WPA guidance on mental health and mental health care in migrants

The WPA is committed to promote equity in the access to mental health services for persons of different age, gender, race/ethnicity, religion and socioeconomic status. As part of this commitment, the Association decided to devote one of the guidances to be developed within its Action Plan 2008–2011 1,2 to mental health and mental health care in migrants. A Task Force was appointed for this purpose, which produced the present document. Mental health practitioners work in an increasingly multicultural world, shaped by the migrations of people of many different cultural, racial and ethnic backgrounds. People migrate for many reasons: political, socioeconomic and educational. The diversity of cultures, ethnicity, races and reasons for migration can make understanding experiences of illness challenging in migrants whose background differs significantly from the clinician. Culture has an important role in the presentation of distress and illness, and cultural differences impact upon the diagnosis and treatment of migrant populations in part due to linguistic, religious and social variation from the clinician providing care. Additionally, it appears that the incidence and prevalence of mental disorders varies among people of different cultural backgrounds, due to an interplay of biological, psychological and social factors. The provision of health care is necessarily influenced by the demands of people of many different cultures, and it is important that cultural differences be appreciated and understood to arrive at a correct diagnostic impression and treatment plan. Migration is defined as the process of going from one country, region or place of residence to settle in another. The duration of this new settlement varies, but for the purposes of this report the focus is on individuals who relocate either semi-permanently or permanently to another country. Migrants may move en masse or singly. For example, people who migrate for economic or educational reasons may move singly and at a later date be joined by their families, whereas people who migrate due to political reasons may move en masse but with or without their families 3. A significant proportion of people who migrate will become an ethnic minority in the new country. The process of migration has been described as occurring in broadly three stages. The first stage is pre-migration, involving the decision and preparation to move. The second stage, migration, is the physical relocation of individuals from one location to another. The third stage, post-migration, is defined as the “absorption of the immigrant within the social and cultural framework of the new society”. Social and cultural rules and new roles may be learnt at this stage 4,5. The initial stage of migration may have comparatively lower rates of mental illness and health problems than the latter stages, due to the younger age at that stage, and the problems with acculturation and the potential discrepancy between attainment of goals and actual achievement in the latter stages 6. It is worth noting that the stages are often not discrete and merge into one another. During the stages of migration, there may be factors that predispose individuals to mental disorders. Pre-migration factors include the personality structure of an individual, forced migration, and persecution, among others. Migration factors include cultural bereavement. Culture shock, a discrepancy between expectations and achievement, and acceptance by the new nation are potential post-migration factors 7,8. Table 1 provides a guide to the assessment of the above factors in migrants. Some groups have additional factors that need to be taken into account in assessment and management. Women may be the primary migrant or they may follow the primary migrant. Their experiences of migration and response to the stress will be different from those of men. Furthermore, changes in gender role after migration and gender role expectations will influence the way women respond to the stress of migration and post-migration adjustment. Increasing changes in demographics towards more women migrating and working full time mean that stress on women is increasing further. Children and adolescents may have different reasons to migrate and may accompany the family or migrate by themselves, especially as refugees or asylum seekers. Separation from one or both parents, as part of or as a sequel of migration, may create problems in attachment and subsequent development. Seasonal regular migration of parents or serial migration of family members and other patterns of migration will create additional stress. Children may have difficulty in adjusting both at home and in school, and older children may end up looking after the younger ones. The reasons for migration of older adults may differ in comparison with younger ones. Elderly people may have migrated at an earlier stage of their career and life and may already feel settled down in the new country, or may migrate at an older age to the new country in order to join their family. Multiple jeopardy of ageing migrants related to racism, ageism, gender, poor access to services may all act as barriers to help seeking and health 9. Dementia, depression and anxiety among the elderly may vary according to the migrant status, but help seeking may vary as well 9,10. According to the Geneva Convention, a refugee is someone who has a “well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or owing to such fear is unwilling to avail himself of the protection of that country”. An asylum seeker is someone who has left his/her country of origin, has applied to be recognized as a refugee and is awaiting a decision from the new government. Refugees are perhaps the most vulnerable of all migrant groups to mental and physical ill health. Lack of preparation, attitudes of the new country, poor living conditions, poor or lack of employment and variable social support all add to this vulnerability. Rates of mental disorders may be high in some refugee groups: those of common mental disorders are twice as high in refugee populations in comparison with economic migrants 11. The risk of post-traumatic stress disorder and common mental disorders increases with the length of stay in detention 12,13 and is also related to unemployment, lack of family support and the complicated asylum process 11. Asylum seekers are less likely to engage with mental health services 14,15. Pathologization and medicalization of common experiences must be avoided. Lesbian, gay, bisexual and transgender individuals (LGBT) may wish to escape if their country of origin holds these behaviours to be illegal. They may have problems coming out to themselves and to others, adding to internalized stress. They may choose to escape but the laws in the new countries may not allow this or prevalent public attitudes to LGBT may colour the societal responses. For transgender individuals, it may be a search for surgical/medical interventions which drives them. Attitudes of the family, the ego-dystonia in the individual and homophobia in the new society will affect settling down. The loss of one's social structure and culture can cause a grief reaction 16. Migration involves the loss of the familiar, including language (especially colloquial and dialect), attitudes, values, social structures and support networks. Grieving for this loss can be viewed as a healthy reaction and a natural consequence of migration; however, if the symptoms cause significant distress or impairment and last for a significant period of time, psychiatric intervention may be warranted. Eisenbruch 17 has defined cultural bereavement as an experience resulting from loss of social structures, cultural values and self-identity. The person lives in the past, is visited by supernatural forces from the past while asleep or awake, and experiences feelings of guilt. Images of the past (including traumatic images) intrude into his/her life, and he/she is struck by anxieties, morbid thoughts, and anger. The symptoms of cultural bereavement may be misdiagnosed due to problems with language and culture, and the use of Western diagnostic criteria in non-Western people. Psychosocial changes experienced by immigrants include acculturation, a process that may be voluntary or forced, which results in the assimilation of cultural values, customs, beliefs and language of the majority community 18. Changes in attitudes, family values, generational status and social affiliations can occur in both the majority and minority cultures as the two interact; however, typically one culture tends to dominate 19. Cultural changes in identity can be stressful and result in problems with self-esteem and mental health. Contact between the immigrant, or minority, community with the dominant, or new community may lead to assimilation, rejection, integration or deculturation 4. Rejection, in which the individual or minority group withdraws from the majority group, can lead to apartheid or segregation in extreme cases. Deculturation, in which the individual or minority group experiences a loss of cultural identity, alienation and acculturative stress, can lead to ethnocide 4. Post-migration stresses include culture shock and conflict, both of which may lead to a sense of cultural confusion, feelings of alienation and isolation, and depression 7. New societies’ attitudes, including racism, compounded by stresses of potential unemployment, a discrepancy between achievement and expectations, financial hardships, legal concerns, poor housing and a general lack of opportunities for advancement within the host society, can lead to mental health problems in vulnerable individuals. Acculturation may enable culturally bereaved individuals to gain a semblance of equilibrium. Migrants who experience the loss of their culture and guilt over leaving their homeland may find that, as acculturation proceeds, a sense of belonging in the new country occurs. The majority culture may seem less threatening and more inviting as the individual becomes more linguistically and socially proficient in this new culture. Social support can ensue in the forms of friendships, employment opportunities, and medical care. Integration and assimilation can help reduce feelings of loss and grief as the migrant starts to incorporate aspects of the majority culture. In acculturation, the interaction of the migrant's culture with the majority culture of the new country is a dynamic and reciprocal process that can result in changes in the broader cultural group, enhancing the ability of people of the dominant culture to better appreciate and understand aspects of the immigrant's culture and recognize some of the needs of those who have migrated. Ethnic density, i.e. the size of a particular ethnic group in proportion to the total population in a specified area, may be a factor that influences the rates of mental disorders in ethnic minorities. Additionally, a sense of alienation may occur if the cultural and social characteristics of an individual differ from those of the surrounding population, whereas a sense of belonging tends to occur if the individual and surrounding population have similar cultural and social characteristics. An increase in ethnic density may improve the social support and the adjustment of some individuals who have migrated, yet increase distress in others, in particular if there exists a cultural conflict between the individual and his/her culture of origin 8. This may account for some of the conflicting results from studies of the relationship between ethnic density and the incidence of mental illness in ethnic minority groups. For example, an inverse correlation between the incidence of schizophrenia in non-White ethnic minorities in London and the proportion of those minorities in the local population was found; it was hypothesized that increased exposure to or a lack of protection from stress may increase the rate of schizophrenia in non-White ethnic minorities 20; however, a previous study failed to support the ethnic density hypothesis for the increased incidence of schizophrenia in immigrant groups 21. It is important to consider the nature of the society an individual has migrated from and to, and the social characteristics of the individual who has migrated, in determining how well a person will adjust during the migration process. Sociocentric or collectivist societies stress cohesiveness, strong ties between individuals, group solidarity, emotional inter-dependence, traditionalism and a collective identity. Egocentric or individualistic societies stress independence, loose ties between individuals, emotional independence, liberalism, self-sufficiency, individual initiative, and autonomy. has hypothesized that individuals who migrate from or societies into a society that is or are likely to have problems adjusting to the new culture, especially if the individuals are in their A lack of an social support a between expectations and and a self-esteem may result from this in culture between the individual and the surrounding An increase in ethnic density may help the distress of the individual in this especially by providing a social support For example, a person who to the a society, from a society, may feel and especially if the individual is in of and alienation may be and social support if other people from with this person in the of however, the individual may on the of the new society and social of the dominant culture may not be Cultural bereavement may also be if the immigrant is to ties to the culture of origin, either increased ethnic density, social support or of religious beliefs and who migrate from a culture into a society that is in nature may experience in the way of and a to the new culture, if they are or in their In this an increase in ethnic density may be and or cause cultural conflict and mental first that the rates of schizophrenia among who migrated to the with in that the of rates after migration and this as a result of studies have that especially in the and in the have rates of schizophrenia between and those of local populations A risk for schizophrenia in migrants has been in a and that rates of with schizophrenia among the and migrants. They to these which are The first hypothesis was that countries have high rates of studies from the Rates of schizophrenia in the have been to be among the younger that factors may not a role and other social and factors may be important A second hypothesis was that schizophrenia to The individual with schizophrenia and this to potential not are there to support if that the rates be high in migrant group, which is not is A third hypothesis was that migration stress. Migration and related are significant life and may to the of as the of the rates is Separation from parents has been to be more common in in comparison with and also in comparison with community which may that attachment patterns may to a sense of the cultural identity. A hypothesis was that a of schizophrenia was due to a lack of of culture and that, in their of but than the London also cultural differences in Ethnic density has been to be an important factor in understanding the rates of schizophrenia in some migrant groups that cultural people with similar cultural values to one may be more important in this work is to cultural and ethnic density with and hypothesized that a discrepancy between achievement and may have to high rates of in their This has been in especially for discrepancy between and in housing which may affect an this lack of self-esteem lead to schizophrenia and not depression needs to be further. is not and may to self-esteem to the rates of in migrants. have been a of population studies in the which have at the rates of common mental disorders in migrants. The have not been It is not that after migration individuals may be and and of depression and which may as they to settle feel down by the new culture and perhaps their culture and to over they have to Some studies that the rates of common mental disorders among migrants are than among the members of the new culture, but either or lower rates The study in the that women more likely and women less likely to have common mental disorders the that older women of and origin rates of common mental disorders. This may the period migration and to be further. is that the migrant and a sense of which may lead to and in an with that those who migrated the age of or who in more likely for the and group, and in the and to a diagnosis of an anxiety who in especially more likely to be with an anxiety refugees or those or natural will respond to that refugee women in their as a cultural including and and of which are a culturally response to experiences have been described among and refugees The rates of and have been to be in the the The rates are among younger women but not among adolescents This increase the age that, women to and find their way in the world, an of culture conflict with their parents or family members may a cultural identity between the adolescents and their parents, it was that adolescents who less with their that rates of than among older Rates of among New and migrants to with the rates in their countries of origin rates among as a result of health also from that rates among while women status for cultural and for women and of life and emotional are some of the factors rates of Table a of to and to improve mental health care in migrants. Some more are in the The physical health of migrants needs to be in assessment for a of Mental disorders may be which may influence their may be by psychiatric from countries may not in and may present with symptoms which may become to often adding to stress. The clinician must out a full physical and as providing a for is to different and of a of ethnic groups an increased to a of experienced significantly more than are to the of a to and are more to are to be at risk of the a that for is less must out for differences in migrants and that are at and are cultures have different attitudes and expectations of may as more natural and ethnic groups with a strong of may beliefs to the of The may engage in home preparation of the are is and to a new is a to these it will be and the illness Cultural attitudes also affect the of which may into the by the For the of is to be but a culturally on are by and these are with the that of from the is but not as it may loss of is influenced by the of the The of the as an in conditions, by and groups in the not to the in other cultures, a more is the and the cultural groups have been in conflict, this may be out in the to a cultural and which will affect the with psychiatric treatment in is to be a result of this factor Cultural will also impact upon the of a is by and by and the latter is by and and The of by in to a in of and is by religious values, rates vary significantly ethnic groups. over a also will occur in this is such as and many of often not to the either it is as or it is that will not understand may cause and in increase the of of and may may of such as and that can cause of changes in and will influence and of such as or can the and of a must attitudes the expectations of its religious and use of and It is worth at a it and the and his/her as as Migrants particular seeking from not their that such services may not to or be for them. An understanding of a cultural background is an to a For psychological to especially in the of the must be to the The must allow the to be by the of the their families or who may have significant on the than the other way the most may be to the with the most of Western and the to the most Migrants may with to the their experience of racism, economic or This must be to and taken to work with in which it was to allow the of of racism, and during to allow to the of acculturation of a will make a in It is that especially older may the as and a they are than A in the stages may the The must be of the within the primary culture. of may be in some cultures with of of is It can be that in cultures it be to use group but this may also of and cultural values adding to of and acculturation will add to An group may some according to ethnic and racial with racial a may feel that they are their culture, which may additional stress. a multicultural group is more with a group upon the and the of the these potential that group can be in migrants with mental that group can be if the minority members themselves that the is to their and in a group with an population, the with the in that the not the of group other migrants for the first time may a mental of their and to from This will be culturally expectations and from a background in culture may the role of the to be to the role of the or who and in a in culture in some of and that that the most the is the person a according to this a of The experience in and in working with ethnic minorities in will affect The by of his/her may with the new culture to a than his/her to In or will of their especially related to acceptance by their family or which may cause additional stress. This may be as an in that in some they are family which is an of the role expectations in the new culture may and cause stress. must the is distress due to cultural between the two or other factors. Refugees and asylum seekers may the as an who in their can enable to stay in the country, and help social support and other the make the of the and also expectations and may be with if the asylum is and he/she is In initial stages, the may a the to his/her Some such after or physical may be of The and the on the and the of earlier in their that It is to engage who have different beliefs and as as these are not Migration in can be a stressful not all migrants will experience or respond to the stress in the will be influenced by a of social and cultural factors. Some of these factors can be by social support and cultural is to that some migrant groups are more at risk of mental disorders. and need to be of needs that migrants may have and how these needs are Migrants can and to the new cultures and it is that their mental health needs be in a culturally way and services are to and for their and are also due to for inviting and for his support for the and his and help in the