From the Editor

Last week, when in Halifax, I went to Pier 21, a museum that now stands where more than a million immigrants entered this country by ship. The exhibits describe the aspirations, the experiences, and the struggles of these people – our people. As a nation of immigrants, here’s an important question to ask: what impact does immigration have on mental health?

Different studies show different things of the immigrant experience. On the one hand, some studies find that immigrants (and refugees) have higher rates of psychosis (including a recent Canadian paper by Anderson et al.); on the other hand, other studies show a “healthy migrant effect” – that is, immigrants have lower rates of mental illness overall.

The August issue of The Canadian Journal of Psychiatry has a thoughtful paper that considers immigration and mental illness. The authors tread on familiar ground – there is a rich body of work in this area, but they offer a Canadian perspective by looking at people in Montreal, and they consider mental health utilization and service satisfaction.

Pier 21: A boat, a pier, and the beginning of the new beginning for hundreds of thousands – but are there implications for mental illness?

Spoiler alert: immigrants tended to have lower rates of depression and alcohol dependence than the general population.



Immigration and Illness

“Mental Health Status, Health Care Utilisation, and Service Satisfaction among Immigrants in Montreal: An Epidemiological Comparison”

Rob Whitley, JiaWei Wang, Marie-Josee Fleury, Aihua Liu, Jean Caron

The Canadian Journal of Psychiatry, August 2017

According to the latest census, approximately 20% of Canada’s population are immigrants. This proportion is rising, and immigrant integration is a key government priority. The recently published “Mental Health Strategy for Canada” notes that immigrants “face significant barriers to their seeking or obtaining help…health organizations need to be attuned to differences…and take into account cultural diversity”. As such, it is vitally important to document and analyse the nature and extent of any mental health variations experienced by immigrants.

In the study of immigrant health, immigrant life experience is often categorised into 3 stages: 1) premigration, 2) the migration journey, and 3) postmigration. Economic immigrants to Canada—for example, those from Western Europe or the United States—may have an unproblematic immigration experience. However, immigrants from other regions may be exposed to chronic or acute stressors during these stages. In the premigratory stage, immigrants from certain regions may have been exposed to civil instability, poverty, natural disaster, or other adverse social conditions. This is especially so for refugees, who may also experience a difficult migration journey. In the postmigratory stage, immigrants (especially non-European ones) may face unemployment, underemployment, and racism. This can even apply to skilled immigrants, especially when there is a discrepancy between aspiration and achievement.

A large body of European research suggest that rates of psychosis are significantly elevated in immigrants from Africa and the Caribbean. A recent Ontario study indicated slightly higher rates of psychotic disorders in refugees and Caribbean immigrants but not in other immigrant populations. The European research attributes this elevation to several factors, including a chronically negative postmigration experience for racialized immigrants.

The above-described research indicates that immigrants frequently experience negative stressors that can affect their mental health. However, a large number of Canadian studies indicate that immigrants generally have better mental health than the native-born population: this is known as ‘the healthy migrant effect’. For example, one large-scale study found that overall health (including mental health) was significantly better in immigrants than the Canadian-born. Likewise, another study found that immigrants had significantly lower rates of depression and alcohol use than the Canadian-born, especially recent immigrants. Numerous studies have confirmed this healthy migrant effect in Canada…

Rob Whitley

So begins a paper written by Whitley et al. that considers the immigration experience.

The corpus of research on immigrant mental health is inconsistent. Some research indicates that immigrants have higher risk and rates of mental illness, while other research suggests a healthy migrant effect.

Here’s what they did:

  • The data is drawn from the ongoing longitudinal cohort Epidemiological Catchment Area Study of Montreal South-West (ZEPSOM).
  • People were recruited from southwest Montreal, starting with the time period between May 2007 and November 2008, for a sample of 2,433 participants of 269,720 residents, with immigrants representing 17% of the population. This cohort has been followed every 2 years, to the period of February 2014 and May 2015.
  • Basic background information was collected, including age, marital status, and educational level. They also collected information on years of residence and region of birth (grouped into areas such as Latin America/Caribbean and Africa).
  • Twelve variables were chosen to measure various aspects of mental health and illness (including mood disorders, anxiety disorders, and alcohol dependence). Scales were used to describe psychological distress. Health care utilization was also considered.
  • Different statistical analyses were done, including chi-square tests and regression analyses.

Here’s what they found:

  • Demographically, immigrants tended to be younger than non-immigrants (age 42.2 and 45.1), and more likely to be married (46.9% and 26.7%). Some basic background information: “Immigrants have been in Canada for 19.6 years on average. Immigrants had significantly higher education levels, but their household income was significantly lower than nonimmigrants.”
  • “In terms of mental health, immigrants fared significantly better on 7 of the 12 variables measured. There were no significant differences in the other 5 variables, although consistent and clear trends can be observed in favour of better mental health for immigrants.” Immigrants had lower prevalence of mood disorders and alcohol dependence.
  • “At all 3 time points, immigrants (as a whole) reported a lower frequency of health care services utilisation but higher health services satisfaction scores than nonimmigrants.” Interestingly, over time, immigrants in Canada for more than 16 years had higher rates of utilization than recent immigrants.
  • “At baseline, immigrants reported significantly lower frequency of health service utilisation compared to nonimmigrants. Specifically, the frequency of health service utilisation in the past 12 months was on average 1.47 units lower in immigrants (P = 0.02). No significant longitudinal associations were found between immigration status, duration of residence, region of origin, and utilisation.”

A key finding of this study is that immigrants’ mental health was significantly better than nonimmigrants on 7 of the 12 relevant variables measured. They had significantly fewer mental disorders, lower scores of psychological distress, and higher scores of mental well-being… This is in contrast to some of the US and UK literature, which indicates that immigrants and minorities often have worse mental health.

The authors go on to conclude:

The rates of underutilisation, as well as the less than perfect rates of service satisfaction, suggest a need for targeted strategies to engage immigrants with mental health care and likewise improve services for them. This is especially so for Asian and African immigrants. This could be a key activity for the Mental Health Commission of Canada, whose mandate was recently renewed for a further 10 years.

A few thoughts:

  1. This is a good paper.
  1. There are clear limitations here – the sample of immigrants and non-immigrants is confined to one city in the country. (Still, the sample size isn’t small, and they measure things over time.) And the study doesn’t distinguish between immigrants and refugees.

Montreal at sunrise: many immigrants and mentally healthy immigrants?

  1. The news isn’t all good, particularly with certain sub-populations. The authors’ suggestion of targeting these groups in terms of services seems prudent.
  1. How do we reconcile this paper with the Anderson et al. paper showing certain migrant groups are more at risk of psychosis than the general population? (The paper was considered two years ago in a Reading; you can find it here: Note that the papers are very different: Whitley et al. looked at a small Montreal population, and focused on psychological distress and diagnoses like depression; Anderson et al. used a massive database, and focused on psychosis. And they could both be right: on the whole, immigrants enjoy good mental health (compared to the general population) but some – especially refugees from certain parts of the world – are at higher risk of psychosis.
  1. The Whitley et al. is from the August issue of The Canadian Journal of Psychiatry, which is particularly strong. Dr. Richard Hibbard’s perspective paper, “The Psychiatrist as Clinical Behavioural Scientist,” is thought-provoking and interesting. It begins: “Poor public access to evidence-based care is the biggest current challenge for psychiatrists in Canada.” It’s a clever start to a clever piece. The full paper is here:


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.