Migration and schizophrenia: an examination of five hypotheses

The semiology of migration

INTRODUCTION

The phenomenon of migration generates a series of experiences in the human being that are translated into emotions, feelings, adaptation processes, grief and psychopathological processes, and even pathological expressions, represented by clinical pictures of different kinds.

OBJECTIVE

The purpose of this article is to carry out a conceptual and clinical reflection on the semiology around the concept and experience of migration, in order to illustrate the complexity that it entails as a human phenomenon.

METHODS

A reduced narrative review, circumscribed and restricted to the semiological, psychopathological and clinical aspects of migration.

DISCUSSION

The separation, ruptures and losses that derive from migration do not go unnoticed by the individual. They are inscribed in his/her corporality as physiological injuries that affect his/her life and as symbolic injuries that affect his/her existence.

CONCLUSIONS

Migration supposes a rupture of the totality of being. The context, the perception of others and relationships are cut off from the total unity that is the individual, as if he/she lost half of him/herself.

The Semiology of Migration

INTRODUCTION

The phenomenon of migration generates a series of experiences in the human being that are translated into emotions, feelings, adaptation processes, grief and psychopathological processes, and even pathological expressions, represented by clinical pictures of different kinds.

OBJECTIVE

The purpose of this article is to carry out a conceptual and clinical reflection on the semiology around the concept and experience of migration, in order to illustrate the complexity that it entails as a human phenomenon.

METHODS

A reduced narrative review, circumscribed and restricted to the semiological, psychopathological and clinical aspects of migration.

DISCUSSION

The separation, ruptures and losses that derive from migration do not go unnoticed by the individual. They are inscribed in his/her corporality as physiological injuries that affect his/her life and as symbolic injuries that affect his/her existence.

CONCLUSIONS

Migration supposes a rupture of the totality of being. The context, the perception of others and relationships are cut off from the total unity that is the individual, as if he/she lost half of him/herself.

Immigration and psychopathology: a clinical study

Three groups of 342 Greek, Iberian and Belgian psychiatric patients were compared, matched for sex, age, and time of hospitalization in a university hospital in Brussels. Schizophrenia, schizoaffective disorder/atypical psychosis were diagnosed more among immigrant patients. Somatic anxiety, loss of libido, delusions and hallucinations were symptoms that clinicians observed more in immigrant than in native patients. Atypical symptomatology and change of diagnosis were more likely to occur among immigrant patients. A higher proportion of second generation immigrant patients had a diagnosis of schizophrenia than either the first generation or the Belgians. Male immigrant patients were prescribed anxiolytic drugs more frequently than male natives, but were less likely to be referred to psychotherapy. The authors query whether these findings derive from specificities in the use of psychiatric services and/or from biases in clinicians'attitudes towards patients of different ethnic origin.

Psychosis, migration and social environment: an age-and-gender controlled study

Purpose

Adverse social experiences are frequently invoked to explain the higher rate of psychosis among migrant groups. The aim of the present study was to establish the socio-environmental factors distinguishing migrant psychotic patients from autochthonous patients.

Subjects and method

We conducted a cross-sectional survey involving 341 migrant psychotic patients matched for age and gender with 341 autochthonous psychotic patients.

Results

Migrant patients lived more often with their parental family, were less often enrolled with a referral psychiatrist, presented a lower rate of employment, a lower percentage of alcohol misuse and of suicide attempts.

Discussion

Our findings add to the growing body of results showing that more attention needs to be focused on socio-environmental variables in psychosis research. However, several limitations have to be taken into account, particularly with regard to selection biases and age of onset of the psychotic illness.

Conclusion

Our results are compatible with the hypothesis that unemployment is a contributing factor in the risk for psychosis among migrant groups. Migrants’ families are an important keystone in the mental health care process of their sick relatives. Our service models need to be adapted with the aim to make the treatment easier for migrant patients.

Migration and psychosis: a meta-analysis of incidence studies

BACKGROUND

The aims of this meta-analysis are (i) to estimate the pooled relative risk (RR) of developing non-affective psychotic disorder (NAPD) and affective psychotic disorder (APD) among migrants and their children; (ii) to adjust these results for socioeconomic status (SES); (iii) to examine the sources of heterogeneity that underlie the risk of NAPD.

METHODS

We included population-based incidence studies that reported an age-adjusted RR with 95% confidence interval (CI) published 1 January 1977-12 October 2017 and used a random-effects model.

RESULTS

We retrieved studies performed in Europe (n = 43), Israel (n = 3), Canada (n = 2) and Australia (n = 1). The meta-analysis yielded a RR, adjusted for age and sex, of 2.13 (95% CI 1.99-2.27) for NAPD and 2.94 (95% CI 2.28-3.79) for APD. The RRs diminished, but persisted after adjustment for SES. With reference to NAPD: a personal or parental history of migration to Europe from countries outside Europe was associated with a higher RR (RR = 2.94, 95% CI 2.63-3.29) than migration within Europe (RR = 1.88, 95% 1.62-2.18). The corresponding RR was lower in Israel (RR = 1.22; 0.99-1.50) and Canada (RR = 1.21; 0.85-1.74). The RR was highest among individuals with a black skin colour (RR = 4.19, 95% CI 3.42-5.14). The evidence of a difference in risk between first and second generation was insufficient.

CONCLUSIONS

Positive selection may explain the low risk in Canada, while the change from exclusion to inclusion may do the same in Israel. Given the high risks among migrants from developing countries in Europe, social exclusion may have a pathogenic role.

Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses

PURPOSE

Although excess risks particularly for a diagnosis of schizophrenia have been identified for ethnic minority people in England and other contexts, we sought to identify and synthesise up-to-date evidence (2018) for affective in addition to non-affective psychoses by specific ethnic groups in England.

METHODS

Systematic review and meta-analysis of ethnic differences in diagnosed incidence of psychoses in England, searching nine databases for reviews (citing relevant studies up to 2009) and an updated search in three databases for studies between 2010 and 2018. Studies from both searches were combined in meta-analyses allowing coverage of more specific ethnic groups than previously.

RESULTS

We included 28 primary studies. Relative to the majority population, significantly higher risks of diagnosed schizophrenia were found in Black African (Relative risk, RR 5.72, 95% CI 3.87-8.46, n = 9); Black Caribbean (RR 5.20, 95% CI 4.33-6.24, n = 21); South Asian (RR 2.27, 95% CI 1.63-3.16, n = 14); White Other (RR 2.24, 95% CI 1.59-3.14, n = 9); and Mixed Ethnicity people (RR 2.24, 95% CI 1.32-3.80, n = 4). Significantly higher risks for diagnosed affective psychoses were also revealed: Black African (RR 4.07, 95% CI 2.27-7.28, n = 5); Black Caribbean (RR 2.91, 95% CI 1.78-4.74, n = 16); South Asian (RR 1.71, 95% CI 1.07-2.72, n = 8); White Other (RR 1.55, 95% CI 1.32-1.83, n = 5); Mixed Ethnicity (RR 6.16, 95% CI 3.99-9.52, n = 4).

CONCLUSIONS

The risk for a diagnosis of non-affective and affective psychoses is particularly elevated for Black ethnic groups, but is higher for all ethnic minority groups including those previously not assessed through meta-analyses (White Other, Mixed Ethnicity). This calls for further research on broader disadvantages affecting ethnic minority people.

Migration and mental illness

Human beings have moved from place to place since time immemorial. The reasons for and the duration of these migrations put extraordinary stress on individuals and their families. Such stress may not be related to an increase in mental illness for all conditions or to the same extent across all migrant groups. In this paper, we provide an overview of some observations in the field of migration and mental health, hypothesise why some individuals and groups are more vulnerable to psychiatric conditions, and consider the impact of migration experiences on provision of services and care.

Biological aspects of human migration and mobility

This paper reviews how migration, both geographical and social, impacts on variation in some human biological traits. Migration and mobility are considered in relation to anthropometric traits and indices, psychometric traits, health, disease and nutrition, temperature regulation and metabolism, mental health and gene flow. It is well known that migration is important in disease transmission but, as this paper demonstrates, migration can have both positive and negative impacts on both donor and recipient populations for a wide range of human traits.

Associations Between Sociodemographic Characteristics, Pre Migratory and Migratory Factors and Psychological Distress Just After Migration and After Resettlement: The Indian Migration Study

BACKGROUND/OBJECTIVES

Migration is suspected to increase the risk for psychological distress for those who enter a new cultural environment. We investigated the association between sociodemographic characteristics, premigratory and migratory factors and psychological distress in rural-to-urban migrants just after migration and after resettlement.

METHODS

Data from the cross-sectional sib-pair designed Indian Migration Study (IMS, 2005-2007) were used. The analysis focused on 2112 participants aged ≥18 years from the total IMS sample (n = 7067) who reported being migrant. Psychological distress was assessed based on the responses of the 7-questions in a five-point scale, where the respondents were asked to report about their feelings now and also asked to recall these feelings when they first migrated. The associations were analyzed using multiple logistic regression models.

RESULTS

High prevalence of psychological distress was found just after migration (7.3%; 95% confidence interval [CI]: 6.2-8.4) than after settlement (4.7%; 95% CI: 3.8-5.6). Push factors as a reason behind migration and not being able to adjust in the new environment were the main correlates of psychological distress among both the male and female migrants, just after migration.

CONCLUSIONS

Rural-urban migration is a major phenomenon in India and given the impact of premigratory and migratory related stressors on mental health, early intervention could prevent the development of psychological distress among the migrants.

Cross-national diffusion of mental health policy

BACKGROUND

Following the tenets of world polity and innovation diffusion theories, I focus on the coercive and mimetic forces that influence the diffusion of mental health policy across nations. International organizations' mandates influence government behavior. Dependency on external resources, namely foreign aid, also affects governments' formulation of national policy. And finally, mounting adoption in a region alters the risk, benefits, and information associated with a given policy.

METHODS

I use post-war, discrete time data spanning 1950 to 2011 and describing 193 nations' mental health systems to test these diffusion mechanisms.

RESULTS

I find that the adoption of mental health policy is highly clustered temporally and spatially. RESULTS provide support that membership in the World Health Organization (WHO), interdependence with neighbors and peers in regional blocs, national income status, and migrant sub-population are responsible for isomorphism. Aid, however, is an insufficient determinant of mental health policy adoption.

CONCLUSION

This study examines the extent to which mental, neurological, and substance use disorder are addressed in national and international contexts through the lens of policy diffusion theory. It also adds to policy dialogues about non-communicable diseases as nascent items on the global health agenda.

Psychiatric morbidity, phenomenology and management in hospitalized female foreign domestic workers in Lebanon

40 million female domestic workers worldwide experience the inhumane conditions associated with this unregulated occupation, a situation that induces psychiatric morbidities in many. The case in Lebanon is not any better where it is estimated that one foreign domestic worker (FDW) commits suicide weekly. 33 female FDW and 14 female Lebanese (control group, CG) were enrolled. Brief Psychotic Rating Scale (BPRS) and Clinical Global Impression (CGI) scales were administered on admission and discharge and socio-demographic, living conditions, mental health care data and phenomenological observations were collected. Sexual, physical, and verbal abuses were detected in FDW (12.5, 37.5, and 50.0 %. respectively). 66.7 % of them were diagnosed with brief psychotic episode. The mean duration of hospital stay (13.1 days) was significantly lower in the FDW group. The mean cumulative antipsychotic dose of the FDW was 337.1 mg of chlorpromazine equivalent and the mean BPRS total pre-score of FDW was 66.4 with a much improved state on the CGI global improvement scale, all of which were nonsignificantly different from the CG. Striking phenomenological findings among FDW were acute anorexia (39.4 %), nudity (30.3 %), catatonic features (21.2 %), and delusion of pregnancy (12.1 %). Inpatient FDW are more diagnosed with psychotic than affective disorders and receive approximately similar treatment as controls in spite of the trend to rapidly discharge and deport the worker to limit the costs. Both groups presented with similar severity, although the FDW had peculiar phenomenological observations.

Religious and cultural aspects of psychotherapy in Muslim patients from tradition-oriented societies

Patients from collective cultures with a tradition-bound Islamic cultural background (e.g. people from the Middle East and some Far-East countries such Pakistan and Indonesia), have a different perception of disease and different conceptions of healing, which up till now have not been sufficiently appreciated in modern multimodal therapeutic approaches and health management. Taking patients' value systems into consideration in a culture-sensitive way, with reference to their notions of magic, healing ceremonies and religious rituals and especially patterns of relations and experience in the treatment of psychological diseases in medical psychotherapeutic work, with due regard to scientific psychotherapeutic standards, can be used as an intercultural resource and lead to establishing partnership-like relationships between patients and therapists.

Country of birth and hospital treatment for psychosis in New South Wales

BACKGROUND

Migration has been found to be a risk factor for schizophrenia in several high-income countries.

AIM

To examine whether overseas migrants to New South Wales (NSW) have higher rates of admission to psychiatric hospitals for psychotic disorders, including schizophrenia and mania, compared to people born in Australia.

METHODS

The country of birth of people admitted to public mental health units for the treatment of psychotic illness and for non-psychotic disorders between 2001 and 2010 was compared to the country of birth for the NSW population in the 2006 census. Meta-analysis was used to estimate the odds of being admitted for any psychotic disorder, for a schizophrenia-related psychosis and for mania compared to non-psychotic disorder, for those born in Australia, New Zealand and for nine global regions.

RESULTS

Those born in Oceania (including Melanesia, Fiji, Samoa, Tonga and other Polynesian islands, but excluding Hawaii and New Zealand) had the highest odds of admission for the treatment of psychosis compared to a non-psychotic disorder and had the highest odds of being admitted with a diagnosis of schizophrenia or mania.

CONCLUSIONS

In the years 2001-2010, those born in Oceania were at an increased risk of admission to NSW psychiatric hospitals for the treatment of psychotic illness.

Schizophrenia: from epidemiology to rehabilitation

Purpose/Objective:

We discuss recent evidences about schizophrenia (frequency, onset, course, risk factors and genetics) and their influences to some epidemiological myths about schizophrenia diffuse between psychiatric and psychopathology clinicians. The scope is to evaluate if the new acquisitions may change the rehabilitation approaches to schizophrenia modifying the balance about the neurodevelopmental hypothesis of schizophrenia accepting that the cognitive deficits are produced by errors during the normal development of the brain (neurodevelopmental hypothesis) that remains stable in the course of illness and the neurodegenerative hypothesis according of which they derived from a degenerative process that goes on inexorably.

Research Method/Design:

A review of the literature about epidemiology of schizophrenia has been performed and the contributions of some of these evidence to neurodevelopmental hypothesis and to rehabilitation has been described.

Results:

It cannot be definitively concluded for or against the neurodevelopmental or degenerative hypothesis, but efforts in understanding basis of schizophrenia must go on. Until now, rehabilitation programs are based on the vulnerability-stress model: supposing an early deficit that go on stable during the life under favorable circumstances. So, rehabilitation approaches (as neuro-cognitive approaches, social skill training, cognitive-emotional training) are focused on the individual and micro-group coping skills, aiming to help people with schizophrenia to cope with environmental stress factors.

Conclusions/Implications:

Coping of cognitive deficits in schizophrenia may represents the starting-point for further research on schizophrenia, cohort studies and randomized trials are necessary to defined the range of effectiveness and the outcome of the treatments.

A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants

BACKGROUND

There is increasing acceptance of migration as a risk factor for schizophrenia and related disorders; however, the magnitude of the risk among second-generation immigrants (SGIs) remains unclear. Generational differences in the incidence of psychotic disorders among migrants might improve our understanding of the relationship between migration, ethnicity and psychotic disorders. This meta-analysis aimed at determining the risk of psychotic disorders among SGIs in comparison with non-migrants and first-generation immigrants (FGIs).

METHOD

Medline, EMBASE and PsycINFO databases were searched systematically for population-based studies on migration and psychotic disorders published between 1977 and 2008. We also contacted experts, tracked citations and screened bibliographies. All potential publications were screened by two independent reviewers in a threefold process. Studies were included in the meta-analysis if they reported incidence data, differentiated FGIs from SGIs and provided age-adjusted data. Data extraction and quality assessment were conducted for each study.

RESULTS

Twenty-one studies met all inclusion criteria. A meta-analysis of 61 effect sizes for FGIs and 28 for SGIs yielded mean-weighted incidence rate ratios (IRRs) of 2.3 [95% confidence interval (CI) 2.0-2.7] for FGIs and 2.1 (95% CI 1.8-2.5) for SGIs. There was no significant risk difference between generations, but there were significant differences according to ethno-racial status and host country.

CONCLUSIONS

The increased risk of schizophrenia and related disorders among immigrants clearly persists into the second generation, suggesting that post-migration factors play a more important role than pre-migration factors or migration per se. The observed variability suggests that the risk is mediated by the social context.

WPA guidance on mental health and mental health care in migrants

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outlined, as well as the specific problems of groups such as women, children and adolescents, the elderly, refugees and asylum seekers, and lesbian, gay, bisexual and transgender individuals. The concepts of cultural bereavement, cultural identity and cultural congruity are discussed. The epidemiology of mental disorders in migrants is described. A series of recommendations to policy makers, service providers and clinicians aimed to improve mental health care in migrants are provided, covering the special needs of migrants concerning pharmacotherapies and psychotherapies.

Migrants’ Mental Health Perceptions and Barriers to Receiving Mental Health Services

This article addresses the various perceptions people from other cultures have regarding mental health and mental illness and the unique coping mechanisms they use based on their cultural beliefs and values. The various barriers to receiving mental health services and the reasons for such barriers are also discussed. In addition, the article stresses the importance of using and implementing culturally appropriate and sensitive assessments and therapeutic interventions.

Enhancing social support, hardiness, and acculturation to improve mental health among Asian Indian international students

International students, upon relocation to a foreign country, undergo a major life event which can cause distress that can potentially affect their mental health. This study pilot tested an internet-based intervention to enhance the social support, hardiness, and acculturation among students of Asian Indian origin at a large midwestern university. A pretest-posttest randomized design was employed. The pretest was administered to 60 students who were then randomly assigned to experimental and comparison groups. The experimental group was offered online instruction about social support, hardiness, and acculturation through Blackboard over 2 months. The comparison group received an equivalent protocol based on general wellness. Repeated measures ANOVA was done which showed significant improvement in mental health variable (F(1, 37) = 4.768, p < 0.05). Recommendations for replicating such interventions in other groups of international students are presented.

Ethnic origin and increased risk for schizophrenia in immigrants to countries of recent and longstanding immigration

OBJECTIVES

Compare the risk for schizophrenia in immigrants to countries of recent and longstanding immigration. Compare prevalence and incidence rates in black subjects under different conditions.

METHOD

An electronic literature search was complemented by review articles and cross-references. Studies reporting standard diagnosis and incidence or prevalence rates were included.

RESULTS

Immigrants had an increased risk for schizophrenia in countries of longstanding immigration, but with lower risk ratios than in those of recent immigration. The risk was higher in black immigrants and the black population living in the United States. But incidence and prevalence rates in Africa and the Caribbean were similar to those of international studies.

CONCLUSION

Comparing the most recent generation of immigrants with descendants of previous ones may account for the lower risk ratios observed in countries of longstanding vs. recent immigration. Two neurobiological hypotheses are proposed to explain the epidemiological findings in black populations and in immigrants.

Barriers to care in the mental health service: who gets in - who gets out?

"People with mental health problems are particularly vulnerable to social exclusion" - Vision for Change. People with mental health problems are very vulnerable. However those with mental health problems who have additional social problems are even more vulnerable. Currently psychiatric services in Ireland are provided on a 'catchment area' basis, with a consultant psychiatrist leading a multi-disciplinary team providing a service to the population of a defined geographical area. These services comprise both outpatient and inpatient care, and there is significant regional variation in terms of both bed availability and multidisciplinary team staffing. Sub-specialities, with the exception of child psychiatry and psychiatry of old age, are often unavailable, particularly outside Dublin. In such cases, some additional duties (eg. liaison, rehabilitation, perinatal) are assumed by the local general adult services. However, the overall distribution of services is uneven. Instead of services being concentrated upon those areas of greatest need, the opposite is often the case, with the most deprived areas having the least services in terms of acute beds and community mental health teams per thousand people. These areas also have less psychological services and specialist services despite increased levels of mental illness. Within this vulnerable population there are a number of sub-groups who are even further marginalised, and for whom there are significant barriers both at point of contact with services and with accessing appropriate follow up services. These include the homeless, the ever-increasing cohort of migrants to this country, those in prison and children and adolescents. Stigma and discrimination are the greatest barriers to social inclusion, quality of life and recovery for people with mental illness.

Migration and mental health: Evidence from a natural experiment

People migrate to improve their well-being. Yet a large literature suggests that migration can be a stressful process, with potentially negative impacts on mental health. However, to truly understand the effect of migration one must compare the mental health of migrants to what their mental health would be had they stayed in their home country. The existing literature is not able to do this. New Zealand allows a quota of Tongans to immigrate each year with a random ballot used to choose amongst the excess number of applicants. Experimental estimates of the mental health effects of migration are obtained by comparing the mental health of migrants who were successful applicants in the random ballot to the mental health of those who applied to migrate under the quota, but whose names were not drawn. Migration is found to lead to improvements in mental health, particularly for women and those with poor mental health.

Measuring acculturation and symptoms of depression of foreign immigrants in the Athens area

BACKGROUND

Acculturation is the phenomenon that results when a group with one culture comes into continuous contact with a host culture and changes occur in the original culture of either one or both groups. Acculturation has also been linked with stress-related psychological disorder and depression.

AIMS

This article investigates the acculturation process and the depressive state of foreign immigrants living in the greater Athens area.

METHODS

All consecutive cases of 157 foreign immigrants who visited a nongovernmental organization (NGO) providing consultative services to immigrants were interviewed using a structured questionnaire including the Immigrant Acculturation Scale (IAS) and the Centre for Epidemiologic Studies - Depression (CES-D) scale.

RESULTS

Factor analysis of IAS yielded a three-factor solution and 17 items with loadings ranging from 0.74 to 0.41. This scale was also tested and proven to be reliable. The main finding is that the higher the acculturation level of the immigrant individual, the lower the CES-D scale score; the fewer the depressive symptoms are self-reported. Length of stay, existence of family in Greece, legal status of residence and employment were also found to have an effect on depressive symptomatology.

CONCLUSION

Acculturation could be seen as a beneficial mechanism protecting the individual to be exposed to stressful non-adaptive behaviour.

Schizophrenia in black Caribbeans living in the UK: an exploration of underlying causes of the high incidence rate

The incidence of schizophrenia in black Caribbeans living in the UK is substantially higher than in the white British population. When first reported, these findings were assumed to be a first-generation migrant effect or merely the result of methodological artefacts associated with inconsistencies in the diagnosis of schizophrenia in black Caribbeans and doubts about population denominators. More recently, it has become clear that the incidence of schizophrenia, based on standardised diagnosis and sophisticated census methods, is higher still in second-generation black Caribbeans. The largest study to date has demonstrated a ninefold higher risk of schizophrenia in UK-resident black Caribbeans: findings that are of concern to black Caribbean communities, to their GPs, and to health service managers responsible for resource allocation. A literature search was carried in order to explore possible reasons for the reported excess incidence of schizophrenia in UK-resident black Caribbeans. Competing hypotheses are reviewed and the paper concludes with a summary of specific social and psychological risk factors of significance within the black Caribbean community. Awareness of the factors associated with the onset and presentation of schizophrenia in black Caribbeans may help early diagnosis and rapid access to appropriate treatment which, in turn, appear to be related to improved long-term outcomes.

The incidence of schizophrenia in European immigrants to Canada

OBJECTIVE

The risk for schizophrenia in immigrants to Europe is approximately three times that of native-born populations. Discrimination and marginalization may influence the risk for schizophrenia within migrant populations. The primary objective of the present study was to determine whether the risk associated with migration was also evident 100 years ago. A second objective was to determine whether changing social stresses are associated with changes to the incidence of schizophrenia.

METHOD

During the first two decades of the twentieth century, the Provincial Mental Hospital was the sole provider of psychiatric services in British Columbia, Canada. Detailed clinical records have been preserved for 99.5% of 2477 patients who had a psychiatric admission between 1902 and 1913. Diagnoses were made after a detailed file review and 807 patients met DSM-IV criteria for first-episode schizophrenia, schizophreniform disorder, schizoaffective disorder, or psychosis not otherwise specified. Diagnoses had high inter-rater reliability. The incidence of schizophrenia in migrants from Britain or Continental Europe was compared with that in the Canadian-born population using indirect standardization and Poisson models.

RESULTS

Migration from Britain or Continental Europe to Canada in the early twentieth century was associated with an increased rate of schizophrenia; IRR=1.54, (95% CI=1.33-1.78). Incidence increased over time in immigrants but not in the native-born population and this increase occurred during a period of economic recession.

CONCLUSIONS

Migration was a risk factor for schizophrenia a century ago as it is today. This risk occurred in white migrants from Europe and increased during a period of increased social stress.

Psychosocial factors and distress: a comparison between ethnic Norwegians and ethnic Pakistanis in Oslo, Norway

BACKGROUND

In the Norwegian context, higher mental distress has been reported for the non-Western immigrants compared to the ethnic Norwegians and Western immigrants. This high level of distress is often related to different socio-economic conditions in this group. No efforts have been made earlier to observe the impact of changed psychosocial conditions on the state of mental distress of these immigrant communities due to the migration process. Therefore, the objective of the study was to investigate the association between psychological distress and psychosocial factors among Pakistani immigrants and ethnic Norwegians in Oslo, and to investigate to what extent differences in mental health could be explained by psychosocial and socioeconomic conditions.

METHOD

Data was collected from questionnaires as a part of the Oslo Health Study 2000-2001. 13581 Norwegian born (attendance rate 46%) and 339 ethnic Pakistanis (attendance rate 38%) in the selected age groups participated. A 10-item version of Hopkins Symptom Checklist (HSCL) was used as a measure of psychological distress.

RESULTS

Pakistanis reported less education and lower employment rate than Norwegians (p < 0.005). The Pakistani immigrants also reported higher distress, mean HSCL score 1.53(1.48-1.59), compared to the ethnic Norwegians, HSCL score 1.30(1.29-1.30). The groups differed significantly (p < 0.005) with respect to social support and feeling of powerlessness, the Pakistanis reporting less support and more powerlessness. The expected difference in mean distress was reduced from 0.23 (0.19-0.29) to 0.07 (0.01-0.12) and 0.12 (0.07-0.18) when adjusted for socioeconomic and social support variables respectively. Adjusting for all these variables simultaneously, the difference in the distress level between the two groups was eliminated

CONCLUSION

Poor social support and economic conditions are important mediators of mental health among immigrants. The public health recommendations/interventions should deal with both the economic conditions and social support system of immigrant communities simultaneously.

Assessment of need for psychosocial interventions in an Asian population of carers of patients with schizophrenia

AIM

This paper reports on a study to establish the profile of need for psychosocial family interventions and to examine the concurrent validity of the Relatives' Cardinal Needs Schedule with an Asian population of carers in England, UK.

BACKGROUND

Although psychosocial interventions for schizophrenia have a strong evidence base, little is known of the needs of Asian families. A cardinal need is indicative of the existence of a problem causing the carer a strain for which the carer is willing to co-operate if help is offered and for which systematic help has not been provided in the last 12 months.

METHODS

The Relatives' Cardinal Needs Schedule was used to assess needs in a small randomly selected sample of Asian carers in one English locality and to compare the results with independent measures of patient symptoms and carer distress.

RESULTS

Feedback from carers indicated that the Relatives' Cardinal Needs Schedule was culturally acceptable and appropriate to their needs. There was evidence for the validity of the assessment in that there were large and statistically significant associations between the number of needs detected by the Relatives' Cardinal Needs Schedule and independent measures of both carer distress (as measured by the 28 item General Health Questionnaire) and patient symptom severity (as reliably assessed from case notes).

CONCLUSION

The Relatives' Cardinal Needs Schedule may prove useful for nurses and service managers in establishing the need for psychosocial family interventions amongst Asian families in the United Kingdom.

Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1)

BACKGROUND

This paper is a part of the work of the group that carried out the report "The state of the mental health in Europe" (European Commission, DG Health and Consumer Protection, 2004) and deals with the mental health issues related to the migration in Europe.

METHODS

The paper tries to describe the social, demographical and political context of the emigration in Europe and tries to indicate the needs and (mental) health problems of immigrants. A review of the literature concerning mental health risk in immigrant is also carried out. The work also faces the problem of the health policy toward immigrants and the access to health care services in Europe.

RESULTS

Migration during the 1990s has been high and characterised by new migrations. Some countries in Europe, that have been traditionally exporters of migrants have shifted to become importers. Migration has been a key force in the demographic changes of the European population. The policy of closed borders do not stop migration, but rather seems to set up a new underclass of so-called "illegals" who are suppressed and highly exploited. In 2000 there were also 392,200 asylum applications. The reviewed literature among mental health risk in some immigrant groups in Europe concerns: 1) highest rate of schizophrenia; suicide; alcohol and drug abuse; access of psychiatric facilities; risk of anxiety and depression; mental health of EU immigrants once they returned to their country; early EU immigrants in today disadvantaged countries; refugees and mental health. Due to the different condition of migration concerning variables as: motivation to migrations (e.g. settler, refugees, gastarbeiters); distance for the host culture; ability to develop mediating structures; legal residential status it is impossible to consider "migrants" as a homogeneous group concerning the risk for mental illness. In this sense, psychosocial studies should be undertaken to identify those factors which may under given conditions, imply an increased risk of psychiatric disorders and influence seeking for psychiatric care. COMMENTS AND REMARKS: Despite in the migrants some vulnerable groups were identified with respect to health problems, in many European countries there are migrants who fall outside the existing health and social services, something which is particularly true for asylum seekers and undocumented immigrants. In order to address these deficiencies, it is necessary to provide with an adequate financing and a continuity of the grants for research into the multicultural health demand. Finally, there is to highlight the importance of adopting an integrated approach to mental health care that moves away from psychiatric care only.

Ethnic density, cultural congruity and mental illness in migrants

Migration is now well understood to be associated with mental illness in many parts of the world. However, the cause and effects of migration that are associated with mental illness continue to be a point of debate. The Ethnic Density concepts give a plausible explanation. On further elaboration, we conclude that a move from a sociocentric society to an egocentric one leads to more distress and more mental illness. Cultural incongruity faced by a migrant in an alien culture has a similar impact. Several theories on migratory distress have tried to explain psychiatric morbidity: high morbidity at source, individual predisposition, stress, misdiagnosis and racial discrimination. We hypothesise that the impact of ethnic density and cultural congruity occurs in a social context.

A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology

BACKGROUND

Understanding variations in the incidence of schizophrenia is a crucial step in unravelling the aetiology of this group of disorders. The aims of this review are to systematically identify studies related to the incidence of schizophrenia, to describe the key features of these studies, and to explore the distribution of rates derived from these studies.

METHODS

Studies with original data related to the incidence of schizophrenia (published 1965-2001) were identified via searching electronic databases, reviewing citations and writing to authors. These studies were divided into core studies, migrant studies, cohort studies and studies based on Other Special Groups. Between- and within-study filters were applied in order to identify discrete rates. Cumulative plots of these rates were made and these distributions were compared when the underlying rates were sorted according to sex, urbanicity, migrant status and various methodological features.

RESULTS

We identified 100 core studies, 24 migrant studies, 23 cohort studies and 14 studies based on Other Special Groups. These studies, which were drawn from 33 countries, generated a total of 1,458 rates. Based on discrete core data for persons (55 studies and 170 rates), the distribution of rates was asymmetric and had a median value (10%-90% quantile) of 15.2 (7.7-43.0) per 100,000. The distribution of rates was significantly higher in males compared to females; the male/female rate ratio median (10%-90% quantile) was 1.40 (0.9-2.4). Those studies conducted in urban versus mixed urban-rural catchment areas generated significantly higher rate distributions. The distribution of rates in migrants was significantly higher compared to native-born; the migrant/native-born rate ratio median (10%-90% quantile) was 4.6 (1.0-12.8). Apart from the finding that older studies reported higher rates, other study features were not associated with significantly different rate distributions (e.g. overall quality, methods related to case finding, diagnostic confirmation and criteria, the use of age-standardization and age range).

CONCLUSIONS

There is a wealth of data available on the incidence of schizophrenia. The width and skew of the rate distribution, and the significant impact of sex, urbanicity and migrant status on these distributions, indicate substantial variations in the incidence of schizophrenia.

Migration and mental health

OBJECTIVE

Migration and its accompanying stressors affect migrating individuals and their families. The process of migration is not simple or straightforward. The aim of this review is to distil existing information on how migration influences individuals' mental state and how it determines help seeking as well as pathways to care.

METHOD

The review relies on published studies in both MEDLINE and non-MEDLINE journals as well as relevant monographs. The search was employed using migration, ethnic communities, stress and other relevant words for purposes of the review.

RESULTS

The review provides a background on the typology of migration, its impact on communities as well as individuals. Furthermore, the relationship of mental illness to migration is explored and described. Future research plans are advocated in relationship with these findings.

CONCLUSION

Migration is and can be a very stress-inducing phenomenon. Yet not all migrants go through the same process. The clinician needs to be aware of coping strategies as well as resilience among migrants.

Psychiatric disorders and social characteristics among second-generation Moroccan migrants in Belgium: an age-and gender-controlled study conducted in a psychiatric emergency department

PURPOSE

Clinically, one of the most consistent clinical findings among migrant patients is an increase in the rate of psychosis. The aim of the present study was to confirm this finding in Belgium by comparing second-generation Moroccan migrant patients with Belgian patients, matched for the variables of age and gender.

SUBJECTS AND METHOD

We conducted a cross-sectional survey on 272 patients admitted in a psychiatric emergency unit during the year 1998. We used univariate and multivariate analyses to compare the two subgroups.

RESULTS

Multivariate analyses showed that migrant patients lived more often with their parental family and that they presented a higher rate of admission for psychotic disorders and a lower rate of employment.

DISCUSSION

Our findings add to the growing body of results showing increased incidence of psychosis among immigrants to European countries, but several factors have to be taken into account, particularly with regard to selection biases and differences in help-seeking behaviour and in family perception of the mental illness.

CONCLUSION

Our results are compatible with the hypothesis that unemployment is a contributing factor in the risk for psychosis among migrant groups. Further studies would be needed to better explain some of our results, particularly the role played by the families of migrant patients.

Migration and schizophrenia

OBJECTIVE

Since the beginning of the human race, individuals have migrated alone or in groups. This process of migration has often been considered to be an aetiological factor in the genesis of many mental disorders.

METHOD

Two studies collecting rates of first onset schizophrenia in Trinidad and in London using the same assessment instruments.

RESULTS

The sending countries have low rates of schizophrenia. The impact of migration itself produces high stress but rates of schizophrenia are even higher in the second generation, suggesting that that other social factors may be responsible for the increase if genetic vulnerability is excluded.

CONCLUSION

Individual social factors, such as cultural identity and the impact of racism, are more likely to play a key role in the genesis of schizophrenia.

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.

Understanding the excess of psychosis among the African-Caribbean population in England. Review of current hypotheses

BACKGROUND

Increased rates of schizophrenia continue to be reported among the African-Caribbean population in England.

AIMS

To evaluate the competing biological, psychological and social explanations that have been proposed.

METHOD

Literature review.

RESULTS

The African-Caribbean population in England is at increased risk of both schizophrenia and mania; the higher rates remain when operational diagnostic criteria are used. The excess of the two psychotic disorders are probably linked: African-Caribbean patients with schizophrenia show more affective symptoms, and a more relapsing course with greater social disruption but fewer chronic negative symptoms, than White patients. No simple hypothesis explains these findings.

CONCLUSIONS

More complex hypotheses are needed. One such links cultural variation in symptom reporting, the use of phenomenological constructs by psychiatrists and social disadvantage.

Mental illness and Irish people: stereotypes, determinants and changing perspectives

The causes of psychological illness in Irish people have been identified with colonial rule and the catastrophic conditions deriving from famine in the nineteenth century. In particular, the scourge of unremitting emigration, resulting from famine, has formed a background against which speculative theories of inferiority, alienation and mental illness have been constructed. In particular, the long standing idea that Irish people exhibit higher rates of schizophrenia, both in Ireland and abroad, is discussed. Contemporary studies which suggest that these elevated rates do not correspond to international diagnostic criteria for schizophrenia are introduced. Rather, these enhanced rates may reflect a malaise which resembles schizophrenia but which is really a product of historical dispossession. The importance of these factors is underscored by the previous neglect of Irish people, considered as an ethnic minority, as well as the particular distaste which many Irish people display towards such a notion.

Migration and health in the European Union

The paper gives a brief overview of a wide spectrum of health issues and problems, ranging from communicable disease to mental health and family formation, which affect migrants and host countries.

Social determinants of psychiatric morbidity and well-being in immigrant elders and whites in east London

OBJECTIVES

The social conditions under which migrants to the UK live may be more significant than the experience of migration itself in leading to increased risk of mental illness. We aimed to compare the prevalence of mental, physical and social health problems in elderly Somalis, Bengalis and whites living in a deprived inner London area and examine associations between environmental circumstances, social support, physical health status, mood and life satisfaction in these groups. In addition, we wanted to test the hypothesis that differences in mental health between immigrants and whites are explained by social disadvantages rather than ethnicity.

DESIGN

Cross-sectional survey with participants drawn from age-sex registers of general practices, augmented by other sources.

SETTING

East London--'first-generation' Somali and Bengali immigrants and white British.

SUBJECTS

A total of 274 people aged 60+ years: 72 Somalis, 75 Bengalis and 127 whites.

MAIN OUTCOME MEASURES

Symptoms of Anxiety and Depression Scale (SAD), Life Satisfaction Index (LSI). High SAD scores indicate more anxiety and depression symptoms; high LSI scores indicate greater life satisfaction.

MAIN RESULTS

Highest SAD scores were found among Bengalis; lowest LSI scores were found among Bengalis and Somalis. The prevalences of depression (SAD score 6+) were 25% in Somalis, 77% in Bengalis and 25% in east London whites. Physical health status and SAD scores were associated in Somalis (r = +0.31, p < or = 0.01). Bengalis (r = +0.47, p < or = 0.001) and east London whites (r = +0.27, p < or = 0.01). Physical health problems also related to lower LSI scores in Somalis (r = -0.24, p < or = 0.05) and east London whites (r = -0.24, p < or = 0.01). Social factors (i.e. poor housing conditions, low family support and reported need of community services) were strongly associated with SAD scores among Somalis (r = +0.5, p < or = 0.001) and, to a lesser extent, among Bengalis (r = +0.33, p < or = 0.01). Ethnicity (i.e. being an immigrant as opposed to a non-immigrant) became a statistically non-significant risk factor for high SAD scores after adjusting for the effects of age, weekly income, physical health and social problems (OR = 0.71, 95% CI = 0.5-1.1, p = 0.09). A residual, but much attenuated effect for ethnicity on LSI scores persisted in the estimated model after controlling for the same set of independent risk factors (OR = 0.7, 95% CI = 0.4-1, p = 0.05).

CONCLUSION

The marked variation in mental health between ethnic groups in east London might be a reflection of socioeconomic and health differentials acting concomitantly and adversely. Inequalities in housing, social support, income and physical health status accounted for variation in mood observed between immigrants and whites, and may partly explain differences in life satisfaction. These results seem to support a 'multiple jeopardy' theory of ageing in ethnic minorities in east London. Greater efforts are needed to recognize anxiety and depression in immigrant elders. Better social support and housing among 'minority ethnic' elders who live alone might be expected to alleviate social stress and improve mental health and psychological well-being.

Immigration, moving house and psychiatric admissions

This study was designed to elucidate psychiatric admission rates for native Swedes and foreign-born individuals during the period 1991-1994, when Sweden had a great influx of refugees. During the same period, and even earlier, psychiatric in-patient care had been reduced. Tests of differences between Swedes and foreign-born individuals in first psychiatric admission rates were performed using Poisson regressions, and the risk of a readmission was assessed using a proportional hazard model. Foreign-born individuals and native Swedes, both males and females, showed a similar admission pattern with regard to the number of admissions. Foreign-born males under 55 years of age and foreign-born females under 35 years of age had significantly higher admission rates than native Swedes. In total, native Swedes, both males and females, were hospitalized for a significantly longer period than the foreign-born subjects. About 43% of the patients were readmitted. The risk of a readmission was significantly increased among those with a high rate of internal migration. The high admission rates for young foreign-born individuals might be explained by a high incidence of mental illness owing to the trauma of being violently forced to migrate, acculturation difficulties, or unsatisfactory social circumstances such as high unemployment. The shorter hospitalization time could be due to undertreatment or less serious mental illness.

Ethnic differences in substance use and alcohol-use-related mortality among first generation migrants to England and Wales

Epidemiological studies among migrant ethnic groups are potentially important as a way to provide insight into the relative importance of genetic, cultural, and socioeconomic factors in the etiology of substance use disorders. This paper summarizes prior United Kingdom studies of the prevalence of substance-use-associated problems in different ethnic groups before analyzing trends in recent mortality data by country of birth. On this evidence, rates of alcohol-related mortality may be marginally higher for those born in the Caribbean than for the native British, but are substantially raised for those born in Ireland and the Indian subcontinent. There is some indication that rates for the Caribbean and possibly the Irish groups have risen more rapidly than for the national population over a 12-year period. These differences in mortality rates seem to have arisen for complex reasons.

Onset study of English-speaking temporary residents in Japan

This is a study of the onset time of psychiatric episodes of 103 English-speaking temporary residents in Japan. The onset time is defined as the interval between the time of arrival in Japan and the request for treatment. The best-fit model was composed of 13 factors and had a highly significant effect on onset time. The existence of a past history of psychiatric disorder was linked with a high vulnerability. Higher proficiency in the language and experience of having been married indicated a lower vulnerability. Vulnerability defined by onset time may share a certain common ground with liability defined by prevalence.

Inner london collaborative audit of admission in two health districts. III: Reasons for acute admission to psychiatric wards

BACKGROUND

In this series, rates of admission and daily bed use in south Southwark were 30% higher than in Hammersmith & Fulham, principally because of a higher rate of admission for affective disorders. Factors associated with compulsory admission did not differ between the districts. This final paper examines the severity of symptoms, the reasons given for admission and factors relevant to the judgement to admit, in order to test the hypothesis that more resources mean better service.

METHOD

Sampling and data collection methods were described in the first paper.

RESULTS

In both districts, major reasons for admission were self-neglect and risk of self-harm, poor adaptive functioning, and poor acceptance of medication. In south Southwark, a group of patients had affective disorders and less severe symptoms but a stated risk of suicide. Rates for, and severity of, schizophrenia were similar in the two districts. Social and preventive reasons for admission were given more frequently in south Southwark, where patients had more often been in contact with services before admission. Staff there, but not in Hammersmith & Fulham, suggested that many could have benefited from alternative forms of residential care.

CONCLUSIONS

A 'buffer' of hospital beds in south Southwark may have allowed a more acceptable service, particularly for affective disorders. The possibility that this buffer could be replaced by a wider range of residential accommodation, including hostels away from the District General Hospital, is discussed. Ten recommendations are listed.