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Common mental health problems in immigrants and refugees: General approach in primary care

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  • Direction régionale de santé publique de Montréal

Abstract and Figures

Recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care poses a challenge because of differences in language and culture and because of specific stressors associated with migration and resettlement. We aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care. We searched and compiled literature on prevalence and risk factors for common mental health problems related to migration, the effect of cultural influences on health and illness, and clinical strategies to improve mental health care for immigrants and refugees. Publications were selected on the basis of relevance, use of recent data and quality in consultation with experts in immigrant and refugee mental health. The migration trajectory can be divided into three components: premigration, migration and postmigration resettlement. Each phase is associated with specific risks and exposures. The prevalence of specific types of mental health problems is influenced by the nature of the migration experience, in terms of adversity experienced before, during and after resettlement. Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. These issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations. Systematic inquiry into patients' migration trajectory and subsequent follow-up on culturally appropriate indicators of social, vocational and family functioning over time will allow clinicians to recognize problems in adaptation and undertake mental health promotion, disease prevention or treatment interventions in a timely way.
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Review
CMAJ
CMAJ
© 2010 Canadian Medical Association or its licensors
1
Changing patterns of migration to Canada pose new
challenges to the delivery of mental health services
in primary care. For the first 100 years of Canada’s
existence, most immigrants came from Europe; since the
1960s, there has been a marked shift, with greater immigra-
tion from Asia, Africa, and Central and South America.1The
mix differs across the provinces, although nearly all immi-
grants settle in Canada’s largest cities.2The task of prevent-
ing, recognizing and appropriately treating common mental
health problems in primary care is complicated for immi-
DOI:10.1503/cmaj.090292
Canadian Guidelines for Immigrant Health
Common mental health problems in immigrants and
refugees: general approach in primary care
Laurence J. Kirmayer MD, Lavanya Narasiah MD MSc, Marie Munoz MD, Meb Rashid MD,
Andrew G. Ryder PhD, Jaswant Guzder MD, Ghayda Hassan PhD, Cécile Rousseau MD MSc,
Kevin Pottie MD MClSc; for the Canadian Collaboration for Immigrant and Refugee Health (CCIRH)
From the Division of Social and Transcultural Psychiatry (Kirmayer), McGill
University, and the Culture & Mental Health Research Unit, Lady Davis Insti-
tute, Jewish General Hospital, PRAIDA (Narasiah, Munoz), CSSS de la Mon-
tagne, Montréal, Que., Department of Family and Community Medicine
(Rashid), University of Toronto, Toronto, Ont., the Department of Psychol-
ogy (Ryder), Concordia University, and the Culture & Mental Health
Research Unit, Jewish General Hospital, the Division of Social and Transcul-
tural Psychiatry (Guzder, Rousseau), the Department of Psychiatry, McGill
University, the Department of Child Psychiatry (Guzder), Jewish General
Hospital, the Department of Psychology (Hassan), Université du Québec à
Montréal, Youth Mental Health (Rousseau), CSSS de la Montagne (CLSC Parc
Extension), Montréal, Que., and the Departments of Family Medicine and
Community Health and Epidemiology, Institute of Population Health (Pot-
tie), University of Ottawa, Ottawa, Ont.
CMAJ 2010. DOI:10.1503/cmaj.090292
Key points
Among immigrants, the prevalence of common mental
health problems is initially lower than in the general
population, but over time, it increases to become similar to
that in the general population.
Refugees who have had severe exposure to violence often
have higher rates of trauma-related disorders, including
post-traumatic stress disorder and chronic pain or other
somatic syndromes.
Assessment of risk for mental health problems includes
consideration of premigration exposures, stresses and
uncertainty during migration, and postmigration
resettlement experiences that influence adaptation and
health outcomes.
Clinical assessment and treatment effectiveness can be
improved with the use of trained interpreters and culture
brokers when linguistic and cultural differences impede
communication and mutual understanding.
Background: Recognizing and appropriately treating men-
tal health problems among new immigrants and refugees
in primary care poses a challenge because of differences in
language and culture and because of specific stressors
associated with migration and resettlement. We aimed to
identify risk factors and strategies in the approach to men-
tal health assessment and to prevention and treatment of
common mental health problems for immigrants in pri-
mary care.
Methods: We searched and compiled literature on preva-
lence and risk factors for common mental health problems
related to migration, the effect of cultural influences on
health and illness, and clinical strategies to improve men-
tal health care for immigrants and refugees. Publications
were selected on the basis of relevance, use of recent data
and quality in consultation with experts in immigrant and
refugee mental health.
Results: The migration trajectory can be divided into three
components: premigration, migration and postmigration
resettlement. Each phase is associated with specific risks
and exposures. The prevalence of specific types of mental
health problems is influenced by the nature of the migra-
tion experience, in terms of adversity experienced before,
during and after resettlement. Specific challenges in
migrant mental health include communication difficulties
because of language and cultural differences; the effect of
cultural shaping of symptoms and illness behaviour on
diagnosis, coping and treatment; differences in family
structure and process affecting adaptation, acculturation
and intergenerational conflict; and aspects of acceptance
by the receiving society that affect employment, social sta-
tus and integration. These issues can be addressed through
specific inquiry, the use of trained interpreters and culture
brokers, meetings with families, and consultation with
community organizations.
Interpretation: Systematic inquiry into patients’ migration
trajectory and subsequent follow-up on culturally appropri-
ate indicators of social, vocational and family functioning
over time will allow clinicians to recognize problems in
adaptation and undertake mental health promotion, dis-
ease prevention or treatment interventions in a timely way.
Abstract
Early release, published at www.cmaj.ca on July 5, 2010. Subject to revision.
Review
grants and refugees because of differences in language, cul-
ture, patterns of seeking help and ways of coping.3–6
In consultation with experts in immigrant and refugee
mental health, we reviewed the literature to determine associ-
ated risks and clinical considerations for primary care practi-
tioners in the approach to common mental health problems
among new immigrant or refugee patients.7–10 In this paper,
we review the effect of migration on mental health, use of
health care and barriers to care. We outline basic clinical
strategies for primary mental health care of migrants includ-
ing the use of interpreters, family interaction and assessment,
and working with community resources.
Methods
We designed a search strategy in consultation with a librar-
ian scientist to identify systematic reviews and guidelines
that address clinical considerations for assessment, treat-
ment and prevention of common mental disorders among
immigrants and refugees in primary care. The search cov-
ered MEDLINE, HealthStar (Ovid), EMBASE, PsycINFO,
CINAHL and the Cochrane Database of Systematic
Reviews from January 1998 to December 2009. This search
was supplemented by articles identified through evidence
reviews conducted for other topics in the guidelines of the
Canadian Collaboration for Immigrant and Refugee Health
(CCIRH) (e.g., depression, post-traumatic stress disorder,
intimate partner violence and child maltreatment). Articles
were selected on the basis of relevance to key questions,
recent publication and quality of evidence. Details of the
search and selection strategy can be found on the CCIRH
website (www.ccirh.uottawa.ca). We provide a descriptive
synthesis and discussion of the results.
Results
The search identified 840 articles addressing detection, pre-
vention and management of common mental health problems
among immigrants and refugees in primary care. There were
no published guidelines. After assessment for relevance and
quality, we retained 113 articles, including 10 systematic
reviews and 5 meta-analyses (Figure 1).
How does migration affect mental health?
Rates of mental disorders vary in different migrant groups,
but these differences do not simply reflect the rates in the
countries of origin.11 Instead, prevalence of specific types of
problems and rates of health care use in particular groups can
be linked to migration trajectories in terms of adversity expe-
rienced before, during and after resettlement and to policies
and practices that determine who gains admittance to
Canada.12 Table 1 lists some of the migration-related factors
that influence mental health and that can be explored in a
clinical assessment.12–23 The effect of these factors varies
greatly with their severity and with their specific meaning for
patients, their families and their communities, as well as for
the wider society. Postmigration factors that moderate the
effects of premigration stress and that ensure employment and
economic stability are especially important in ensuring good
health outcomes.22,23
In general, population studies find that the health of immi-
grants tends to be better than that of the general population in
both the sending and receiving countries.24,25 Immigrants to
Canada often show slightly lower rates of mental disorders
than the general population.26,27 The 2000–2001 Canadian
Community Health Survey found that newly arrived immi-
grants (length of residence less than one to four years) had the
lowest rates of depression (odds ratio [OR] 0.33, 95% confi-
dence interval [CI] 0.26–0.41) and alcohol dependence (OR
0.05, 95% CI 0.02–0.12) compared with the Canadian-born
population.28 Rates in immigrants varied by region of origin,
with the highest rates found among immigrants from Europe
and the lowest among those from Africa and Asia.
The “healthy immigrant effect” reflects the fact that
immigrants must pass through a variety of filters to achieve
immigrant status. However, the health of immigrants tends to
worsen over time to match that of the general population.29,30
For example, a recent analysis of data from the United States
found that rates of depression and other disorders were lower
for new immigrants (OR 0.7, 95% CI 0.5–0.9) but rose over
CMAJ
2
Records
identified
through
database
searching
n = 74
5
Identification
Eligibility
Included
Additional
records
identified
through other
sources
n = 11
5
Screening
Records screened
n = 840
Excluded n = 477
SRs, guidelines
and other studies
n = 144
Excluded n =
2
19
(lack of relevance)
Excluded n = 20
(duplicates)
Full-text articles
assessed for
eligibility n = 363
Records included
in review
(including 10
systematic
reviews and 5
meta-analyses)
n = 113
Excluded n = 31
(lack of relevance,
outdated, poor quality)
Figure 1: Search and selection flow sheet. Note: SR = systematic
review.
Review
time to local levels. Rates were similar to those in the general
population for immigrants who arrived before age 12 and for
the children of immigrants.31 In contrast, systematic reviews
and meta-analyses confirm that refugees are at substantially
higher risk than the general population for a variety of spe-
cific psychiatric disorders — related to their exposure to war,
violence, torture, forced migration and exile and to the
uncertainty of their status in the countries where they seek
asylum with up to 10 times the rate of post-traumatic
stress disorder as well as elevated rates of depression,
chronic pain and other somatic complaints.22,32–35 Exposure to
torture is the strongest predictor of symptoms of post-trau-
matic stress disorder among refugees.35
Strong evidence shows that some groups of migrants have
an elevated incidence of psychotic disorders after migration.36–39
A recent meta-analysis found a mean weighted relative risk of
schizophrenia among first-generation migrants of 2.7 (95%
CI 2.3–3.2); even higher rates were found in the second gen-
eration.40 Factors related to increased risk included coming
from a developing country and an area where most of the
population is black, suggesting that racism and discrimination
have a role in elevated incidence. A similar effect of migra-
tion has not been found for mood disorders in the United
Kingdom,41 but there is evidence for an increase in the preva-
lence of common mental disorders among men (but not
women) from the Caribbean after migrating to the US.42
These issues have not been studied in Canada, although expo-
sure to racism and discrimination has been shown to have
negative effects on the mental health of immigrants and
refugees.43–45
Migration involves three major sets of transitions: changes
in personal ties and the reconstruction of social networks, the
move from one socio-economic system to another, and the
shift from one cultural system to another.46,47 The migration
trajectory can be divided into three components: premigra-
tion, migration and postmigration resettlement. Each phase is
associated with specific risks and exposures. The premigra-
tion period often involves disruptions to usual social roles and
networks. During migration, immigrants can experience pro-
longed uncertainty about their citizenship status as well as sit-
uations that expose them to violence.19 Those seeking asylum
in particular sometimes spend extended periods in refugee
camps with poor resources and endemic violence. In some
countries, asylum seekers are kept in detention centres with
harsh conditions, which lead to a sense of powerlessness.48
This sense can provoke or aggravate depression and other
mental health problems.18,49,50
Once future status is decided, resettlement usually brings
hope and optimism, which can have an initially positive effect
on well-being. Disillusionment, demoralization and depression
can occur early as a result of migration-associated losses, or
later, when initial hopes and expectations are not realized and
when immigrants and their families face enduring obstacles to
advancement in their new home because of structural barriers
and inequalities aggravated by exclusionary policies, racism
and discrimination.45,51,52 For example, some immigrants
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Table 1: Factors related to migration that affect mental health12–23
Premigration Migration Postmigration
Adult
Economic, educational and occupational
status in country of origin Trajectory (route, duration) Uncertainty about immigration or
refugee status
Disruption of social support, roles and
network
Exposure to harsh living conditions
(e.g., refugee camps)
Unemployment or underemployment
Trauma (type, severity, perceived level of
threat, number of episodes)
Exposure to violence Loss of social status
Political involvement (commitment to a
cause)
Disruption of family and community
networks
Loss of family and community social
supports
Uncertainty about outcome of migration Concern about family members left
behind and possibility for reunification
Difficulties in language learning,
acculturation and adaptation
(e.g., change in sex roles)
Child
Age and developmental stage at
migration
Separation from caregiver Stresses related to family’s adaptation
Disruption of education Exposure to violence Difficulties with education in new
language
Separation from extended family and
peer networks
Exposure to harsh living conditions
(e.g., refugee camps)
Acculturation (e.g., ethnic and religious
identity; sex role conflicts;
intergenerational conflict within family)
Poor nutrition Discrimination and social exclusion (at
school or with peers)
Uncertainty about future
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encounter difficulties in having their credentials recognized,
which compromises their ability to find work commensurate
with their education level.33 Events that evoke elements of past
trauma and loss can contribute to the re-emergence of anxiety,
depression or post-traumatic stress disorder.53 An extensive
body of qualitative research of good quality and surveys with
clinical and community samples suggests that the main
domains of resettlement stress include social and economic
strain, social alienation, discrimination and status loss, and
exposure to violence.17,18,54–56 Culture change itself poses distinct
challenges for individual identity and family life.47 Risk factors
for mental health problems can differ for men and women; for
example, language proficiency often has a greater influence on
men’s employment and subsequent mental health.57
In general, immigrants and refugees are less likely than
their Canadian-born counterparts to seek out or be referred to
mental health services, even when they experience compara-
ble levels of distress.58–63 This can reflect both structural and
cultural barriers, including the lack of mobility or ability to
take time away from work, lack of linguistically accessible
services, a desire to deal with problems on one’s own, the
concern that problems will not be understood by practitioners
because of cultural or linguistic differences, and fear of
stigmatization.64–68 In many developing countries, mental
health services are associated only with custodial or hospital
treatment of the most severely ill and psychotic patients.
Partly as a consequence, and also because of specific cultural
explanations of illness, mental disorders are highly stigma-
tized in most countries, and patients are extremely reluctant to
attribute symptoms to a mental disorder. The stigma of a psy-
chiatric diagnosis affects not only patients but also their sib-
lings and other family members.
Adolescents and children
Research on the mental health of adolescents who are immi-
grants or refugees shows wide variation in rates across stud-
ies.15,69 Although some studies from treatment facilities and
small community samples find that migrant youth are at
higher risk for psychopathologic disorders, including post-
traumatic stress disorder, depression, conduct disorder (juve-
nile delinquency) and problems resulting from substance
abuse, results from a few large-scale community surveys
show that the rate of psychiatric disorder among immigrant
youth is not higher than that of native-born children.25,70 In
fact, many immigrant youth do exceptionally well upon
arrival and some surpass their native-born peers in aspiration
and academic achievement.71 Other studies reveal that many
children coping with a history of exposure to war and politi-
cal violence manage to have relatively good mental health.72–74
Studies in many countries including Canada find high lev-
els of distress and depression among young refugees.15,32,75–77
During the premigration period, most refugee children and
their families face social upheaval and disruptions to their
social and educational development. During migration, many
youth are separated from their parents and no longer have the
emotional, physical and financial support of their relatives.
Unaccompanied minors and children with unstable living sit-
uations are at particularly high risk for mental health prob-
lems.78–81 In the postmigration phase, youth often face accul-
turative stress and family poverty.82 Even after being reunited
with their families, children and adolescents must learn a new
language, renegotiate their cultural identity, and deal with
social isolation, racism, prejudice and discrimination.83 As
youth acculturate, many come into conflict with parents and
relatives who hold ideals and values different from those
being adopted by their children. Postmigration factors, includ-
ing the quality of reception and support in the country of asy-
lum, are important predictors of long-term outcome.33,84,85
Women
The many roles and responsibilities of immigrant women in
the home and the workplace can impede their access to men-
tal health services.86 Immigrant women are at two to three
times the risk of their Canadian-born counterparts for post -
partum depression.87–89 Women generally do not proactively
seek help for postpartum depression.90 Barriers to seeking
help that could be more common or have a greater effect
among migrant women include a lack of knowledge about
postpartum depression and treatment options, reluctance to
disclose emotional problems outside the family, unwilling-
ness to undertake medical treatment for what is perceived as a
psycho social problem, concern that maternal mental illness
will burden or stigmatize the family, feelings of shame at
being labelled mentally ill, and fear of losing one’s children
to authorities.90–92
Refugee women seen in specialized clinics have high rates
of exposure to violence and post-traumatic stress disorder that
often have not been addressed clinically.93 Experts emphasize,
however, that exploring the history or sequelae of rape or
other forms of sexual violence requires great clinical sensitiv-
ity and should always be guided by patients’ needs and com-
fort levels.53,94
Seniors
Seniors make up a smaller proportion of the refugee and
immigrant population in the initial migration, sometimes
arriving later to join the family. Risk factors for psychological
distress among newly arrived older immigrants include
female sex, less education, unemployment, poor self-rated
health, chronic diseases (heart disease, diabetes, asthma),
widowhood or divorce, and lack of social support or living
alone.95–97 When seniors join an already settled family, issues
can include slower rates of learning the language and accul-
turation; separation from extended family, peers and familiar
surroundings; decreased social support and isolation because
extended family and community networks are lost; increased
dependency on others because of language and mobility diffi-
culties; fewer opportunities for meaningful work and produc-
tivity; and loss of status as a respected elder in the new cul-
tural context.98,99
Clinical considerations
Which clinical strategies are effective?
In general, the same methods that are effective in diagnosing
and treating common mental health problems in primary care
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for the general population can be extended to migrants from
diverse backgrounds. However, experts in migrant mental
health agree that, for maximum effectiveness, attention must
be given to various contextual and practical issues that influ-
ence illness behaviour, patient–physician communication
and intercultural understanding.100 Specific challenges in
migrant mental health include communication, cultural shap-
ing of symptoms and illness behaviour, the effect of family
structure and process on acculturation and intergenerational
conflict, and the receiving society’s facilitation of or imped-
ance of adaptation and social integration.25 There is limited
but consistent evidence from qualitative studies and clinical
experience in intercultural primary care that these challenges
can be addressed through specific enquiry into social and
cultural context, the use of interpreters and culture brokers,
meetings with families and consultation with community
organizations.101–104
How does culture affect health and illness?
Because migration often brings people together from very dif-
ferent cultural backgrounds, it is important to give explicit
attention to cultural dimensions of the illness experience.105
Place of origin can affect exposure to endemic diseases,
childhood immunization and health care experiences. Culture
can profoundly influence every aspect of illness and adapta-
tion, including interpretations of and reactions to symptoms;
explanations of illness; patterns of coping, of seeking help
and response; adherence to treatment; styles of emotional
expression and communication; and relationships between
patients, their families and health care providers.106 The out-
line for cultural formulation in the Diagnostic and statistical
manual of mental disorders, fourth edition, provides a basic
set of considerations that can be incorporated into assessment
of patients to explore clinically relevant aspects of their iden-
tity, illness explanations, psychosocial environment and
expectations for patient–physician relationships.107–110
Most patients in primary care with mental health problems
present with physical complaints, which can lead to under-
recognition and treatment of common mental disorders.111
Patients with depression or anxiety sometimes focus on physi-
cal symptoms or use culture-specific bodily idioms to express
distress.111,112 Medically unexplained symptoms, particularly
pain, fatigue, and gastrointestinal and genitourinary symptoms,
are common in the community and in primary care.113 When
interviewed outside medical settings, more patients report psy-
chosocial stressors, which they sometimes are reluctant to
reveal to physicians because they think such stressors are inap-
propriate topics for medical attention or they believe that their
situation will not be understood.64,114 There is limited but emerg-
ing evidence that information about associated psychological
distress and social predicaments can be elicited by enquiring
about the effect of the physical symptoms or other presenting
concerns on activities of daily living, stressors, social supports,
functioning in work and family, or community contexts.113,115–118
Use of multiple sources of help is common among
migrants, who may consult traditional forms of healing as
well as biomedical practitioners.119 In urban settings, patients
make use of treatments from many traditions in addition to
those related to their own cultural background or geographic
region of origin.120 If medications are being considered or
pres cribed, it is important to enquire about whether the
patient is using any home remedy or complementary medi-
cine that might interact with the metabolism and effective-
ness of a prescribed drug.121 Broad questions about use of any
medication, food or substance taken for health or medicinal
purposes can be followed by specific questions about the use
of commonly available substances, such as St. John’s wort
(Hypericum perforatum) or Ginkgo biloba, and about
whether patients receive medicines from family, friends or
country of origin. Finally, questions about previous or ongo-
ing consultations with a physician, healer or helper from
their own or other communities can uncover medication use
or other health concerns that can affect adherence, treatment
response and coping.6,122
Working with interpreters and culture brokers
Although most immigrants to Canada have some knowledge
of English or French, they might be limited in their ability to
express their concerns, describe symptoms and social predica-
ments, and negotiate treatment. Any patient who has limited
proficiency in the languages known by the clinician should be
encouraged to use a medical interpreter. Failure to use inter-
preters has been identified as one of the most important barri-
ers to accessing services for newcomers.123 Professional inter-
preters should be used to facilitate communication; telephone
interpreting services can be used when no local interpreter
can be found.124 Recent systematic reviews find that the use of
professional interpreters, rather than ad hoc translators (e.g.,
family friends, children, staff), improves communication sub-
stantially and helps reduce disparities in use of a range of
medical services.101,103 Professional interpreters can improve
communication and increase disclosure of psychological
symptoms among asylum seekers,14,125–127 and can be used to
deliver psychosocial interventions.128 Working effectively
with interpreters involves a collaborative process and specific
skills (Box 1).6
Except in urgent situations where there is no alternative,
family members or untrained lay people should not be used as
interpreters.129 Several studies have documented the limits of
nurses acting as interpreters. Because they are closer to the
physician’s position, nurses or other health professionals
might not convey some of the doubts and concerns or
requests made by the patient.130
Interpreters or other mediators can also take the role of
culture broker and advocate, translating not language but cul-
tural concepts or frameworks.131 However, if patients have
concerns about confidentiality vis-à-vis other members of
their linguistic community, they could perceive the presence
of an interpreter or culture broker as threatening. Each situa-
tion requires a specific assessment of the patient’s needs and
requirements for communication in the language in which he
or she is most fluent and comfortable.
Working with families
Many newcomers to Canada come from cultural back-
grounds where family members are usually consulted about
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any health problem and accompany patients to physicians’
visits. Migration can stress and fragment families; close
members might be left behind, sometimes in dangerous cir-
cumstances. The tendency to focus on the patient in primary
care must be supplemented by close attention to the family
system and social network, which can include crucial mem-
bers in other countries. It is important to acknowledge and
welcome family members who accompany the patient.
Rather than excluding them because of privacy, meeting
family members together soon before meeting alone with a
patient can be an important step to building trust and a
source of valuable information.
Rules of confidentiality and disclosure should be applied
in a way that respects cultural context. For example, although
Canadian law protects confidentiality for youth older than 14
years and recognizes adult status at age 18, the cultural legiti-
macy of parental authority over adolescents should be taken
into account. For counselling and treating youth, interventions
should be framed in ways that avoid alienating family mem-
bers or aggravating intergenerational conflicts. Similarly, dis-
closure of diagnostic issues and family “secrets” (e.g., about
traumatic events) should be approached carefully, with an
understanding of what is at stake for the family. Finally, when
ambivalence toward treatment or nonadherence is an issue,
involvement of such mediators as a key family member or
trusted family ally in discussions of the different treatment
alternatives can strengthen the therapeutic alliance, empower
the family and provide necessary support to the patient.124
Working with community organizations
Resettlement after migration is strongly affected by the
policies, practices and opportunities of the resettlement
society as well as existing ethnocultural community organi-
zations and religious institutions, which support migrants in
work and in legal, religious and social aspects of their
adaptation.9,23,132 The presence of welcoming links within
ethnic communities or religious congregations can buffer
the effects of migration losses, isolation and discrimination.
Migrant youth living in communities with a high proportion
of immigrants from the same background are better
adjusted, partly because they have positive role models, a
stronger sense of ethnic pride and social support, which can
help them deal with the stressors of poverty, discrimination
and racism.71 Becoming familiar with existing community
and religious organizations can help practitioners identify
and mobilize psychosocial support and other resources
when needed.
In urban centres with large immigrant populations, com-
munity resources can be divided into two broad categories:
multiethnic organizations that offer services related to settle-
ment and integration, and groups specific to various ethnic
backgrounds that provide a sense of belonging and support
for a particular ethnocultural identity. Before referring a
patient, it is important to identify which community he or she
feels part of and not to assume that the patient necessarily will
feel comfortable with a group that shares aspects of national,
religious or ethnic identity.
It is useful for practitioners to have a list of community
resources for specific needs (e.g., housing, food, language
courses, social support) and of the ethnocultural groups these
resources represent. However, a personalized referral (e.g.,
giving a specific name or calling the person in front of the
patient) is much more likely to result in success, particularly
in the case of a depressed, anxious and traumatized patient for
whom re-establishment of a social network is difficult
because of fear and distrust. In smaller communities, develop-
ing networks across social sectors and ethnocultural groups as
well as with colleagues in other centres can be useful.133
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Box 1: Clinical approach to working with interpreters
and culture brokers
Before the interview
Meet with the interpreter to explain the goals of the inter-
view.
Discuss whether the interpreter’s social position in country
of origin and local community could influence the
relationship with the patient.
Explain the need for especially close translation in the
mental status examination (e.g., to ascertain thought
disorder, emotional range and appropriateness, suicide
risk).
Ask the interpreter to indicate when a question or
response is difficult to translate.
Discuss any relevant etiquette and cultural expectations.
Arrange seating in a triangle so that the clinician is facing
the patient and the interpreter is to one side.
During the interview
Introduce yourself and the interpreter and explain your
roles.
Discuss confidentiality and ask for the patient’s consent to
have the interpreter present.
Look at and speak directly to the patient; use direct speech
(e.g., “you” instead of “she” or “he”).
Avoid jargon or complex sentence constructions; use clear
statements in everyday language.
Slow down your pace; speak in short units to allow the
interpreter time to translate.
Do not interrupt the interpreter; keep looking at the
patient while the interpreter is speaking.
Clarify ambiguous responses (verbal or nonverbal) and ask
the patient for feedback to make certain that crucial
information has been communicated clearly.
Give the patient a chance to ask questions or express
concerns that have not been addressed.
After the interview
Discuss the interview and ask the interpreter to assess the
patient’s degree of openness or disclosure.
Consider translation difficulties and misunderstandings
and clarify any important communication that was not
translated or was unclear, including nonverbal
communication.
Ask the interpreter if he or she had any emotional
reactions or concerns of his or her own during the
interview.
Plan future interviews; whenever possible, work with the
same interpreter or culture broker for the same patient.
More detailed information and resources for locating interpreters and
culture brokers can be found at www.mmhrc.ca.
Review
Conclusion and research needs
Migration poses specific stresses, yet most immigrants do
well with the transitions of resettlement. Systematic enquiry
into the migration trajectory and subsequent follow-up on cul-
turally appropriate indicators of social, vocational and family
functioning will allow clinicians to recognize problems in
adaptation and undertake mental health promotion, preven-
tion or treatment interventions in a timely fashion.
Because the evidence is limited, research is needed to
develop and evaluate primary care strategies for promoting
mental health and preventing mental illness that respond to
the increasing diversity of immigrants and refugees in
Canada.
This article has been peer reviewed.
Competing interests: Lavanya Narasiah has received speaker fees for
“travel health” presentations to GlaxoSmithKline.
Contributors: Laurence J. Kirmayer led the literature review process. Each
of the authors reviewed portions of the literature and wrote drafts of sections
of the paper. All of the authors reviewed and approved the final version sub-
mitted for publication.
Acknowledgements: Tomas Jurcik and Sudeep Chaklabanis coordinated the
review process; Jocelyne Andrews, Teodora Constantinu and Lynn
Dunikowski designed the bibliographic searches. Kay Berckmans and
Antonella Clerici provided secretarial support. John Feightner provided cru-
cial editorial input and advice.
Funding: The Canadian Collaboration for Immigrant and Refugee Health
acknowledges the funding support of the Public Health Agency of Canada,
the Canadian Institutes of Health Research (Institute of Health Services and
Policy Research), the Champlain Local Health Integrated Network and the
Calgary Refugee Program. The views expressed in this report are the views
of the authors and do not necessarily reflect those of the funders. Travel and
accommodations for the Ottawa Expert Panel Conference were funded by the
Public Health Agency of Canada. The Public Health Agency of Canada
funded background papers in chronic diseases and mental illness. The Cal-
gary Refugee Program, Champlain Local Integrated Network and Canadian
Institutes of Health Research (Institute of Health Services and Policy
Research) contributed to dissemination.
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Correspondence to: Dr. Laurence J. Kirmayer, Institute of
Community & Family Psychiatry, Jewish General Hospital, 4333
Côte Ste Catherine Rd., Montréal QC H3T 1E4;
laurence.kirmayer@mcgill.ca
CMAJ 9
Information on accessing resources to assist with intercultural
mental health care can be found through the Multicultural
Mental Health Resource Centre at www.mmhrc.ca
Clinical preventive guidelines for newly arrived immigrants
and refugees to Canada
This article is part of a series of guidelines for primary care
practitioners who work with immigrants and refugees. The
series was developed by the Canadian Collaboration for
Immigrant and Refugee Health.
... A systematic review found that the principal factors affecting the mental health of an immigrant are the alteration of social roles; loss of family and community support; and uncertainty regarding their migratory and employment status [5]. A cohort study carried out in Sweden found that refugees faced an increased risk for schizophrenia and other nonaffective psychiatric disorders when compared to non-refugee immigrants from similar regions and the native population [6]. ...
... With respect to time since arrival in the destination country and the mental health of immigrants, it has been reported that immigrants with less time in the country are generally healthier and have lower mortality rates compared to the native population than those immigrants with more time in the country [5]. This socalled 'immigrant paradox' is based on the assumption that poorer populations, like the immigrant population, should have worse health status. ...
... No article that associated additional years of age with SR was found in our literature search. However, there are studies that have evidenced mental health deterioration until reaching a level akin to the native population [5]. Among the factors which influenced mental health deterioration were employment status and income, which are encompassed in the SR domain [38]. ...
Article
Full-text available
Background Immigrants arriving in a new country face changes that affect their social, employment, and migratory status. We carried out a mixed-methods study in the rapidly growing Venezuelan immigrant population in Lima, Peru. The objective was to determine whether there was an association between time in Peru and self-perception of symptom distress (SD), interpersonal relationships (IR), and social role (SR). Methods The quantitative central component consisted of a cross-sectional study, surveying 152 participants using the Outcome Questionnaire 45.2 (OQ-45.2). The qualitative component, based on phenomenology, explored experiences and challenges during the migration process. Semi-structured in-depth interviews were conducted in 16 informants. Results An association that was observed was the increase in the risk of clinically significant SR score with additional years of age. All informants mentioned having witnessed or experienced xenophobia in Peru. Every informant stated that significant labor differences existed between the countries. The most reported somatic symptoms were symptoms of anxiety and alterations of sleep. Additionally, no informant expressed a desire to remain in Peru long term. Conclusions A minority of participants registered a clinically significant total score and in each of the three domains of SD, IR, and SR. No association between months in Lima and the self-perception of distress was found. However, this could be due to the short amount of time spent in Peru and any change in self-perception might only be perceived after years or decades spent in Peru. This study is one of the first to use mixed-methods to explore the mental health of the immigrant Venezuelan population.
... Because refugees are forcibly displaced due to conflict and persecution, many have directly experienced or witnessed traumatic events prior to and during the process of migration. A large body of research has consistently attributed premigration traumatic exposure to psychiatric symptoms and impaired functional health (Kirmayer et al., 2011). However, recent studies have shown that postmigration stressors such as poverty, unemployment, and marginalization have a greater or similar effect on refugees' health as war trauma (Porter & Haslam, 2005). ...
Article
Trauma exposure and postmigration stress are associated with adverse health outcomes among refugees, yet the relative effect of these factors for subgroups of refugees and those resettled long-term remains unclear. Drawing on life course theory, this study evaluated the associations between war trauma, postmigration stress, and health among Southeast Asian refugee women in the United States, and whether these patterns differ across the life span. A community sample of Vietnamese and Cambodian refugee women aged 30–72 years (N = 293) reported mental and physical health outcomes, conflict-based trauma exposure, and postmigration measures of discrimination and community violence. Both trauma exposure and discrimination were associated with mental and physical health problems, with the relative effect of each stressor varying across specific health outcomes; community violence was associated with poorer mental health. Age moderated the effect of trauma exposure across health outcomes, with stronger associations between trauma and health for older women in particular. Findings provide support for the influence of trauma exposure and the importance of postmigration stressors on health across the life span for refugees. Attending to age group differences in the effects of these stressors, and to subgroups such as women, has implications for interventions addressing the long-term health of refugee populations.
We conducted a qualitative study involving African migrants (n = 20) and service providers (n = 10) in South Australia to explore mental health stressors, access to mental health services and how to improve mental health services for African migrant populations. This paper presents the views and experiences of African migrants about the post-migration stressors they faced in resettlement that pose mental health challenges. The participants were recruited using the snowball sampling technique. To align with the COVID-19 pandemic protocol, the data collection was conducted using one-on-one online interviews through Zoom or WhatsApp video calls. Data analysis was guided by the framework analysis. The post-migration stressors, including separation from family members and significant others, especially spouses, imposed significant difficulties on care provision and in managing children’s attitudes and behavior-related troubles at school. African cultural practices involving the community, especially elders in care provision and disciplining children, were not consistent with Australian norms, compounding the mental health stressors for all involved. The African cultural norms, that do not allow young unmarried people to live together, also contributed to child–parent conflicts, enhancing parental mental stressors. Additionally, poor economic conditions and employment-related difficulties were post-migration stressors that the participants faced. The findings indicate the need for policy and intervention programs that address the above challenges. The provision of interventions, including social support such as subsidized or free childcare services, could help leverage their time and scheduled paid employment, creating time for effective parenting and improving their mental health and wellbeing. Future studies exploring what needs to be achieved by government and non-governmental institutions to support enhanced access to social and employment opportunities for the African migrant population are also recommended.
Article
This study made a claim that perceived discrimination, socio-economic strain, and structural strain on displaced people have an adverse impact on their mental health. Our claim also acknowledges that these people potentially have a unique set of strengths and abilities that they rely on to overcome their immediate and future problems. The aim of this study is thus to examine the relationship between post-migration life adversity and mental health problems, and assess the potential mediating role of resilience among asylum seekers and refugees (219 asylum seekers and 42 recognized refugees) living in South Korea. Structural equation modelling was used to examine hypothesized pathways between post-migration life adversity, mental health and resilience. Fit indices showed adequate to excellent fit of the examined models with mental health as the outcome. Mental health was positively regressed on PMLA and negatively regressed on R. In addition, R partially mediated the association between PMLA and MH. In addition to providing the academic contributions of this study to the ongoing study of resilience and its social welfare implications, the result of the study indicated the necessity of improving the present and future socio-environmental factors that foster resilience among refugees and asylum seekers.
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Este libro nos ofrece cuidadosas revisiones de la literatura, conclusiones claras, y recomendaciones explicitas sobre las migraciones internacionales en Chile en la actualidad. Los y las autores enfatizan, definen, y reconocen dinamismos en las categorías sociales (como etnia, raza, identidad, cultura, asimilación, y muchas otras) más usadas en las discusiones y debates sobre la salud intercultural. Las tres secciones del libro (Propuestas Teóricas, Evidencia Científica y Gris, y Experiencias y Aprendizajes) facilitan comparaciones entre autores, conceptos, y estrategias de intervención. Los autores revelan herramientas útiles para empujar lo que se denomina “diálogos entre epistemologías” para integrar perspectivas locales de las migraciones con las de los servicios de salud. En los diversos capítulos se reconoce la importancia de lo histórico en lo contemporáneo, o sea, como los conflictos y cambios precedentes puedan condicionar posibles caminos (estrategias y políticas) en la actualidad. Junto con esto, los capítulos presentan retratos detallados de estudios e intervenciones que enfatizan la importancia de un enfoque de salud intercultural al abordar a poblaciones migrantes internacionales.
Article
Background: A bidirectional association between depression and diabetes exists, but has not been evaluated in the context of immigrant status. Given that social determinants of health differ between immigrants and nonimmigrants, we evaluated the association between diabetes and depression incidence, depression and diabetes incidence, and whether immigrant status modified this association, among immigrants and nonimmigrants in Canada. Methods: We employed a retrospective cohort design using data from the Canadian Longitudinal Study on Aging Comprehensive cohort (baseline [2012-2015] and 3-year follow-up [2015-2018]). We defined participants as having diabetes if they self-reported it or if their glycated hemoglobin A1c level was 7% or more; we defined participants as having depression if their Center for Epidemiological Studies Depression score was 10 or higher or if they were currently undergoing depression treatment. We excluded those with baseline depression (Cohort 1) and baseline diabetes (Cohort 2) to evaluate the associations between diabetes and depression incidence, and between depression and diabetes incidence, respectively. We constructed logistic regression models with interaction by immigrant status. Results: Cohort 1 (n = 20 723; mean age 62.7 yr, standard deviation [SD] 10.1 yr; 47.6% female) included 3766 (18.2%) immigrants. Among immigrants, 16.4% had diabetes, compared with 15.6% among nonimmigrants. Diabetes was associated with an increased risk of depression in nonimmigrants (adjusted odds ratio [OR] 1.27, 95% confidence interval [CI] 1.08-1.49), but not in immigrants (adjusted OR 1.12, 95% CI 0.80-1.56). Younger age, female sex, weight change, poor sleep quality and pain increased depression risk. Cohort 2 (n = 22 054; mean age 62.1 yr, SD 10.1 yr; 52.2% female) included 3913 (17.7%) immigrants. Depression was associated with an increased risk of diabetes in both nonimmigrants (adjusted OR 1.39, 95% CI 1.16-1.68) and immigrants (adjusted OR 1.60, 95% CI 1.08-2.37). Younger age, male sex, waist circumference, weight change, hypertension and heart disease increased diabetes risk. Interpretation: We found an overall bidirectional association between diabetes and depression that was not significantly modified by immigrant status. Screening for diabetes for people with depression and screening for depression for those with diabetes should be considered.
Article
Women from a refugee background suffer higher psychological distress levels than men with a refugee background. Conceptualization of mental health plays an important role in using mental health services for people from refugee groups. The purpose of this review is to synthesize literature describing how Middle Eastern refugee women perceive mental health and its influence on mental health service utilisation. The review is registered with Prospero, and we conducted an analysis that complies with PRISMA guidelines and identified 8 relevant documents, including 6 peer-reviewed papers, and two dissertations. The findings of four qualitative, three mixed-method, and one quantitative studies were synthesized through data extraction and thematic analysis. Based on the findings, cultural beliefs, values, and expressions play a critical role in understanding mental health. These included: (a) culturally influenced idioms of distress in conceptualising mental health (b) the role of stigma in mental health perception and service utilisation. (c) a preferred method such as professional services or lay techniques including prayer and social support for mental health treatment. The discussion section contextualizes and examines these key themes to consider how a better understanding of mental health can be used to support the development of programs and policies to increase the use of mental health services by individuals from a refugee background. This may, in the end, lead to reduced burdens of diseases related to mental health among those seeking asylum or seeking refugee status.
Article
This paper explores how real scenarios of racial hostility and discrimination trigger anger rumination tendencies in refugees, asylum seekers and immigrants (hereafter RASI). Undergoing discrimination often leads to the development of negative thoughts and behaviors, and to a loss of meaning and self-worth. This could make young RASI particularly vulnerable to being recruited and exploited by extremist groups as they search for identity. We developed a picture-elicitation instrument (the PEI) to provide professionals with a tool that could identify groups of RASI according to their reactions to discrimination scenarios and explore how racial hostility might influence withdrawal levels. The tool was applied with the Anger Rumination Scale (ARS_19) to 509 RASI of Latin American origin living in Spain. Four categories were identified, according to how RASI processed anger when observing discrimination scenarios: “Social desirability”, “Chewing”, “Grudge”, and “Vengeful”. Further analyses showed that the youngest (18–29) fell under the “Grudge” and “Vengeful” categories and revealed more despair and social isolation. This study makes a positive contribution by being the first to investigate the problem of anger rumination in RASI undergoing racial hostility. Moreover, it equips professionals with two tools that, once validated, may help plan and implement strategies to reduce the impact of hostility on both RASI and their host societies.
Article
Transition to life in a new country represents complex and challenging tasks for young adults. This transition can be conceptualized as goal-directed action. To date, the literature has not described how these transitions intersect in the goal-directed life projects in which young newcomers engage. Similarly, the literature has not reported attempts to facilitate these processes through brief, goal-oriented supportive counseling interventions. In this study, 12 newcomers to Canada, aged 20–34 years, participated in an individual counseling support intervention intended to assist them to identify and engage in their transition-oriented projects. Qualitative data were collected using the action-project method over approximately a six-month period. Findings indicated that participants engaged in a range of transition projects, thematically grouped as relationship, career, and identity. The findings also revealed information about participants’ engagement with the intervention as part of their transition projects. Implications for research and practice are drawn.
Article
INTRODUCTION AND DIAGNOSIS OF POSTTRAUMATIC STRESS DISORDER The impact of traumatic events and the behavioral sequelae associated with them has been recognized for over 100 years under a variety of different labels, including compensation neurosis, nervous shock, hysteria, and war neurosis. The introduction of posttraumatic stress disorder (PTSD) into the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III in 1980 (APA, 1980) and its placement among the anxiety disorders reflects the perception that anxiety is a core component of an individual's reaction to a traumatic experience. Accordingly, PTSD is an anxiety disorder that develops in some individuals after a traumatic event defined by the DSM-IV (APA, 1994) as (1) experiencing, witnessing, or being confronted with an event that involves actual or threatened death or injury, or a threat to their physical integrity or that of others, and (2) responding to the event with intense fear, helplessness, or horror. In addition to experiencing or witnessing a traumatic event, a diagnosis of PTSD requires the individual to meet the following three symptom criteria: (1) At least one reexperiencing symptom, such as distressing recollections of the trauma, distressing dreams of the event, reliving the experience through flashbacks, psychological distress at exposure to internal or external reminders of the event, or physiological reactivity to those trauma reminders. (2) At least three symptoms of persistent avoidance such as making an effort to avoid trauma-related thoughts or feelings, making an effort to avoid trauma-related activities or situations, amnesia for important aspects of the event, diminished interest in activities, detachment from others, restricted range of affect, or a sense of a foreshortened future.
Article
This article reviews cultural variations in the clinical presentation of depression and anxiety. Culture-specific symptoms may lead to underrecognition or misidentification of psychological distress. Contrary to the claim that non-Westerners are prone to somatize their distress, recent research confirms that somatization is ubiquitous. Somatic symptoms serve as cultural idioms of distress in many ethnocultural groups and, if misinterpreted by the clinician, may lead to unnecessary diagnostic procedures or inappropriate treatment. Clinicians must learn to decode the meaning of somatic and dissociative symptoms, which are not simply indices of disease or disorder but part of a language of distress with interpersonal and wider social meanings. Implications of these findings for the recognition and treatment of depressive disorders among culturally diverse populations in primary care and mental health settings are discussed.
Article
Some evidence suggests that West Indian immigrants in Canada are a marginalized and over-burdened group. However, little attention has been given to examining health status and beliefs. We partly redress this gap by investigating health beliefs of West Indian immigrants in Montreal with somatic, emotional, or medically unexplained symptoms. The overall aim was to elicit and explore illness narratives, explanatory models, symptom-attribution and help-seeking in the community. A sample of 15 West Indian immigrants took part in semi-structured interviews. We found that participants overwhelmingly ascribed their symptoms to post-migratory experience. They particularly highlighted the importance of two related factors: chronic overwork since migration and irregular patterns of daily living. Many worked long hours, including overtime and moonlighting. Participants related their irregular patterns of daily living to disturbances of bodily functions (e.g., sleeping, eating) as well as to social functions (e.g., family life). These themes reflected elements of ethno-physiological beliefs common in the West Indies, as well as North American illness models. Attributing medically unexplained symptoms to overwork and irregularity in personal and social realms may be a socially acceptable way of critiquing perceived injustices in participants' work, social and interpersonal situations. This is especially so because the dominant discourse regarding race and ethnicity in Canada tends to emphasize positive aspects of multiculturalism—only reluctantly acknowledging conflict and inequality. Narratives could be interpreted as an oblique criticism of Canadian society's apparent indifference to participants' ongoing marginalization.
Article
We examined the symptom experience and illness explanations of Vietnamese immigrants to Canada through narratives collected during a study of pathways and barriers to mental health care. The narratives presented two culture-related explanatory models: phong thâp and uâ't u'ć. Common elements in the narratives of those who suffered from uâ't u'ć were experiences of injustice and indignation, along with the persistent inability to denounce these injustices because of the sufferer's social status. In contrast, phong thâp - an explanation analogous to rheumatism - was a socially acceptable way to describe distress that was attributed to depletion of energy, cold and environmental effects. Talk about phong thâp also served as an idiom of distress that permitted older people to express negative feelings about their life situation in Canada in a socially acceptable way. The contrast between these models throws into relief the complex interaction of explanatory models and idioms of distress in the co-construction of narratives of distress.
Article
About 6% of older people in the UK are immigrants. Concentrated in deprived inner-city areas, their numbers are rising rapidly, with the ageing of those arriving after the Second World War. Cultural, language and educational differences cause problems in studying this group's mental health. Idioms of distress may affect presentation, help-seeking behaviour and acceptability of treatment. Ethnic elders may be considered vulnerable to depression because of socio-economic deprivation, immigrant status and old age but studies are contradictory and may use inappropriate screening instruments. Relatively few consider immigrant status and dementia. Uncontrolled hypertension could relate to higher dementia rates in Black immigrants which are not reflected in the country of origin. No genetic risk has been found. There is potential for prevention in this population. Abstract Box 1 Difficulties in studying immigrant populations Misinterpretation of responses because of cultural difference, language and education Idioms of distress may affect presentation, help- seeking behaviour, likelihood of diagnosis and acceptability of treatment Unjustifiable assumption of homogeneity of people from a single large geographical area Varying reasons for immigration, e.g. education, asylum, employment