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.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 immigration from Asia, Africa, and Central and South America.¹ The mix differs across the provinces, although nearly all immigrants settle in Canada’s largest cities.² The task of preventing, recognizing and appropriately treating common mental health problems in primary care is complicated for immigrants and refugees because of differences in language, culture, patterns of seeking help and ways of coping.^3–6In consultation with experts in immigrant and refugee mental health, we reviewed the literature to determine associated risks and clinical considerations for primary care practitioners 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 including the use of interpreters, family interaction and assessment, and working with community resources.     

The circle of the soul: the role of spirituality in health care

This paper examines the critical attitude of behavioral professionals toward spiritual phenomena, and the current growing openness toward a scientific study of spirituality and its effects on health. Health care professionals work amidst sickness and suffering, and become immersed in the struggles of suffering persons for meaning and spiritual direction. Biofeedback and neurofeedback training can facilitate relaxation, mental stillness, and the emergence of spiritual experiences. A growing body of empirical studies documents largely positive effects of religious involvement on health. The effects of religion and spirituality on health are diverse, ranging from such tangible and easily understood phenomena as a reduction of health-risk behaviors in church-goers, to more elusive phenomena such as the distant effects of prayer on health and physiology. Psychophysiological methods may prove useful in identifying specific physiological mechanisms mediating such effects. Spirituality is also a dimension in much of complementary and alternative medicine (CAM), and the CAM arena may offer a window of opportunity for biofeedback practice.     

Informal complaints procedure in general practice: first year's experience.

OBJECTIVE--To evaluate the first year''s experience of an informal patient complaints system that encourages extensive patient participation. DESIGN--Audit of an informal complaints procedure. SETTING--The Marylebone Health Centre, London. SUBJECTS--39 complaints received over the audit period. MAIN OUTCOME MEASURES--Types of complaints (administrative, about doctors or medical care or both, staff about patients, mixed, other) and resolution of complaints (how complaints were dealt with and their resolution). RESULTS--37 of the 39 complaints were resolved within two weeks. Two complaints sent direct to the family health services authority were resolved (with patients'' agreement) by the informal complaints procedure. CONCLUSIONS--The informal complaints procedure was more cost effective than the family health services authority system and was comparatively straightforward to implement within the practice without major organisational restructuring. The two way process of the procedure ensured patients received a quick response to complaints and helped morale of health centre staff.     

Beyond health care reform: immigrants and the future of medicine

Abstract

I first discuss the fundamental responsibilities of physicians and relate them to an increasingly fragmented medical system made even more complex by government regulations. I focus on trust as a vital component in the doctor–patient relationship, and note the difficult conditions surrounding the treatment of poor and marginal populations. Subsequently, I sketch the elements of a new vision to extend medical services to neglected populations. In that pursuit, the part played by physicians is only as important as the willingness of neighbourhoods and communities to support health as a public good.     

Life on the edge: immigrants confront the American health system

Abstract

On the basis of a study of forty health care delivery institutions in Florida, California, and New Jersey, this paper examines the interaction between the immigration and health systems in the USA. We investigate barriers to care encountered by the foreign born, especially unauthorized immigrants, and the systemic contradictions between demand for their labour and the absence of an effective immigration policy. Lack of access and high costs have forced the uninsured poor into a series of coping strategies, which we describe in relation to commercial medicine. We highlight regional differences and the importance of local politics and history in shaping health care alternatives for the foreign born.     

Perinatal depression: implications for child mental health

Perinatal depression is common and primary care holds a crucial role for detecting, treating or, if necessary, providing referrals to mental health care for affected women. Family doctors should be aware of risk factors for peripartum depression, including previous history of depression, life events and interpersonal conflict. Perinatal depression has been associated with many poor outcomes, including maternal, child and family unit challenges. Infants and young children of perinatally depressed mothers are more likely to have a difficult temperament, as well as cognitive and emotional delays. The primary care setting is uniquely poised to be the screening and treatment site for perinatal depression; however, several obstacles, both at patient and systems level, have been identified that interfere with women's treatment engagement. Current published treatment guidelines favour psychotherapy above medicines as first line treatment for mild to moderate perinatal depression, while pharmacotherapy is first choice for severe depression, often in combination with psychosocial or integrative approaches. Among mothers who decide to stop taking their antidepressants despite ongoing depression during the perinatal period, the majority suffer from relapsing symptoms. If depression continues post-partum, there is an increased risk of poor mother-infant attachment, delayed cognitive and linguistic skills in the infant, impaired emotional development and risk for behavioural problems in later life. Complex, comprehensive and multilevel algorithms are warranted to treat perinatal depression. Primary care doctors are best suited to initiate, carry out and evaluate the effectiveness of such interventions designed to prevent adverse outcomes of maternal perinatal depression on mother and child wellbeing.     

Medication error in mental health: implications for primary care

Medication errors are associated with significant morbidity and people with mental health problems may be particularly susceptible to medication errors due to various factors. Primary care has a key role in improving medication safety in this vulnerable population. The complexity of services, involving primary and secondary care and social services, and potential training issues may increase error rates, with physical medicines representing a particular risk. Service users may be cognitively impaired and fail to identify an error placing additional responsibilities on clinicians. The potential role of carers in error prevention and medication safety requires further elaboration. A potential lack of trust between service users and clinicians may impair honest communication about medication issues leading to errors. There is a need for detailed research within this field.     

Health and the city: physical health and mental health

In France, city size has very little bearing on the mortality rate as a function of age and life expectancy and it is in large cities that these indicators are the most favorable. No increase in maternal or infant mortality rates or deaths due to cancers has been observed in large cities. The lower mortality rate linked to respiratory and cardiovascular diseases in large urban areas contradicts the fears concerning the impact of air pollution. Deaths linked to lifestyle are less frequent in big cities, which could be due to social structures (socio-professional level: the proportion of white-collar workers and professionals is higher in bigger cities than in the suburbs or small cities). However, although the overall mortality rate is lower, it should be emphasized that there is in large cities a greater incidence of sexually transmitted diseases, AIDS and certain infectious diseases (because of social diversity and the fact that certain individuals seeking anonymity and marginality are drawn to large cities). In terms of mental health, the breakdown of family structures, instability, unemployment, the lack of parental authority and failing schools render adolescents vulnerable and hinder their social integration. When the proportion of adolescents at risk is high in a neighborhood, individual problems are amplified and social problems result. In order to restore mental and social health to these neighborhoods, ambitious strategies are necessary which take into account family and social factors as well as environmental ones. At the present time, when physical health is constantly improving, the most pressing problems are those related to lifestyle and mental health which depend for a large part on social factors.     

The health status of Russian-speaking immigrants in Germany.

INTRODUCTION: Germany developed today into a country of immigration, which creates an additional burden for the social security system and results in a new challenge for the healthcare. In the last 17 years more than two million "Russia Germans" have been repatriated and about two hundred thousand Jewish refugees have resettled in Germany from the former Soviet Union. Nevertheless relevant data concerning migration-related public health care are very scare. METHODS: Search of PubMed and Journals extracts combined with the own researches, analysing the health status indices of the Russian-speaking immigrants in Germany. RESULTS: Both repatriates of German origin and Jewish refugees demonstrated higher prevalence of impaired lipid metabolism in comparison with native population. 42 % of the 503,040 HBsAg (hepatitis B s-Antigen) carriers in Germany were migrants. The Jewish refugees demonstrated the highest rates of depression and anxiety and the highest levels of awakening cortisol. On the other side German resettlers showed lower cardiovascular as well as all-cause death rates compared to the native Germans. CONCLUSION: The development of adequate health care programmes to address migratory aspects as well as the establishment of quality standards will realistically enhance the capability of responding rapidly to migrant health aspects and help to tackle inequalities in health.