Immigrants and borderline personality disorder at a psychiatric emergency service

Treating immigrant patients in psychiatric emergency rooms

We examine whether patient variables (geographic origin, gender, Spanish language proficiency) and subjective clinician aspects in emergency department psychiatric encounters (diagnostic certainty, clinician's comfort level with patient) are associated with diagnosis and the use of coercive measures. Using a descriptive cross-sectional design, we recorded 467 visits (400 foreign-born and 67 native-born patients) in hospital psychiatry emergency rooms (ERs) in Barcelona between 2007 and 2015. We first assessed the association of patient variables and subjective clinician aspects of psychiatric encounters with service use outcomes and with mental illness diagnosis. Fitted logistic models predicted the likelihood of service use outcomes and estimated the propensity of receiving each diagnosis. The null model evaluated the role of patient's geographical origin, while the full model evaluated the additional roles of patient's gender and language, the clinician's assessment of the influence of culture in diagnosis, and clinician comfort with two outcomes: patient's diagnosis and use of coercive measures in the ER. Women were less likely to receive coercive measures or intramuscular medications compared to men. Significant ethnic/racial and gender differences were found in receiving certain diagnoses. Additionally, a patient's lower Spanish proficiency was correlated with a higher probability of receiving a psychosis diagnosis. The clinician's level of diagnostic certainty was also positively correlated with increasing clinician-reported comfort with patient. Overall, ethnic factors and the subjective aspects of psychiatric encounters were found to influence diagnosis and the use of coercive measures. Cultural competency programs and interpreter services within psychiatric ER settings should thus be required.

Comparative exposure to antipsychotic medications in immigrant and native-born populations of a Spanish health region

Background

Raised rates of psychoses among ethnic minorities have been reported. Exposure to antipsychotic medications can give information on mental illness management and ethnic-related differences.

Objective

To compare exposure to antipsychotic medications in immigrant and native-born populations in Spain.

Method

Descriptive cross-sectional study of the dispensation of antipsychotic medications to the population aged 15 to 64 years, in a Spanish Health Region during 2008.

Results

1.9% of the native-born population was exposed to antipsychotic medications as compared to 0.4% of the immigrant population. Native-born women were exposed from 1.8 to 5.3 times more and native-born men from 3.6 to 6.3 times more than immigrants of the same gender. The least exposed were persons from Eastern Europe and men from sub-Saharan Africa. Active ingredients prescribed were similar between the two groups. Of the immigrant group, 15.7% were admitted to a psychiatric ward as compared to 6.4% of the native-born population. In the former, non-specific diagnoses were predominant.

Conclusions

All immigrant groups had lower exposure to antipsychotic medications, were admitted to inpatient care more often and had less specific diagnoses. Both diagnostic processes and adherence to treatment need improvement in the regional immigrant population.

Pathways to and Results of Psychiatric Consultation for Patients Referred from the Emergency Department. Are there Differences between Migrant and Native Patients?

The aim of this study was to compare migrants and native Italians on the pathways to care and results of psychiatric consultation (PC) in the emergency department (ED). Patients who were referred from the ED for psychiatric consultation (EDPC) at the Maggiore della Carità Hospital between March 2008 and March 2015 were recruited consecutively. Socio-demographic, clinical and consultation variables were recorded along with information about suicidal behaviours; migrants ( n = 379; 42.74% males, 57.26% females; age: 45.38 ± 16.95 years) were compared with native Italians ( n = 2942; 43.51% males, 56.49% females; age: 42.08 ± 15.89 years). Migrants were younger, more likely to be unemployed and less likely to be already under the care of a psychiatrist. Symptoms related to use of alcohol or substances were more frequent in migrants, especially female migrants. Migrants were less likely than native Italians to be referred for PC because of the presence of psychiatric symptoms, however they were more likely to be referred because of self-harming behaviour. Nonetheless, migrant status was not identified as a risk factor for suicidal behaviour in the multivariate analysis. The outcome of EDPC showed differences between migrants and natives. In absolute terms migrants were less likely to be admitted to a psychiatric ward after the EDPC than native Italians, while they were more likely to be monitored in the ED before being discharged or referred to outpatient care. In a high percentage of psychiatric examinations of migrants, no psychiatric symptoms were identified. Further studies are warranted to disentangle the meaning of these findings.

Mental health morbidity among people subject to immigration detention in the UK: a feasibility study

AIMS

The UK has one of the largest systems of immigration detention in Europe.. Those detained include asylum-seekers and foreign national prisoners, groups with a higher prevalence of mental health vulnerabilities compared with the general population. In light of little published research on the mental health status of detainees in immigration removal centres (IRCs), the primary aim of this study was to explore whether it was feasible to conduct psychiatric research in such a setting. A secondary aim was to compare the mental health of those seeking asylum with the rest of the detainees.

METHODS

Cross-sectional study with simple random sampling followed by opportunistic sampling. Exclusion criteria included inadequate knowledge of English and European Union nationality. Six validated tools were used to screen for mental health disorders including developmental disorders like Personality Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Autistic Spectrum Disorder (ASD) and Intellectual Disability, as well as for needs assessment. These were the MINI v6, SAPAS, AQ-10, ASRS, LDSQ and CANFOR. Demographic data were obtained using a participant demographic sheet. Researchers were trained in the use of the screening battery and inter-rater reliability assessed by joint ratings.

RESULTS

A total of 101 subjects were interviewed. Overall response rate was 39%. The most prevalent screened mental disorder was depression (52.5%), followed by personality disorder (34.7%) and post-traumatic stress disorder (20.8%). 21.8% were at moderate to high suicidal risk. 14.9 and 13.9% screened positive for ASD and ADHD, respectively. The greatest unmet needs were in the areas of intimate relationships (76.2%), psychological distress (72.3%) and sexual expression (71.3%). Overall presence of mental disorder was comparable with levels found in prisons. The numbers in each group were too small to carry out any further analysis.

CONCLUSION

It is feasible to undertake a psychiatric morbidity survey in an IRC. Limitations of the study include potential selection bias, use of screening tools, use of single-site study, high refusal rates, the lack of interpreters and lack of women and children in study sample. Future studies should involve the in-reach team to recruit participants and should be run by a steering group consisting of clinicians from the IRC as well as academics.

The epidemiology of personality disorders in the Sao Paulo Megacity general population

Introduction

Most studies on the epidemiology of personality disorders (PDs) have been conducted in high-income countries and may not represent what happens in most part of the world. In the last decades, population growth has been concentrated in low- and middle-income countries, with rapid urbanization, increasing inequalities and escalation of violence. Our aim is to estimate the prevalence of PDs in the Sao Paulo Metropolitan Area, one of the largest megacities of the world. We examined sociodemographic correlates, the influence of urban stressors, the comorbidity with other mental disorders, functional impairment and treatment.

Methods

A representative household sample of 2,942 adults was interviewed using the WHO-Composite International Diagnostic Interview and the International Personality Disorder Examination-Screening Questionnaire. Diagnoses were multiply imputed, and analyses used multivariable regression.

Results and discussion

Prevalence estimates were 4.3% (Cluster A), 2.7% (Cluster B), 4.6% (Cluster C) and 6.8% (any PD). Cumulative exposure to violence was associated with all PDs except Cluster A, although urbanicity, migration and neighborhood social deprivation were not significant predictors. Comorbidity was the rule, and all clusters were associated with other mental disorders. Lack of treatment is a reality in Greater Sao Paulo, and this is especially true for PDs. With the exception of Cluster C, non-comorbid PDs remained largely untreated in spite of functional impairment independent of other mental disorders.

Conclusion

Personality disorders are prevalent, clinically significant and undertreated, and public health strategies must address the unmet needs of these subjects. Our results may reflect what happens in other developing world megacities, and future studies are expected in other low- and middle-income countries.

Undocumented Immigrant Women in Spain: A Scoping Review on Access to and Utilization of Health and Social Services

This scoping review summarizes and analyzes relevant studies related to the evidence published on undocumented immigrant women's access to and utilization of health and social services in Spain. Scientific literature was identified by entering search terms in seven electronic databases which combined retrieved health sciences peer-reviewed articles (Pubmed, Embase, CINAHL Plus and Scopus) and grey literature databases (Europa OpenGrey, DART-Europe and Google Scholar) published between 2004 and 2014 and written in Spanish or in English presenting data about Spain. Those that fulfill the inclusion criteria were selected after a blind peer reviewed process when pertinence and quality was debated. A total of 16 publications were included, the main topics being socio-cultural differences in the access and utilization of social and health services and barriers faced by immigrant women. None of the studies focused exclusively on undocumented women, hence further research is needed in this area.

Cross-cultural bias in the diagnosis of borderline personality disorder

Borderline personality disorder (BPD) is an internationally recognized disorder, although it is slightly varied in its nosology in the International Classification of Diseases, 10th Revision (ICD-10), the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), and the Chinese Classification of Mental Disorders (CCMD). While it is recognized by genetic and neurobiological patterns, instability of affect, impaired interpersonal relationships, and unstable sense of self, its manifestation is extremely varied based on environmental factors, particularly culture. Several studies of the manifestation of BPD between and across countries, particularly in immigrant populations, identify variations in symptom prevalence based on culture. These findings reveal a need for more unified dimensional-based categorization of BPD to reduce cross-cultural bias and improve identification.

Hispano-Americans in Europe: what do we know about their health status and determinants? A scoping review

Background

Policy makers and health practitioners are in need of guidance to respond to the growing geographic mobility of Hispano-American migrants in Europe. Drawing from contributions from epidemiology, social sciences, demography, psychology, psychiatry and economy, this scoping review provides an up-to-date and comprehensive synthesis of studies addressing the health status and determinants of this population. We describe major research gaps and suggest specific avenues of further inquiry.

Methods

We identified systematically papers that addressed the concepts “health” and “Hispano Americans” indexed in five data bases from Jan 1990 to May 2014 with no language restrictions. We screened the 4,464 citations retrieved against exclusion criteria and classified 193 selected references in 12 thematic folders with the aid of the reference management software ENDNOTE X6. After reviewing the full text of all papers we extracted relevant data systematically into a table template to facilitate the synthesising process.

Results

Most studies focused on a particular disease, leaving unexplored the interlinkages between different health conditions and how these relate to legislative, health services, environmental, occupational, and other health determinants. We elucidated some consistent results but there were many heterogeneous findings and several popular beliefs were not fully supported by empirical evidence. Few studies adopted a trans-national perspective and many consisted of cross-sectional descriptions that considered “Hispano-Americans” as a homogeneous category, limiting our analysis. Our results are also constrained by the availability and varying quality of studies reviewed.

Conclusions

Burgeoning research has produced some consistent findings but there are huge gaps in knowledge. To prevent unhelpful generalisations we need a more holistic and nuanced understanding of how mobility, ethnicity, income, gender, legislative status, employment status, working conditions, neighbourhood characteristics and social status intersect with demographic variables and policy contexts to influence the health of the diverse Hispano-American populations present in Europe.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1799-x) contains supplementary material, which is available to authorized users.

Borderline personality disorder, exposure to interpersonal trauma, and psychiatric comorbidity in urban primary care patients

OBJECTIVE

Few data are available on interpersonal trauma as a risk factor for borderline personality disorder (BPD) and its psychiatric comorbidity in ethnic minority primary care populations. This study aimed to examine the relation between trauma exposure and BPD in low-income, predominantly Hispanic primary care patients.

METHOD

Logistic regression was used to analyze data from structured clinical interviews and self-report measures (n = 474). BPD was assessed with the McLean screening scale. Trauma exposure was assessed with the Life Events Checklist (LEC); posttraumatic stress disorder (PTSD) was assessed with the Lifetime Composite International Diagnostic Interview, other psychiatric disorders with the SCID-I, and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report (SAS-SR).

RESULTS

Of the 57 (14%) patients screening positive for BPD, 83% reported a history of interpersonally traumatic events such as sexual and physical assault or abuse. While interpersonal trauma experienced during adulthood was as strongly associated with BPD as interpersonal trauma experienced during childhood, noninterpersonal trauma was associated with BPD only if it had occurred during childhood. The majority (91%) of patients screening positive for BPD met criteria for at least one current DSM-IV Axis I diagnosis and exhibited significant levels of functional impairment.

CONCLUSION

Increased awareness of BPD in minority patients attending primary care clinics, high rates of exposure to interpersonal trauma, and elevated risk for psychiatric comorbidity in this population may enhance physicians' understanding, treatment, and referral of BPD patients.

The influence of personality disorders on the use of mental health services in adolescents with psychiatric disorders

OBJECTIVE

The aims of this study were to explore the influence of personality disorders (PDs) in Spanish adolescents with Axis I psychiatric disorders on their use of mental health services and to analyze the risk of having a comorbid PD in relation to psychiatric service use.

METHODS

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and International Classification of Diseases, Tenth Revision (ICD-10) modules of the semistructured interview International Personality Disorders Examination were administered to a sample of 112 adolescent psychiatric patients (mean age = 15.8 years; SD, 0.8; range, 15-17; 79% women) at the point of initiating treatment. On the basis of the interview, subjects were divided into two groups: a PD group (PDG) and a non-PD group (NPDG). After 3 years of treatment, clinical records were retrospectively analyzed.

RESULTS

The PDG showed a significantly higher number of psychiatric admissions (P < .001), days per psychiatric admission (P < .001), and psychiatric emergencies (P < .010) than the NPDG, although the number of outpatient consultations was not significantly higher. Logistic regression analysis showed that the probability of belonging to the PDG rather than the NPDG increased with each psychiatric admission (odds ratio [OR] = 1.67 for DSM-IV criteria and OR = 1.59 for ICD-10 criteria), after controlling by sex, age, and comorbidity (Axis I disorders).

CONCLUSIONS

Patients with comorbid PD used more inpatient and emergency psychiatric services than did patients without a PD. Large number of psychiatric hospitalizations suggests the likelihood of a PD being present.