INTRODUCTION
Migration has been a constant element influencing human societies across the course
of history. Migration is the process during which a person moves from one cultural
setting to another to settle, either for a longer period or permanently. According
to the IOM-OIM,[1] current estimates are that there are 244 million international
migrants globally (or 3.3% of the world's population). While the vast majority of
people in the world continue to live in the country, in which they were born, an increasing
number of people are migrating to other countries, especially those within their region.
Many others are migrating to high-income countries that are further afield. In this
context, work is the major reason that people migrate internationally, and hence that
migrant workers constitute a large majority of the world's international migrants,
with most living in high-income countries and many engaged in the service sector.[1]
Another reason for migration is global displacement, which is at a record high, with
>70.8 million globally, the number of internally displaced at over 41.3 million, and
the number of refugees >25.9 million.[2] Due to a global increase in social and political
instability as well as socioeconomic and armed conflicts, the number of refugees,
asylum seeker, and migrants over the globe is growing dramatically, and industrialized
countries are likely to receive increasing numbers of people belonging to ethnic minorities
in the form of refugees and asylum seekers. In addition, people migrate due to poverty,
or climate crises in their country of origin, such as drought. Refugees and asylum
seekers are a heterogeneous group, with many different reasons for migration, many
different experiences during the migration, and differing legal status.[3] Most of
them experience stress-related risk factors during the stages of premigration, migration,
and postmigration.
In this editorial, we would like to draw attention to the mental health of migrants
and underline an enormous need for action.
MIGRATION AND MENTAL HEALTH
Because migration is such a complex process, it often brings with it stress, strain,
and risk factors such as poor medical care, separation of family and children as well
as other relatives. It can also include homelessness, lack of food and water, xenophobic
attacks, poor education, perceived and experienced discrimination, and a high risk
of death and injury.[4
5] Furthermore, social factors, including cultural bereavement, culture shock, social
defeat, as well as a discrepancy between expectations and achievement, and acceptance
by the new nation can all affect adjustment.[3
6] Further risk factors in new communities can include social exclusion, stigma, and
discrimination.
Migration and psychosis
According to Cantor-Graae and Selten,[7] chronic experience of social defeat was related
to poor mental health and risk of psychosis in migrants. In a systematic review and
meta-analysis, Henssler et al.[5] suggested that there are increased rates of schizophrenia
and related psychoses in first- and second-generation migrants and refugees. The meta-analysis
was on the incidence of nonaffective psychotic disorders among first- and second-generation
migrants. Furthermore, the authors found substantial evidence for an increased relative
risk of incidence among first- and second-generation migrants compared to the native
population. The findings were interpreted in the context of social exclusion and isolation
stress and provide an explanatory framework that links cultural differences in verbal
communication and experienced discrimination with the emergence of psychotic experiences
and their neurobiological correlates. In addition, the authors suggested that experienced
discrimination and social exclusion are core factors underlying increased rates of
psychotic experiences in subjects with a migration background. In another systematic
review and meta-analysis, Brandt et al.[8] found that the risk of the manifestation
of schizophrenia and associated nonaffective psychoses is statistically significantly
increased in refugees compared with the native population as well as compared with
nonrefugee migrants.
Migration and dementia
Most countries have an aging population with an increasing number of elderly migrants,
and many of these elderly migrants will develop dementia in a country other than that
of their origin. Thus, it can be assumed that dementia will also increase among migrants
in the coming decades. Data on the prevalence of dementia among those with a migrant
background are currently lacking, and it is not yet possible to estimate the size
of the approaching burden on the health system. Aggarwal and Hinton addressed this
subject in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Handbook on the Cultural Formulation Interview, which was edited by Lewis-Fernández
et al. (2016)[9] in the chapter on “the Cultural Formulation Interview (CFI) supplementary
module for older adults.”
In a few studies, it was reported that the risk of developing dementia among certain
groups of migrants is higher in comparison to people who grew up in the host country.
Pettit et al.[10] found a prevalence rate of 17.3% among Caribbean migrants in the
UK, which was higher than among other groups of the population. The authors discussed
that cardiovascular comorbidity may be responsible for the higher rate of dementia.
According to a Danish study, a prevalence rate of 13.3% was found among people with
a Turkish migration background in comparison to the prevalence rate of 7% in the indigenous
population.[11] Nielsen and Waldemar[12] highlighted that in the diagnosis of dementia,
in particular, the interpretation of cognitive tests continues to present a challenge.
The existing screening tools have been demonstrated to require modification for use
among those from an educationally disadvantaged background, those lacking knowledge
of the health system, and first-generation migrants.[11] Neuropsychological dementia
assessment of migrants is limited regarding the testing of cognitive abilities as
well as the recording of everyday activities (Activities of Daily Living). Linguistic,
educational, lifestyle, and cultural-religious factors have not been taken into account
in psychometric instruments.[13] In addition, culturally and linguistically diverse
elderly people with dementia face many unique challenges and have particular needs
owing to the impairment of verbal and nonverbal language, which worsens with the degenerative
process of dementia. Bilingual people with dementia also tend to mix languages and
have problems with language separation.[14] The authors emphasized that communication
is essential for social life, regardless of cognitive function, and for avoiding isolation,
strengthening patients' identity, and decreasing depression and anxiety. With a growing
aging population and increased global migration, language reversion is an upcoming
and challenging topic that has received little research attention.[14] Therefore,
the assessment of elderly migrants is necessary for adapting health-care services
and interventions. Dissemination of accumulated knowledge from studies about elderly
migrants and language is urgently needed.
Migration and posttraumatic stress disorder
In a systematic review, Morina et al.[15] reported that the highest prevalence of
psychiatric disorders was registered for post-traumatic stress disorder from 3% to
88%, depression from 5% to 80%, and anxiety disorders from 1% to 81% in refugees and
internally displaced persons after forced displacement. The authors pointed out that
there is an urgent need for large-scale interventions that address psychiatric disorders
in refugees and internally displaced persons after displacement. Lindert et al.[16]
reported prevalence rates for posttraumatic stress disorder (PTSD), which varied from
5% to 71% (mean prevalence rate: 32%) rates for depression varied from 11% to 54%
(mean prevalence rate: 35%) in the refugee population, whereas Bogic et al.[17] published
significant prevalence rates of depression with the range of 2.3%–80%, PTSD from 4.4%
to 86%, and unspecified anxiety disorder from 20.3% to 88%. In this systematic literature
review, the authors found that greater exposure to premigration traumatic experiences
and postmigration stress were the most consistent factors associated with all three
disorders, whilst a poor postmigration socio-economic status was particularly associated
with depression. In all studies, a wide range of prevalence rates were reported, which
were attributable to the diversity of the study samples. Therefore, there is a need
for more methodologically consistent and rigorous research on the mental health of
long-settled war refugees.[17] The increased risk may not only be a consequence of
exposure to wartime trauma but may also be influenced by postmigration socio-economic
factors. According to Giacco et al.,[18] prevalence studies show that, in the first
years of resettlement, only PTSD rates are clearly higher in refugees than in host
countries' populations. The authors further reported that five years after resettlement,
rates of depressive and anxiety disorders were also elevated. Exposure to traumatic
events before or during migration may explain high rates of PTSD. Evidence suggests
that poor social integration and difficulties in accessing care contribute to higher
rates of mental disorders in the long term.[18] Chen et al.[19] also highlighted that
postmigration resettlement-related stressors were the most important correlates of
mental health in migrants fleeing for humanitarian reasons. Postmigration resettlement-related
stressors accounted were both directly associated with mental health issues and also
mediated indirect associations. Thus, targeting resettlement-related stressors through
augmenting psychosocial care programs and social integration would be a key approach
to improve humanitarian migrants' mental health. Winkler et al.[20] found significant
correlations between insecure residency status and the symptoms of mental disorders
in refugees and asylum seekers. In this study, respondents with higher symptom load
took less advantage of the support, participated less in measures designed to assist
integration, and described more difficulties in their hearing. Only 11.6% of asylum
seekers with mental disorders indicating symptoms were in psychiatric treatment.[20]
MENTAL HEALTH CARE SERVICES: BARRIERS TO ACCESS
According to Park et al.,[21] migrant, refugee, and asylum seeker patients have an
elevated need for mental health care, but simultaneously have less access to it. Reasons
for this gap include stigma and shame regarding mental illness,[3] cultural beliefs,
lack of language proficiency as well as financial constraints. Furthermore, real economic
barriers and perceived social consequences could impede service seeking because migrants,
refugees, and asylum seekers often lack health insurance.[22] Bridges et al.[23] pointed
out that the highest barriers to service utilization were economic, because migrant,
refugee, and asylum seeker patients generally have limited financial resources. Other
barriers are linguistic because in many countries there are no legal regulations for
the financing of interpreters. Interestingly, the authors emphasized that economic
barriers were more salient for women than men, and for participants with a psychiatric
disorder in comparison to those without. It is possible that certain cultures prioritize
treatment for the breadwinner in the family. In addition, Bridges et al.[23] reported
that the combination of lack of ability to speak the native language and service providers'
lack of ability to translate into a first language significantly impeded help-seeking.
Furthermore, the general lack of knowledge about help services was reported to be
significantly exacerbated in men as compared to women.
CULTURAL COMPETENCE
According to Bhugra et al.,[3] every psychiatrist should see his/her patients in the
context of his/her culture as well as taking into account their own cultural values
and prejudices.[3] In these intercultural settings, the psychiatrists are experts
in biomedicine and psycho-social factors, while patients are experts in their own
experience of distress. According to Schouler-Ocak et al.,[22] therefore, cultural
competence is a central aspect of the daily work of the psychiatrists. Concepts such
as cultural competence, cultural-sensitivity, humility, and responsiveness are necessary
to help practitioners work with culture and context in clinical care. In this context,
psychiatrists should be aware of their own cultural biases, and be able to productively
engage with interpreters or culture brokers, as well as understand culturally different
family structures, the effects of discrimination, exclusion, unemployment, intergenerational
differences in acculturation, different explanations of illness, symptom presentations
and treatment expectations, and idioms of distress.[24] Furthermore, they should be
aware of the complications that can arise in working with family members or relatives
as well as training in intercultural psychotherapy, including issues of transference
and counter-transference, and somatization.[24] According to Sue et al.,[25] cultural
competence requires knowledge, skills, and attitudes that can improve the effectiveness
of psychiatric treatment. It represents a comprehensive response to the mental health
care needs of refugees, asylum seekers, and migrant patients, and it is important
to be mindful of the risks of stereotyping.[22
26] The main skills of cultural competence are intercultural communication, the capacity
to develop a therapeutic relationship with a culturally different patient, and the
ability to adapt diagnosis and treatment in response to cultural differences between
the psychiatrist and the patient.[22
26] Furthermore, intercultural work requires psychiatrists to challenge their own
perceptions of “reality,” explore their own cultural identity, prejudices, and biases,
and to be willing to adapt to distinct cultural practices.[22] In this context, it
should be highlighted that cultural competence is not the end of a process, technical
expertise that confers on the individual a resolved accreditation which will enable
them to work with patients from all cultures. It is an ongoing process of learning
by training. Recommendations to policymakers, service providers, and clinicians are
set out in the WPA guidance on mental health and mental healthcare in migrants,[6]
the EPA guidance on mental health care of migrants[3] and the EPA guidance on cultural
competence.[22]
INTERCULTURAL COMMUNICATION
Language is the main working tool in psychiatry and psychotherapy. To avoid misdiagnosis,
inappropriate treatment, and frustration, not only do we need good verbal communication,
but we also need to consider different explanatory models regarding the cause, course,
and cure of certain health problems.[27] In this context, a description of the respective
diseases can have a thoroughly different meaning in a specific cultural context. Since
a psychiatrist neither expected to be knowledgeable about all culture-related issues,
nor master the languages of all his/her migrant, refugee, and asylum seeker patients,
the involvement of professionally trained interpreters is inevitable.[22
26] Intercultural psychiatry is hindered not only by language barriers but also by
more complex communication problems, based on different explanations of the causes,
characteristics, and treatment options for various illnesses. However, migrant, refugee,
and asylum seeker patients deserve access to the same professional psychiatric treatment
as native patients. Therefore, costs for interpreters should be covered by the country's
health-care system.
ETHNOPHARMACOLOGY
Pharmacological treatment is the therapy of choice for almost all psychiatric illnesses.
Nevertheless, undesirable side effects, lack of response to medication, and discontinuation
of therapy by patients are common. The right choice of preparation and dosage can
help to avoid or reduce failed therapy attempts. Research findings in recent years
have increasingly demonstrated the importance of individual circumstances when selecting
pharmacological therapy.[28] Ethnicity, membership of a minority, and experience of
migration play a central role alongside other demographic factors such as age, gender,
duration of illness, and others, but are not sufficiently considered in everyday clinical
practice when planning therapy.[28] A decline in access to health services for ethnic
minorities, a more negative attitude toward psychiatric treatment, and a lack of consideration
of cultural factors by psychiatrists play a role, as do biological factors that influence
the metabolism and effects of drugs. There is good evidence of ethnic differences
both in genes for cytochrome enzymes and different transporters and receptors. Even
though the clinical relevance of all these genetic factors is not conclusively clarified
at this point, initial recommendations, such as testing for the presence of the HLA-B*1502
allele in risk populations, have already become established in psychiatric practice.
The greater consideration of cultural and other clinical factors are also increasingly
reflected in practice recommendations.[28
29] Thus, it is important to assess attitudes towards medication, use of traditional
medicine, and the use of tobacco and alcohol.[6]
Recommendations
Worldwide, it is expected that the number of migrants, refugees, and asylum seekers
will continue to rise over the coming decades. Health-care services have to be prepared
for this very heterogeneous population with different concepts of health and disease
as well as expectations about treatment procedures. Health-care services, health-care
professionals, stakeholders, and policymakers should be given the resources to meet
the needs of migrant, asylum seekers, and refugee patients. Using the CFI can help
to provide more information about the impact of culture on key aspects of a patient's
clinical presentation and care. Furthermore, the cultural competence of all professional
staff and the regular use of language and culture mediators could be very useful to
access health care services and reduce the key barriers to service access and use.
Improving the institutional, cultural competence could increase the quality of care
at a systemic, organizational, and institutional level. Therefore, cultural competence
training for all professional staff and initiatives to facilitate institutional, cultural
competence should be implemented to increase the utilization of mental health services.
The recommendations to policymakers, service providers and clinicians that are set
out in the WPA guidance on mental health and mental health care in migrants,[6] the
EPA guidance on mental health care of migrants,[3] and the EPA guidance on cultural
competence[22] should be realized.
According to WHO,[30]“Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity … Health is a resource for everyday
life, not the object of living … and is a fundamental human right, recognized in the
Universal Declaration of Human Rights.” It is incumbent on all mental health professionals
to remember that the right to health is a human right and we should respect it for
all of our patients.