Immigration, moving house and psychiatric admissions

Mental health service use by recent immigrants from different world regions and by non-immigrants in Ontario, Canada: a cross-sectional study

Background

Given that immigration has been linked to a variety of mental health stressors, understanding use of mental health services by immigrant groups is particularly important. However, very little research on immigrants’ use of mental health service in the host country considers source country. Newcomers from different source countries may have distinct experiences that influence service need and use after arrival. This population study examined rates of use of primary care and of specialty services for non-psychotic mental health disorders by immigrants to Ontario Canada during their first five years after arrival. Service use by recent immigrants in broad source region groups representing all world regions was compared to use by age-matched Canadian-born or long term immigrants (called long term residents).

Method

This matched population-based cross-sectional study assessed likelihood of any use and counts of visits for each of primary care, psychiatric care and hospital care (emergency department visits or inpatient admissions) for non-psychotic mental health disorders from 1993–2012. Adult immigrants living in urban Ontario (n = 912,114) were categorized based on their nine world regions of origin. Sex-stratified conditional logistic regression models and negative binomial models were used to compare service use by immigrant region groups to their age-matched long term residents.

Results

Immigrant were more or less likely to access primary mental health care compared to age-matched long term residents, depending on their world region of origin. Regarding specialty mental health care (psychiatry and hospital care), immigrants from all regions used less than long term residents. Across the three mental health services, estimates of use by immigrant region groups compared to long term residents were among the lowest for newcomers from East Asian and Pacific (range: 0.16–0.82) and among the highest for persons from Middle East and North Africa (range: 0.56–1.23).

Conclusion

This population-based study showed lower use of mental health services by recent immigrants than long-term immigrants or native born individuals, with variation in immigrants’ use linked to world region of origin and type of mental health care. Variation across source region groups underscores the importance of identifying underlying individual characteristics that affect service use to make services more responsive to newcomers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0995-9) contains supplementary material, which is available to authorized users.

Symptoms, comorbidity, and clinical course of depression in immigrants: putting psychopathology in context

BACKGROUND

Migration is considered a depression risk factor when associated with psychosocial adversity, but its impact on depression's clinical characteristics has not been specifically studied. We compared 85 migrants to 34 controls, examining depression's severity, symptomatology, comorbidity profile and clinical course.

METHOD

A MINI interview modified to assess course characteristics was used to assign DSM-IV axis I diagnoses; medical files were used for Somatoform Disorders. Severity was assessed with the Montgomery-Asberg scale. Wherever possible, we adjusted comparisons for age and gender using logistic and linear regressions.

RESULTS

Depression in migrants was characterized by higher comorbidity (mostly somatoform and anxiety disorders), higher severity, and a non-recurrent, chronic course.

LIMITATIONS

Our sample comes from a single center, and should be replicated in other health care facilities and other countries. Somatoform disorder diagnoses were solely based on file-content.

CONCLUSION

Depression in migrants presented as a complex, chronic clinical picture. Most of our migrant patients experienced significant psychosocial adversity before and after migration: beyond cultural issues, our results suggest that psychosocial adversity impacts on the clinical expression of depression. Our study also suggests that migration associated with psychosocial adversity might play a specific etiological role, resulting in a distinct clinical picture, questioning the DSM-IV unitarian model of depression. The chronic course might indicate a resistance to standard therapeutic regimen and hints at the necessity of developing specific treatment strategies, adapted to the individual patients and their specific context.

The epidemiology of schizophrenia: replacing dogma with knowledge

Major advances have been made in our understanding of the epidemiology of schizophrenia. We now know that the disorder is more common and severe in young men, and that the incidence varies geographically and temporally. Risk factors have been elucidated; biological risks include a family history of the disorder, advanced paternal age, obstetric complications, and abuse of drugs such as stimulants and cannabis. In addition, recent research has also identified social risk factors such as being born and brought up in a city, migration, and certain types of childhood adversity such as physical abuse and bullying, as well as social isolation and adverse events in adult life. Current research is focussing on the significance of minor psychotic symptoms in the general population, gene-environmental interaction, and how risk factors impact on pathogenesis; perhaps all risk factors ultimately impact on striatal dopamine as the final common pathway.

To what extent may the association between immigrant status and mental illness be explained by socioeconomic factors?

BACKGROUND

Immigrants in Sweden have a higher rate of mental illness than the native Swedes. This study investigated to what extent the association between immigrant status and mental illness can be explained by a different distribution of known risk factors for impaired mental health between groups of immigrants and persons born in Sweden.

METHODS

The study is based on data from the Swedish PART-study, designed to identify risk factors for, and social consequences of, mental illness. The study population consists of a random sample of 10,423 Swedish citizens, whereof 1,109 were immigrants. The data was collected in the year 2000. The immigrants were divided into three groups based on country of origin (Scandinavians born outside Sweden, Europeans born outside Scandinavia, non-Europeans). The occurrence of mental illness among immigrants and native Swedes were compared not adjusting and adjusting for indicators of socioeconomic advantage/disadvantage (education, income, labour market position, etc). Mental illness was approximated with the WHO (ten) wellbeing index scale and depressive symptoms were measured with the major depression inventory scale (MDI).

RESULTS

Immigrants' excess risk for low subjective wellbeing was completely accounted for by adjustment for known risk factors in all the immigrant groups. However, social-economic disadvantages could not account for the non-European immigrants' higher prevalence of depression (MDI), although the increased relative risk found in univariate analyses was substantially reduced.

CONCLUSIONS

The findings in this study suggest that the association between immigrant status and mental illness appears above all to be an effect of a higher prevalence of social and economic disadvantage.

Neighbourhood income and mental health: A multilevel follow-up study of psychiatric hospital admissions among 4.5 million women and men

This multilevel study followed 4.5 million Swedish women and men from 1 January 1998 until 31 December 1999 in order to examine the association between neighbourhood income (defined as proportions of individuals with low income) and psychiatric hospital admissions. Individuals living in the poorest neighbourhoods exhibited a statistically significantly higher risk of being hospitalised for mental disorder than individuals living in the richest neighbourhoods, after adjustment for individual demographic and socioeconomic characteristics. The neighbourhood variance indicated statistically significant differences in psychiatric hospital admissions between neighbourhoods. Both individuals and neighbourhoods need to be targeted in order to enhance mental health in low-income neighbourhoods.

Demand for psychiatric emergency services and immigration. Findings in a Spanish hospital during the year 2003

BACKGROUND

The aim of this study is to investigate differences among immigrants and natives regarding access and pathways to psychiatric care, psychiatric admission rates, length of stay, continuity of care, and main diagnoses.

METHODS

Psychiatric emergency visits (1511) and hospitalizations (410) were registered in a Spanish Hospital with a catchment area of 280 000 people (19.3% immigrants) during the year 2003. Motives for demanding emergency psychiatric care, pathways to care, admission rates, length of stay, continuity of care, and main diagnoses were compared among natives and immigrants.

RESULTS

Immigrants accounted for 13.0% of consultations to the psychiatric emergency room (15.9% of patients) and 11.0% of admissions to the psychiatric hospitalization unit (13.5% of patients). The pathways to care were different for immigrants and natives. Immigrants had a lower rate of readmission to the psychiatric emergency room. Motives for consultation and hospitalization were also different among immigrants and natives. Immigrants showed more self-aggressive behaviours and neuroses, and lower rates of affective disorders and psychoses.

CONCLUSIONS

Immigrants under-used psychiatric emergency and hospitalization services in comparison with natives. They did not consult because of psychoses or affective disorders, but mainly because of reactive conditions related to the stress of migration.

Incidence of schizophrenia or other psychoses in first- and second-generation immigrants: a national cohort study

The main aims of this study were to investigate whether the increased risk of psychotic disorders among certain immigrant groups is present in the next generation and whether having one parent born in Sweden has a protective effect on the risk of psychotic disorders among second-generation immigrants. In total, 2,243,546 individuals were followed from January 1, 1992, until December 31, 1999, for first hospital admission for schizophrenia or other psychoses. Cox regression was used to estimate hazard ratios. The highest risks of psychotic disorders were found among first-generation and second-generation Finns, after adjustment for socioeconomic status. Having one parent born in Sweden had no protective effect on the risk of being hospitalized for psychotic disorders among second-generation immigrants. The disabling symptoms of psychotic disorders call for increased awareness among clinicians and public health planners involved in the treatment and prevention of psychotic disorders, especially among certain immigrant groups.

Incidence of mental disorders in second-generation immigrants in sweden: a four-year cohort study

BACKGROUND

Few studies have investigated mental health among second-generation immigrants who have reached adulthood. The aim of this study was to examine whether second-generation adult immigrants have a higher risk of being hospitalised for mental disorders than the Swedish majority population after adjustment for socio-economic status.

METHODS

In total 1.9 million Swedish-born women and men aged 16-34 were followed from 1 January 1995 to 31 December 1998 for first hospital admissions for mental disorders, categorised in four main diagnosis groups. Second-generation immigrants comprised four groups and the Swedish majority population was used as reference group. Cox proportional hazard models were used to analyse the data.

RESULTS

Second-generation immigrants with one parent born in Sweden and second-generation Finns had higher risks of being hospitalised for psychotic disorders, affective disorders, neurotic disorders, and personality disorders than the Swedish majority population. For second-generation Finns the age- and sex-adjusted hazard ratio for psychotic disorders was 2.42 (CI = 2.09-2.80). No significant hazard ratios were found for second-generation labour immigrants. For second-generation refugees the risk of being hospitalised was higher than for the Swedish majority population but only for psychotic disorders. All results remained significant and decreased only slightly after adjustment for income and education.

CONCLUSIONS

Many groups of second-generation immigrants have a higher risk of being hospitalised for mental disorder than the majority population. With increasing global migration it is crucial for all industrialised countries to take measures to improve mental health among second-generation immigrants.

Gender differences in factors associated with psychological distress among immigrants from low- and middle-income countries--findings from the Oslo Health Study

OBJECTIVE

Despite the high rate of migration from low- and middle-income countries to high-income countries, there is still a lack of comprehensive studies of gender-specific differences in psychological distress in a diverse group of immigrants. We compared psychological distress between male and female immigrants from low- and middle-income countries living in Oslo, and identified factors associated with distress for men and women, separately.

METHOD

A cross-sectional survey with self-administered questionnaires was conducted among 1536 immigrants from low- and middle-income countries living in Oslo. The Hopkins Symptom Checklist (HSCL-10) was used to measure psychological distress. Data on their sociodemographic characteristics, negative and traumatic life events, and social integration and possible discrimination in the Norwegian society were also collected.

RESULTS

One-fourth of the study population was found to be psychologically distressed, with almost equal levels among men and women. Lack of salaried job and recent negative life events were independently associated with psychological distress for both genders. Furthermore, experience of denial of job and past traumatic experiences were other associated negative factors among men, while visits made by Norwegians appeared as a protective factor against distress among men. Older age, Middle East background, living without a partner, and experiencing denial of housing were other associated negative factors among women.

CONCLUSION

Our findings show that, except for adverse living conditions, there are gender differences with regard to factors associated with psychological distress among immigrants living in Oslo. Such gender issues are relevant for assisting immigrants in the integration process as well as for future research in migration and health.

Psychopathology and mental health service utilization by immigrants' children and their families

To investigate the psychopathology of immigrants' children and psychiatric service utilization by the immigrant families, data were collected from the files of all 35 immigrant children seen over a 3-year period at the Community Mental Health Centre of the Athens University Psychiatric Department. Immigrant children were matched by age, gender and intake date with 70 Greek children. Data concerned information about the child's place of birth, current living conditions, parents' country of origin, social and economic situation, occupations and educational status, social insurance, psychiatric history, referral source, diagnostic and therapeutic services rendered, number of sessions and outcome. Utilization of services was assessed 6 months after intake. No significant differences were found regarding family's structure and parents' psychopathology. However, immigrant families had significantly worse economic situations, lower status jobs, worse housing and were usually uninsured. No significant differences were observed regarding service utilization parameters, except concerning 'cooperation with other services' No differences were found regarding frequency or type of psychiatric diagnosis. However, 91% of the immigrant group received a psychosocial diagnosis as opposed to 49% of the Greek group. Immigrant children did not present more serious or diverse psychopathology than did Greek children. Immigrant families had equal levels of service utilization as Greek families. However, it was apparent that immigrant families did not apply for help as readily as their Greek counterparts.

Ethnicity, self reported psychiatric illness, and intake of psychotropic drugs in five ethnic groups in Sweden

STUDY OBJECTIVE

This study hypothesises that the presumed increased risk of self reported longstanding psychiatric illness and intake of psychotropic drugs among Iranian, Chilean, Turkish, and Kurdish adults, when these groups are compared with Polish adults, can be explained by living alone, poor acculturation, unemployment, and low sense of coherence.

DESIGN

Data from a national sample of immigrants/refugees, who were between the ages of 20-44 years old, upon their arrival in Sweden between 1980 and 1989. Unconditional logistic regression was used in the statistical modelling.

SETTING

Sweden.

PARTICIPANTS

1059 female and 921 male migrants from Iran, Chile, Turkey, Kurdistan and Poland and a random sample of 3001 Swedes, all between the ages of 27-60 years, were interviewed in 1996 by Statistics Sweden.

MAIN RESULTS

Compared with Swedes, all immigrants had an increased risk of self reported longstanding psychiatric illness and for intake of psychotropic drugs, with results for the Kurds being non-significant. Compared with Poles, Iranian and Chilean migrants had an increased risk of psychiatric illness, when seen in relation to a model in which adjustment was made for sex and age. The difference became non-significant for Chileans when marital status was taken into account. After including civil status and knowledge of the Swedish language, the increased risks for intake of psychotropic drugs for Chileans and Iranians disappeared. Living alone, poor knowledge of the Swedish language, non-employment, and low sense of coherence were strong risk factors for self reported longstanding psychiatric illness and for intake of psychotropic drugs. Iranian, Chilean, Turkish and Kurdish immigrants more frequently reported living in segregated neighbourhoods and having a greater desire to leave Sweden than their Polish counterparts.

CONCLUSION

Evidence substantiates a strong association between ethnicity and self reported longstanding psychiatric illness, as well as intake of psychotropic drugs. This association is weakened by marital status, acculturation status, employment status, and sense of coherence.

Perfil psicológico de migrantes através da forma IRF do MMPI

Devido à associação freqüentemente apontada na literatura entre o fenômeno da migração e o desenvolvimento de distúrbios mentais, este trabalho tencionou fornecer o perfil psicológico de uma amostra de migrantes, por meio de uma forma reduzida de um instrumento de valor clínico e empírico comprovado: o MMPI. Para tanto, 20 migrantes do sexo masculino, analfabetos e sem comprometimentos intelectuais severos foram submetidos à forma IRF do MMPI, desenvolvida nos Estados Unidos em 1980, destinada a sujeitos com essas características cognitivas. Os resultados se constituíram em altas pontuações na escala F de validade, relacionadas principalmente a questões de ordem cultural e incompreensão dos itens. Em termos clínicos, dentre os protocolos considerados confiáveis para análise, foi detectada uma tendência da IRF a produzir elevações nos resultados das escalas clínicas de um modo generalizado, indicando problemas relativos à padronização, validade e capacidade discriminativa do instrumento para uso na população brasileira não alfabetizada.

Impact of ethnicity, violence and acculturation on displaced migrants: psychological distress and psychosomatic complaints among refugees in Sweden

This study uses data collected in 1996 by the Swedish National Board of Health and Welfare. By means of interviews with 1980 foreign-born immigrants, an attempt was made to determine the impact of a) migration status (country of birth/ethnicity), b) exposure to violence, c) Antonovsky's sense of coherence, d) acculturation status (knowledge of Swedish), e) sense of control over one's life, f) economic difficulties, and g) education, both on psychological distress (using General Health Questionnaire 12) and psychosomatic complaints (daytime fatigue, sleeping difficulties, and headache/migraine). Iranians and Chileans (age-adjusted) were at great risk for psychological distress as compared with Poles, whereas Turks and Kurds exhibited no such risk. When the independent factors were included in the model, the migration status effect decreased to insignificance (with the exception of Iranian men). A low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties were strongly associated with the outcomes, generally accounting for a convincing link between migration status and psychological distress. Furthermore, a low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties in exile seemed to be stronger risk factors for psychological distress in this group than exposure to violence before migration.

Early and late environmental risk factors for schizophrenia

Although a high proportion of liability to schizophrenia is under genetic control, a number of environmental risk factors have been identified. The earliest of these are complications of pregnancy and birth, though whether these cause or reflect disturbed brain development is not absolutely clear. Neurodevelopmental deviance is also indicated by neurological dysfunction, social, behavioural and cognitive deficits during childhood. Immigrant status is a significant risk factor, especially prominent among the African Caribbean population in England, though the mechanism is unknown. Later environmental risk factors include adverse life events and substance abuse. An additive model of multiple genetic and environmental risk factors of small effect may be too simplistic and an interactive model where genetic predisposition is compounded by environmental effects is more in keeping with current evidence. The nature of such interactions can be explored more fully when susceptibility genes for schizophrenia are identified.