and benefit less from psychotherapy. This study aims to compare symptom severity and effects of psychotherapy regarding depression, somatoform disorders, anxiety disorders, and posttraumatic stress disorder (PTSD) in a sample of patients with and without migratory background (MB).

METHODS

Symptom severity of 263 patients (T0, pretreatment) and 256 patients (T1, posttreatment) was assessed using the Patient Health Questionnaire somatization module (PHQ-15), depression module (PHQ-9), and general anxiety disorder module (GAD-7), and the PTSD Checklist (PCL-5). Calculations were made for a completer sample and an intention-to-treat (ITT) sample. To investigate the effectiveness of psychotherapy, we calculated effect sizes (Cohen's d) and clinically significant changes using the reliable change index (RCI).

RESULTS

Patients with MB showed significantly higher symptom burden at admission for somatization (p = 0.025, d = 0.345) and posttraumatic symptoms (p = 0.008, d = 0.424) than patients without MB. At discharge, patients with MB reported significantly higher severity regarding all assessed symptoms (somatization: p = 0.001, d = 0.507; depression: p = 0.045, d = 0.313; anxiety: p = 0.012, d = 0.428; traumatization: p = 0.040, d = 0.329) compared with non-migrant patients. Patients without MB improved significantly regarding all assessed symptoms (somatization: p < 0.001, d = -0.304; depression: p < 0.001, d = -0.692; anxiety: p < 0.001, d = -0.605; posttraumatic symptoms: p < 0.001, d = -0.204). Patients with MB improved significantly concerning depression (p < 0.001, d = -0.649) and anxiety (p = 0.002, d = -0.441). Occurrence of comorbidity was high (87.1% had more than one psychiatric diagnosis). Neurotic, stress-related, and somatoform disorders (F4) and personality disorders (F6) were more frequent among patients with MB.

CONCLUSIONS

Patients with MB showed higher symptom severity at admission. Our study demonstrated a significant reduction of depressive and anxiety symptoms among patients with MB receiving psychotherapy. Further research is needed to identify interventions that effectively improve somatization and posttraumatic stress for patients with MB, since these symptoms were not significantly reduced.

Inequalities in health care utilization among migrants and non-migrants in Germany: a systematic review

BACKGROUND

Despite the growing number of people with migrant background in Germany, a systematic review about their utilization of health care and differences to the non-migrant population is lacking. By covering various sectors of health care and migrant populations, the review aimed at giving a general overview and identifying special areas of potential intervention.

METHODS

A systematic review was conducted in PubMed database including records that were published until 1st of June 2017. Further criteria for eligibility were a publication in a peer-reviewed journal written in English or German language. The studies have to report quantitative and original data of a population residing in Germany. The appropriateness of the studies was judged by both authors. Studies were excluded if native controls were not originated from the same sample. Moreover, indicators of health care utilization have to assess individual behaviour like consultation or participation rates. 63 studies met the inclusion criteria for a qualitative synthesis of the findings.

RESULTS

The overall findings indicate a lower utilization among migrants, although the results vary in terms of health care sector, indicator of health care utilization and migrant population. For specialist care, medication use, therapist consultations and counselling, rehabilitation as well as disease prevention (early cancer detection, prevention programs for children and oral health check-ups) a lower utilization among people with migrant background was found. The lower usage was particularly shown for migrants of the 1st generation, people with two-sided migrant background, children/adolescents and women. Due to the methodological heterogeneity a meta-analysis was not feasible. As most of the studies were cross-sectional, no causal interpretations could be drawn.

CONCLUSIONS

The inequalities in utilization could not substantially be explained by differences in the socioeconomic status. Other reasons of lower utilization could be due to differences in need, preferences, information, language and formal access barriers (e.g. charges, waiting times, travel distances or lost wages). Different migrant-specific and migrant-sensitive strategies are relevant to address the problem for certain health care sectors and migrant populations.

TRIAL REGISTRATION

The review protocol was registered on PROSPERO ( CRD42014015162 ).

Incidence of schizophrenia among migrants in the Netherlands: a direct comparison of first contact and longitudinal register approaches

PURPOSE

To estimate the effect of selective sampling on first contact (FC) studies of the relation between migration and schizophrenia.

METHODS

We compared the FC method directly with a more inclusive longitudinal psychiatric register (LPR) method, by letting both methods estimate age and sex adjusted incidence rate ratios (IRR) in the population of The Hague aged 20-54 years, for the three largest migrant groups (first and second generation Caribbean, Turkish, and Moroccan) relative to the native Dutch population.

RESULTS

Both methods found that the adjusted IRR was higher for migrants than for native Dutch [all migrants IRR = 1.70 (95% Cl 1.30-2.21) for the LPR method and 1.91 (95% Cl 1.15-3.25) for the FC]. The IRR for Moroccans was significantly lower in the LPR [IRR 2.69 (95% 2.10-3.41)] than in the FC study [4.81 (3.41-6.68)]. The FC method was relatively more inclusive for migrants presenting at earlier ages or with shorter durations of prior treatment (DPT) than the native Dutch. This resulted in differential sampling and artificially higher IRRs for Moroccan and, to a lesser extent, Turkish migrants.

CONCLUSION

We confirm that the incidence of schizophrenia is raised twofold for migrants compared to nonmigrants. Using the LPR method, however, IRR estimates were less pronounced for most migrant groups than in a high quality FC study conducted in the same population. The FC method may overestimate the risk of schizophrenia for migrant groups who seek first mental health at a relatively younger age, or who present directly with schizophrenia.

[Acute psychosis as a side effect of efavirenz therapy with metabolic anomalies: an important differential diagnosis of HIV-associated psychoses]

Among patients with human immunodeficiency virus (HIV) infections psychiatric disease poses a particular challenge for caregivers. Neuropsychiatric side effects of efavirenz have been described in up to 40% of patients showing dizziness, insomnia, unusual dreams, mood instability, personality alterations and thought disorders. In immigrants from Africa and South America these side effects may be related to elevated plasma concentrations of efavirenz due to polymorphisms of cytochrome P450 isozymes (especially G516T). Alleles for these polymorphisms are more frequent in African and South American patients. We report a case of a 52-year-old patient from Guinea who was referred to the department of neurology under the diagnosis of HIV-associated neurocognitive disorder (HAND). Since the start of combined antiretroviral therapy (cART) including efavirenz the patient had suffered severe personality alterations, acoustic and visual hallucinations and delusions which led to discrimination and reduced quality of life. Diagnostic procedures including magnetic resonance imaging (MRT) and spinal fluid analysis resulted in normal values and did not explain the disease. After switching to nevirapin instead of efavirenz the psychotic symptoms disappeared within 5 days.

[Transcultural prevention of alcohol-related disorders : effects of a culture- and migration-sensitive approach in elderly migrants with respect to attitudes and behavior: a cluster randomized controlled trial]

BACKGROUND

For migrants who are older than 50, alcohol frequently becomes a problem. Simultaneously alcohol-related prevention measures only reach this group insufficiently. Therefore, a transcultural concept for preventing alcohol-related disorders in elderly (≥ 45 years) migrants has been developed.

METHOD

The transcultural concept, which consisted of a prevention event as well as a cultural and language-sensitive information booklet, was evaluated in a cluster-randomized controlled trial (n = 310 immigrants). As a control condition there was a prevention event with materials from Deutsche Hauptstelle für Suchtfragen (German Centre for Addiction Issues). Data were obtained before and after the event, as well as after 6 months. All materials were available both in German and in Russian, Italian, Spanish and Turkish.

RESULTS

Directly after the event, as well as 6 months thereafter, the transcultural approach was rated significantly better than the general prevention event. 73.4 % of the participants read the cultural and migration-sensitive booklet, whereas only 21.2 % in the control condition (p = 0.0001). Furthermore, significantly more participants of the transcultural approach reported a reduced alcohol consumption (49.4 vs. 16.7 %; p = 0.004) after 6 months.

CONCLUSION

The consideration of diversity with respect to cultural, migration-related, socio demographic und linguistic aspects improves the effectiveness of prevention measures.

Illness perceptions and personality traits of patients with mental disorders: the impact of ethnicity

OBJECTIVE

To identify differences and similarities between immigrants of Turkish origin and native German patients in therapeutically relevant dimensions such as subjective illness perceptions and personality traits.

METHOD

Turkish and native German mentally disordered in-patients were interviewed in three psychiatric clinics in Hessen, Germany. The Revised Illness Perception Questionnaire (IPQ-Revised) and the Neuroticism-Extraversion-Openness Five-Factor Inventory (NEO-FFI) were used. Differences of scales and similarities by k-means cluster analyses were estimated.

RESULTS

Of the 362 total patients, 227 (123 immigrants and 104 native Germans) were included. Neither demographic nor clinical differences were detected. Socioeconomic gradients and differences on IPQ-R scales were identified. For each ethnicity, the cluster analysis identified four different patient types based on NEO-FFI and IPQ-R scales. The patient types of each ethnicity appeared to be very similar in their structure, but they differed solely in the magnitude of the cluster means on included subscales according to ethnicity.

CONCLUSION

When subjective illness perceptions and personality traits are considered together, basic patient types emerge independent of the ethnicity. Thus, the ethnical impact on patient types diminishes and a convergence was detected.

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.