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

Background: 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. Methods: 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. 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 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. Interpretation: 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.

[1]  Robert J. Ursano,et al.  The Cultural Context of Clinical Assessment , 2013 .

[2]  C. Adair,et al.  Risk Factors for Sub-Clinical and Major Postpartum Depression Among a Community Cohort of Canadian Women , 2011, Maternal and Child Health Journal.

[3]  C. Tseng,et al.  Detection of Depression with Different Interpreting Methods Among Chinese and Latino Primary Care Patients: A Randomized Controlled Trial , 2010, Journal of Immigrant and Minority Health.

[4]  M. Beiser.  Resettling Refugees and Safeguarding their Mental Health: Lessons Learned from the Canadian Refugee Resettlement Project , 2009, Transcultural psychiatry.

[5]  A. Kazanjian,et al.  Why do Chinese Canadians not Consult Mental Health Services: Health Status, Language or Culture? , 2009, Transcultural psychiatry.

[6]  M. Alegría,et al.  Pathways and correlates connecting Latinos' mental health with exposure to the United States. , 2009, American journal of public health.

[7]  N. Zane,et al.  Use of specialty mental health services by Asian Americans with psychiatric disorders. , 2009, Journal of consulting and clinical psychology.

[8]  J. Mezzich,et al.  Cultural Formulation Guidelines , 2009, Transcultural psychiatry.

[9]  Z. Steel,et al.  Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. , 2009, JAMA.

[10]  A. Mielck,et al.  Depression and anxiety in labor migrants and refugees--a systematic review and meta-analysis. , 2009, Social science & medicine.

[11]  C. Katona,et al.  Mental health implications of detaining asylum seekers: systematic review. , 2009, The British journal of psychiatry : the journal of mental science.

[12]  D. Michelson,et al.  Psychological Needs, Service Utilization and Provision of Care in a Specialist Mental Health Clinic for Young Refugees: A Comparative Study , 2009, Clinical child psychology and psychiatry.

[13]  C. Dowrick,et al.  What Do Patients Choose to Tell Their Doctors? Qualitative Analysis of Potential Barriers to Reattributing Medically Unexplained Symptoms , 2009, Journal of General Internal Medicine.

[14]  N. Keiding,et al.  Risk of mental disorders in refugees and native Danes: a register-based retrospective cohort study , 2009, Social Psychiatry and Psychiatric Epidemiology.

[15]  Diana L. Gustafson,et al.  Mental Health Needs of Visible Minority Immigrants in a Small Urban Center: Recommendations for Policy Makers and Service Providers , 2009, Journal of Immigrant and Minority Health.

[16]  C. Dowrick,et al.  Primary Care Consultations About Medically Unexplained Symptoms: How Do Patients Indicate What They Want? , 2009, Journal of General Internal Medicine.

[17]  Peter B. Jones,et al.  Raised incidence rates of all psychoses among migrant groups: findings from the East London first episode psychosis study. , 2008, Archives of general psychiatry.

[18]  E. Montgomery.  Long-term effects of organized violence on young Middle Eastern refugees' mental health. , 2008, Social science & medicine.

[19]  B. Kuo,et al.  Depression and Its Psychosocial Correlates Among Older Asian Immigrants in North America , 2008, Journal of aging and health.

[20]  J. Hilden,et al.  Mental health among children seeking asylum in Denmark – the effect of length of stay and number of relocations: a cross-sectional study , 2008, BMC public health.

[21]  J. Kaczorowski,et al.  Understanding the Health of Refugee Women in Host Countries: Lessons from the Kosovar Re-Settlement in Canada , 2008, Prehospital and Disaster Medicine.

[22]  B. Thombs,et al.  Use of an expanded version of the DSM-IV outline for cultural formulation on a cultural consultation service. , 2008, Psychiatric services.

[23]  JianLi Wang,et al.  Ethnic differences in mental health service use among White, Chinese, South Asian and South East Asian populations living in Canada , 2008, Social Psychiatry and Psychiatric Epidemiology.

[24]  W. Vollebergh,et al.  Mental health in migrant children. , 2008, Journal of child psychology and psychiatry, and allied disciplines.

[25]  D. Stewart,et al.  Postpartum Depression Symptoms in Newcomers , 2008, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[26]  E. Hauff,et al.  Mental health of recently resettled refugees from the Middle East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to handle stress , 2008, Social Psychiatry and Psychiatric Epidemiology.

[27]  T. Betancourt,et al.  The mental health of children affected by armed conflict: Protective processes and pathways to resilience , 2008, International review of psychiatry.

[28]  Elizabeth Batista Pinto Wiese,et al.  The Mental Health of Asylum-seeking and Refugee Children and Adolescents Attending a Clinic in the Netherlands , 2007, Transcultural psychiatry.

[29]  Dawn Edge,et al.  Does stigma keep poor young immigrant and U.S.-born Black and Latina women from seeking mental health care? , 2007, Psychiatric services.

[30]  Matthew Porter.  Global Evidence for a Biopsychosocial Understanding of Refugee Adaptation , 2007, Transcultural psychiatry.

[31]  Z. Steel,et al.  No Refuge from Terror: The Impact of Detention on the Mental Health of Trauma-affected Refugees Seeking Asylum in Australia , 2007, Transcultural psychiatry.

[32]  E. Montgomery,et al.  Discrimination, mental problems and social adaptation in young refugees. , 2007, European journal of public health.

[33]  C. Brach,et al.  Integrating literacy, culture, and language to improve health care quality for diverse populations. , 2007, American journal of health behavior.

[34]  S. van Dulmen,et al.  Does training general practitioners to elicit patients' illness representations and action plans influence their communication as a whole? , 2007, Patient education and counseling.

[35]  S. Noh,et al.  Overt and subtle racial discrimination and mental health: preliminary findings for Korean immigrants. , 2007, American journal of public health.

[36]  D. Stewart,et al.  Healthcare worker’s perceptions of barriers to care by immigrant women with postpartum depression: an exploratory qualitative study , 2007, Archives of Women's Mental Health.

[37]  L. Kirmayer,et al.  Use of Health Care Services for Psychological Distress by Immigrants in an Urban Multicultural Milieu , 2007, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[38]  G. Jarvis,et al.  The Social Causes of Psychosis in North American Psychiatry: A Review of a Disappearing Literature , 2007, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[39]  Stella M. Yu,et al.  Depressive Symptomatology and Mental Health Help-Seeking Patterns of U.S.- and Foreign-Born Mothers , 2007, Maternal and Child Health Journal.

[40]  C. Loignon,et al.  GPs' strategies in intercultural clinical encounters. , 2007, Family practice.

[41]  L. Karliner,et al.  Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. , 2007, Health services research.

[42]  I. Hyman,et al.  Health Service Utilization by Ethiopian Immigrants and Refugees in Toronto , 2007, Journal of Immigrant and Minority Health.

[43]  K. Oatley,et al.  Impact of Life Events and Difficulties on the Mental Health of Chinese Immigrant Women , 2007, Journal of Immigrant and Minority Health.

[44]  R. Kessler,et al.  Risk for Psychiatric Disorder Among Immigrants and Their US-Born Descendants: Evidence From the National Comorbidity Survey Replication , 2007, The Journal of nervous and mental disease.

[45]  P. Spinhoven,et al.  Course and predictors of mental health of unaccompanied refugee minors in the Netherlands: one year follow-up. , 2007, Social science & medicine.

[46]  K. Chou.  Psychological distress in migrants in Australia over 50 years old: a longitudinal investigation. , 2007, Journal of affective disorders.

[47]  D. Bhugra,et al.  Cultural competence in mental health care: a review of model evaluations , 2007, BMC Health Services Research.

[48]  J. Selten,et al.  Mood disorders and migration , 2007, British Journal of Psychiatry.

[49]  T. Tran,et al.  Nonlinear Relationship Between Length of Residence and Depression in a Community-Based Sample of Vietnamese Americans , 2007, The International journal of social psychiatry.

[50]  C. Dennis,et al.  Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. , 2006, Birth.

[51]  I. Hyman,et al.  Mental Health Service Utilization by Ethiopian Immigrants and Refugees in Toronto , 2006, The Journal of nervous and mental disease.

[52]  J. Kinzie,et al.  Immigrants and Refugees: The Psychiatric Perspective , 2006, Transcultural psychiatry.

[53]  L. Kirmayer,et al.  The McGill Illness Narrative Interview (MINI): An Interview Schedule to Elicit Meanings and Modes of Reasoning Related to Illness Experience , 2006, Transcultural psychiatry.

[54]  L. Kirmayer,et al.  Public Pressure, Private Protest: Illness Narratives of West Indian Immigrants in Montreal with Medically Unexplained Symptoms , 2006, Anthropology & medicine.

[55]  W. Yule,et al.  Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma. , 2006, Journal of child psychology and psychiatry, and allied disciplines.

[56]  Z. Steel,et al.  A comparison of the mental health of refugees with temporary versus permanent protection visas , 2006, The Medical journal of Australia.

[57]  Arthur Kleinman,et al.  Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It , 2006, PLoS medicine.

[58]  H. Hamilton,et al.  Mental Distress, Economic Hardship and Expectations of Life in Canada among Sudanese Newcomers , 2006, Transcultural psychiatry.

[59]  R. Feldman.  Primary health care for refugees and asylum seekers: a review of the literature and a framework for services. , 2006, Public health.

[60]  M. Lussier,et al.  Intercultural communication competence in family medicine: lessons from the field. , 2006, Patient education and counseling.

[61]  M. Beiser.  Longitudinal Research to Promote Effective Refugee Resettlement , 2006, Transcultural psychiatry.

[62]  L. Kirmayer,et al.  Understanding Immigrants' Reluctance to Use Mental Health Services: A Qualitative Study from Montreal , 2006, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[63]  Z. Steel,et al.  Impact of immigration detention and temporary protection on the mental health of refugees , 2006, British Journal of Psychiatry.

[64]  A. Pumariega,et al.  Mental Health of Immigrants and Refugees , 2005, Community Mental Health Journal.

[65]  N. Haslam,et al.  Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. , 2005, JAMA.

[66]  Amar K. Das,et al.  Depression in US Hispanics: diagnostic and management considerations in family practice. , 2005, The Journal of the American Board of Family Practice.

[67]  Glenn Flores,et al.  The Impact of Medical Interpreter Services on the Quality of Health Care: A Systematic Review , 2005, Medical care research and review : MCRR.

[68]  F. Verhulst,et al.  Mental health in immigrant children in the Netherlands , 2005, Social Psychiatry and Psychiatric Epidemiology.

[69]  J. Danesh,et al.  Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review , 2005, The Lancet.

[70]  K. Newbold.  Self-rated health within the Canadian immigrant population: risk and the healthy immigrant effect. , 2005, Social science & medicine.

[71]  M. Beiser.  The Health of Immigrants and Refugees in Canada , 2005, Canadian journal of public health = Revue canadienne de sante publique.

[72]  P. Zelkowitz,et al.  Factors Associated with Depression in Pregnant Immigrant Women , 2004, Transcultural psychiatry.

[73]  Farah Ahmad,et al.  Popular Health Promotion Strategies Among Chinese and East Indian Immigrant Women , 2004, Women & health.

[74]  L. Kirmayer,et al.  Explaining Medically Unexplained Symptoms , 2004, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[75]  S. Kennedy,et al.  Insights into the 'healthy immigrant effect': health status and health service use of immigrants to Canada. , 2004, Social science & medicine.

[76]  Z. Steel,et al.  Comprehensive health assessment for newly arrived refugee children in Australia , 2004, Journal of paediatrics and child health.

[77]  L. Kirmayer,et al.  Sociosomatic theory in Vietnamese immigrants' narratives of distress , 2004, Anthropology & medicine.

[78]  Dinesh Bhugra,et al.  Migration, distress and cultural identity. , 2004, British medical bulletin.

[79]  L. Kirmayer.  The cultural diversity of healing: meaning, metaphor and mechanism. , 2004, British medical bulletin.

[80]  I. Hyman.  Setting the Stage: Reviewing Current Knowledge on the Health of Canadian Immigrants , 2004, Canadian Journal of Public Health.

[81]  I. Hyman.  Setting the stage: reviewing current knowledge on the health of Canadian immigrants: what is the evidence and where are the gaps? , 2004, Canadian journal of public health = Revue canadienne de sante publique.

[82]  Jennifer Ali,et al.  Recent Research on Immigrant Health from Statistics Canada’s Population Surveys , 2004, Canadian Journal of Public Health.

[83]  N. Lurie,et al.  Assuring the health of immigrants: what the leading health indicators tell us. , 2004, Annual review of public health.

[84]  Peter Salmon,et al.  Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners. , 2004, The British journal of general practice : the journal of the Royal College of General Practitioners.

[85]  J. Redpath.  Canadian Conference on Counter-Terrorism and Public Health: Final Report (insert) , 2004 .

[86]  C. Klier,et al.  Postnatal depression across countries and cultures: a qualitative study , 2004, British Journal of Psychiatry.

[87]  S. Rahimi,et al.  The complexity of trauma response: a 4-year follow-up of adolescent Cambodian refugees. , 2003, Child abuse & neglect.

[88]  Ariel Eytan,et al.  Language barriers between nurses and asylum seekers: their impact on symptom reporting and referral. , 2003, Social science & medicine.

[89]  S. Noh,et al.  Perceived discrimination and depression: moderating effects of coping, acculturation, and ethnic support. , 2003, American journal of public health.

[90]  R. Lim.  Cultural assessment in clinical psychiatry. , 2002, Report.

[91]  Adrian Bauman,et al.  Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study , 2002, The Lancet.

[92]  J. Westermeyer,et al.  Measuring trauma and health status in refugees: a critical review. , 2002, JAMA.

[93]  L. Loutan,et al.  Screening of Mental Disorders in Asylum-Seekers from Kosovo , 2002, The Australian and New Zealand journal of psychiatry.

[94]  L. Kirmayer,et al.  Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. , 2001, The Journal of clinical psychiatry.

[95]  K. M. Lin,et al.  Culture and psychopharmacology. , 2001, The Psychiatric clinics of North America.

[96]  M. Beiser,et al.  Strangers at the Gate: The "Boat People's" First Ten Years in Canada , 2001 .

[97]  R. C. Silver,et al.  When nurses double as interpreters: a study of Spanish-speaking patients in a US primary care setting. , 2001, Social science & medicine.

[98]  Z. Steel,et al.  Policies of deterrence and the mental health of asylum seekers. , 2000, JAMA.

[99]  Lisa V. Rubenstein,et al.  Who is at risk of nondetection of mental health problems in primary care? , 2000, Journal of General Internal Medicine.

[100]  M. Tousignant,et al.  The Quebec Adolescent Refugee Project: psychopathology and family variables in a sample from 35 nations. , 1999, Journal of the American Academy of Child and Adolescent Psychiatry.

[101]  F. Hou,et al.  Perceived racial discrimination, depression, and coping: a study of Southeast Asian refugees in Canada. , 1999, Journal of health and social behavior.

[102]  J. Jaranson,et al.  Refugee and immigrant health care. , 1999, The Medical clinics of North America.

[103]  S. Ebrahim,et al.  Social determinants of psychiatric morbidity and well‐being in immigrant elders and whites in east London , 1998, International journal of geriatric psychiatry.

[104]  S. Klimidis,et al.  The Treated Prevalence of Mental Disorder Amongst Immigrants and the Australian-Born: Community and Primary-Care Rates , 1998, The International journal of social psychiatry.

[105]  J. Aber,et al.  The war experiences and psychosocial development of children in Lebanon. , 1996, Child development.

[106]  I. Hyman,et al.  Immigrant and Refugee Children in Canada , 1995, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[107]  L. H. Rogler.  International migrations. A framework for directing research. , 1994, The American psychologist.

[108]  D. Price,et al.  Group for the Advancement of Psychiatry , 1990 .

[109]  S. Manson,et al.  The Psychiatric Effects of Massive Trauma on Cambodian Children: I. The Children , 1986 .

[110]  Arthur Kleinman,et al.  Patients and Healers in the Context of Culture , 2023 .

[111]  L. Gise,et al.  Group for the Advancement of Psychiatry , 1979 .

[112]  Arthur Kleinman,et al.  Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research , 1978 .

[113]  P. Fearon,et al.  Society and psychosis , 2008 .

[114]  J. de Jong,et al.  Migrant mental health: a model for indicators of mental health and health care consumption. , 2007, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[115]  G. Gee,et al.  Immigration-related factors and mental disorders among Asian Americans. , 2007, American journal of public health.

[116]  David R. Williams,et al.  The mental health of Black Caribbean immigrants: results from the National Survey of American Life. , 2007, American journal of public health.

[117]  P. Fearon.  Ethnic minority groups, particularly African-Caribbean and Black African groups, are at increased risk of psychosis in the UK , 2007 .

[118]  J. Kinzie.  PTSD among traumatized refugees , 2007 .

[119]  Terry L. Schell,et al.  Barriers to mental health care utilization for U.S. Cambodian refugees. , 2006, Journal of consulting and clinical psychology.

[120]  R. Asgary,et al.  Evaluating asylum seekers/torture survivors in urban primary care: a collaborative approach at the Bronx Human Rights Clinic. , 2006, Health and human rights.

[121]  K. Miller,et al.  The role of interpreters in psychotherapy with refugees: an exploratory study. , 2005, The American journal of orthopsychiatry.

[122]  S. Thapa,et al.  Gender differences in factors associated with psychological distress among immigrants from low- and middle-income countries , 2005, Social psychiatry and psychiatric epidemiology.

[123]  E. Cantor-Graae,et al.  Schizophrenia and migration: a meta-analysis and review. , 2005, The American journal of psychiatry.

[124]  A. Kazanjian,et al.  Rate of Mental Health Service Utilization by Chinese Immigrants in British Columbia , 2005, Canadian journal of public health = Revue canadienne de sante publique.

[125]  Knight,et al.  Review of child and adolescent refugee mental health. , 2004, Journal of the American Academy of Child and Adolescent Psychiatry.

[126]  L. Palinkas,et al.  The Journey to Wellness: Stages of Refugee Health Promotion and Disease Prevention , 2004, Journal of Immigrant Health.

[127]  R. Lewis‐Fernández,et al.  The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter , 2004, Psychiatric Quarterly.

[128]  G. Livingston,et al.  Mental health of the ageing immigrant population , 2003 .

[129]  J. Kai.  Ethnicity, health, and primary care , 2003 .

[130]  Caminee K. Blake.  Ethical Considerations in Working with Culturally Diverse Populations: The Essential Role of Professional Interpreters , 2003 .

[131]  Jennifer Ali.  Mental Health of Canada's Immigrants Data Source Main Results , 2002 .

[132]  W. Gardner,et al.  Prospective study of displaced children's symptoms in wartime Bosnia , 1999, Social Psychiatry and Psychiatric Epidemiology.

[133]  Cecil G. Helman,et al.  Culture, health, and illness , 1984 .