Epidemiology of psychiatric morbidity among migrants compared to native born population in Spain: a controlled study
Introduction
The relationship between immigration and psychopathology is unclear, as are the specific factors that may impact the process.
Recent large-scale epidemiological studies carried out in the United States found that immigrants had lower rates of common mental disorders [1], [2], whereas studies carried out in Europe — Belgium [3] and Sweden [4], for example — found the opposite. In their meta-analysis on migration and mood disorders, Swinnen and Selten [5] found a very slim, non-significant increase in risk in immigrants, and Kirmayer et al. [6], in their review, found that immigrants had slightly lower levels of mental disorders than the general population. It would appear, however, that immigrants to Europe, particularly those from the Caribbean and Africa, are vulnerable to developing psychotic disorders, and to a lesser extent affective disorders, as evidenced by a series of recent meta-analyses [7], [8], [9]. It is noteworthy that in the studies cited above and others [10], the prevalence of psychopathology varies, at times significantly, between different immigrant groups. This may be due to differential impact of the factors that are understood to comprise the principle risk, such as “social defeat” [8], cultural dissimilarity [11], and racism or discrimination [6].
Just as psychopathology may vary by immigrant groups, it follows that it would vary by environment or social context [12] there would appear to be a sort of “geopolitical effect” evidenced by differential findings in studies carried out in the United States and Canada which tend to show lower levels of psychopathology, as opposed to those carried out in Europe which show the reverse. Thus, it may be the case that to speak of “immigration and mental health” without taking into consideration the receiving country may be overly reductionistic. There is both conceptual [12] and empirical evidence that suggests that sociopolitical context has an impact on immigration processes and associated mental health [13], [14]. To that end, expanding the locale of epidemiological studies on migration and mental health could be of interest, particularly given that the bulk of studies have been carried out in countries with a long history of migration, 4 of which are English speaking (the US, the UK, Canada and Australia). A study taking place in Southern Europe, with its relatively recent history of mass migration, could provide an interesting counterpoint to existing findings.
Until the end of the 20th century, Spain had been a country of emigrants. With its rising prosperity, proximity to Africa, and relatively porous borders, it became an increasingly popular destination for immigrants [15], and saw an increase from less than 1% of the population in the early 90s to its current rate of around 15%. Spain's relatively recent status as a country of immigrants combined with its historical, cultural, and geographical similarities with some of its immigrant groups (e.g., Latin America; North Africa) suggests that it could provide interesting insights into understanding the relationship between migration and mental health.
The variations found in levels of psychopathology in immigrant and native-born populations may be due to factors specific to the immigrant group in question in conjunction with factors specific to the receiving culture, and/or of some combination thereof. Furthermore, commentators note that cross-cultural research is beset by the challenge of avoiding bias [16], [17]. In this context, bias refers to variation in a measured phenomenon due to group membership rather than variation of the phenomenon in question. Bias is often related to cultural differences in the understanding of the central constructs and in how specific items are understood.
The aim of this paper is to explore the prevalence of psychiatric morbidity in different immigrant groups in Spain relative to the native-born population, and to identify associated sociodemographic factors. It is expected that psychiatric morbidity will be higher in immigrants relative to the native born population, on the one hand, and, on the other, that there will be variation between immigrant groups.
Section snippets
Study design
The current paper describes the main findings of a multicenter, observational, cross-sectional study carried out in primary care settings. At the time of the study, public healthcare was available to all individuals registered with their local municipality, regardless of immigration status. Many municipalities facilitated access for those immigrants lacking correct documentation. The principal barrier to accessing the system are primarily related to linguistic and cultural differences [18].
Results
Fig. 1 summarizes the flowchart of the study. Refusal rate in immigrants was quite low considering the residence status of many of them, and similar to that found in Spanish population.
Table 1 summarizes the distribution of the sample by gender and, for immigrants, by geographical group. Socio-demographic characteristics of the sample are summarized in Table 2. The sample is relatively young and mostly female (61.3%). Immigrants reported a more stable marital relationship, had lower levels of
Discussion
The findings of the study, perhaps more than anything else, demonstrate the complexity of researching the mental health status of immigrants. It was hypothesized that immigrants would have higher levels of psychiatric morbidity than native born Spaniards, which at first glance is not supported by the data. However, this “first glance” belies the complexity of studying psychopathology in immigrant populations. When grouped together as “immigrants” versus “Spaniards”, no difference was found;
Conclusions
Two key findings emerged from this study. One is that there is considerable variability in levels of psychopathology across different immigration groups, and the other is that the receiving country may have an impact on the mental health of immigrants, a conclusion inferred based on the variability in prevalence of psychopathology in immigrant groups in this study relative to studies carried out in other countries. In terms of prevalence, the key issue may not simply be one of being an
Acknowledgments
The authors would like to express their deep appreciation to all of the people who made this study possible, particularly the volunteer interviewers. The authors would also like to thank the anonymous reviewers for their helpful remarks. The study was supported by a grant from the Carlos III Health Institute to JCG and FC, a grant from the Departament de Salut, Government of Catalonia, Spain, and a doctoral grant from the Research Institute of the Vall d’Hebron University Hospital to HWRE.
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