The European Journal of Public Health Advance Access originally published online on March 8, 2006
The European Journal of Public Health 2006 16(4):383-387; doi:10.1093/eurpub/ckl021
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Migration and health |
Demand for psychiatric emergency services and immigration. Findings in a Spanish hospital during the year 2003
M. Mercedes Perez-Rodriguez1, Enrique Baca-Garcia2, Francisco J. Quintero-Gutierrez2, Gloria Gonzalez2, Dolores Saiz-Gonzalez2, Carlota Botillo2, Ignacio Basurte-Villamor2, Juncal Sevilla2 and Jose L. Gonzalez de Rivera2
1 Department of Psychiatry, Ramon y Cajal University Hospital, Madrid,Spain
2 Department of Psychiatry, Fundacion Jimenez Diaz University Hospital, Universidad Autonoma de Madrid, Madrid, Spain
Correspondence: Enrique Baca García, Servicio de Psiquiatría, Fundación Jiménez Díaz, Avenida de los Reyes Católicos 2, Madrid 28040, Spain, tel/fax: +34 91 5504987, e-mail: ebacgar2{at}yahoo.es
Received December 9, 2004, accepted January 19, 2006
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Abstract |
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Background: The aim of this study is to investigate differences among immigrants and natives regarding access and pathways to psychiatric care, psychiatric admission rates, length of stay, continuity of care, and main diagnoses. Methods: Psychiatric emergency visits (1511) and hospitalizations (410) were registered in a Spanish Hospital with a catchment area of 280 000 people (19.3% immigrants) during the year 2003. Motives for demanding emergency psychiatric care, pathways to care, admission rates, length of stay, continuity of care, and main diagnoses were compared among natives and immigrants. Results: Immigrants accounted for 13.0% of consultations to the psychiatric emergency room (15.9% of patients) and 11.0% of admissions to the psychiatric hospitalization unit (13.5% of patients). The pathways to care were different for immigrants and natives. Immigrants had a lower rate of readmission to the psychiatric emergency room. Motives for consultation and hospitalization were also different among immigrants and natives. Immigrants showed more self-aggressive behaviours and neuroses, and lower rates of affective disorders and psychoses. Conclusions: Immigrants under-used psychiatric emergency and hospitalization services in comparison with natives. They did not consult because of psychoses or affective disorders, but mainly because of reactive conditions related to the stress of migration.
Keywords: continuity of care, ethnicity, hospital, immigration, pathway to care, psychiatric care
Immigration is a very important issue in Europe. As the number of immigrants grows, there is increasing concern about their mental health.1
Healthcare systems try to offer the best possible psychiatric care to people from different cultures. To achieve this, psychiatrists need to know if the existing psychiatric facilities have the right tools to treat immigrants, and if immigrants make proper use of them. Traditionally, it has been postulated that immigrants have higher admission rates to psychiatric hospitals than natives,2,3 and studies have shown that they have higher rates of some mental diseases such as schizophrenia.4 However, some recent studies disagree5,6 and argue that immigrants tend to under-use psychiatric services.
Spain has not traditionally received an important number of immigrants, and therefore there is a lack of studies on the mental health of immigrant populations. However, in the past 5 years the number of immigrants has suddenly increased. Immigrants already represent 10.0% of the population of Madrid. The main groups are Latin-Americans (35.0% of all immigrants) and Africans (22.0%).
The aim of this study is to investigate differences among immigrants and natives regarding access and pathways to psychiatric care, psychiatric admission rates, length of stay, continuity of care, and main diagnoses.
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Methods |
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A team of clinical psychiatrists obtained data from all patients seen in the psychiatric emergency room (PER) and/or admitted to the psychiatric hospitalization unit (PHU) in the Fundacion Jimenez Diaz general hospital during the year 2003. This hospital is part of the National Health Service, and provides free medical coverage to natives and immigrants regardless of legal status. The National Health Service provides healthcare coverage for all Spanish citizens and legal immigrants. All individuals with National Health Service coverage get a healthcare card with an identification number. Foreign-born individuals without this identification number were assumed to be illegal immigrants. Direct questioning about the legal status of the patients was avoided to prevent attention biases. Some legislative changes allow all the people (independently of their legal status) to be attended in emergency rooms. Without the healthcare card it is not possible to see a general practitioner or a specialist physician (including psychiatrists) within the public healthcare system. Therefore, illegal immigrants are forced to go directly to the emergency room of the general hospitals when they need general or specialty medical care.
Fundacion Jimenez Diaz is the hospital of reference of a catchment area of 280 000 people that has the highest rate of immigrant population of Madrid (19.3%). The main groups are Ecuadorians (7.3%), followed by Colombians (1.6%) and Moroccans (1.2%).7
‘Immigrants’ were defined as ‘foreign-born individuals, no matter whether they have been granted Spanish nationality or not’.
Motives for demanding emergency psychiatric care, pathways to care, admission rates, length of stay, continuity of care, and main diagnoses were compared among natives and immigrants. The motives for demanding emergency psychiatric care were those reported by the patient. The pathway to care was recorded for each patient. The following variables were included: (i) presence of medical evaluation by clinicians in other specialties before/after psychiatric evaluation; (ii) reasons for referral to the psychiatric emergency services: referred by another department within the hospital or by a different hospital; referred by a general practitioner; referred by a psychiatrist; (iii) who brings the patients to the PER: he/she comes on his/her own; his/her relatives bring him/her; he/she arrives in an ambulance; he/she is brought in by the police. In order to assess the continuity of the care, it was noted whether the patients got a follow-up psychiatric appointment or not when they were released from the facility.
The proportion of immigrants who used the PER and PHU were compared with the proportion of immigrants in the catchment area. Rates were compared using two-group tests of proportions.
Patients were diagnosed using the International classification of disease (ICD-10) criteria. Emergency diagnoses were assigned by clinical psychiatrists after reviewing all available information, including data from medical records and clinical interviews with the patient and relatives. Clinical diagnoses during admissions are the result of an intensive diagnostic and treatment process by well-trained clinical psychiatrists, including data from medical records, other research assessments, and clinical interviews. Diagnoses were grouped according to the ICD-10 chapter headings.
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Results |
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There were 1511 consultations in the PER involving 1015 different patients who lived in the catchment area.
In two cases it could not be determined whether the patient was an immigrant or a Spanish-born individual, and they were removed from the study. In 410 of the emergency consultations the patient was admitted to the PHU (involving 319 patients).
A total of 41.7% did not have a National Health Service number upon arrival at the PER, and were thus assumed to be illegal immigrants. Of those admitted to the PHU, 33.3% failed to provide a National Health Service number during their stay, and were classified as illegal immigrants. The mean ages and gender distribution of the main groups of immigrants and natives are listed in table 1.
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Psychiatric emergency room
The proportion of immigrants seen at the PER was significantly lower than the proportion of immigrants in the catchment area (P = 0.0012) (table 2). The proportion of PER consultations by immigrants was also significantly lower than the proportion of immigrants in the catchment area (P < 0.0001).
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Immigrants had lower rates of readmission than natives (Mann–Whitney U-test 61 200.0; P = 0.0060). A total of 76.9% of natives and 86.3% of immigrants, respectively, visited the PER once, 12.8% of natives and 10.6% of immigrants visited it twice, and 10.3% of natives and 3.1% of the immigrants visited the PER in more than two occasions.
The proportion of Ecuadorians seen at the PER was significantly lower than the proportion of Ecuadorians in the catchment area (P < 0.0001).
Psychiatric hospitalization unit
The proportion of immigrants admitted to the PHU was significantly lower than the proportion of immigrants in the catchment area (P = 0.0036). The proportion of hospitalizations by immigrants was also significantly lower than the proportion of immigrants in the catchment area (P < 0.0001) (table 3).
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Immigrants had lower rates of readmission than natives. A total of 82.7% of natives and 90.2% of immigrants respectively were hospitalized once, 11.9% of natives and 9.8% of immigrants were hospitalized twice, and 5.4% of natives but none of the immigrants visited the PER in more than two occasions. However, none of these differences were statistically significant (Mann–Whitney U-test 5241.0; P = 0.1960).
Ecuadorians accounted for just 1.9% of PHU patients, while they represented 7.3% of the catchment area population (P < 0.0001) (table 3).
The average length of hospitalization was not significantly different (t = –0.2; df = 407; P = 0.8430) in Spanish-born individuals (14.3 days; SD = 13.0) and immigrants (14.7 days; SD = 16.4) (table 4).
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Pathway to care
A significantly greater proportion of natives than immigrants came to the PER by their own free will (P < 0.0010), and a significantly greater proportion of immigrants than natives were brought to the PER by an ambulance (P = 0.0160) (table 4).
Continuity of care
There were no significant differences between the proportions of natives and immigrants who got a follow-up psychiatric appointment after being released from the psychiatric facilities, even after controlling for legal status/presence of National Health Service Card (table 4).
Motives for demanding emergency psychiatric care
The motives for demanding emergency psychiatric care among immigrants and natives are listed in table 4. The motives for demanding emergency psychiatric care were significantly different in immigrants and in natives (
2 = 24.4; df = 4; P < 0.0010).
Motives for hospitalization
Motives for hospitalization in immigrants and natives are listed in table 4. The proportion of immigrants who were given a psychiatric diagnosis (78.8%) was significantly lower (Fisher's exact test P < 0.0010) than that of natives (91.3%).
Immigrants suffered more neuroses (Fisher's exact test P = 0.0170), suicide attempts (Fisher's exact test P = 0.0150),and development disorders (Fisher's exact test P = 0.0170) than natives, and less organic mental disorders (Fisher's exact test P = 0.0270), psychoses (Fisher's exact test P < 0.0010), and affective disorders (Fisher's exact test P = 0.0170).
The rates of compulsory admission were not significantly different in immigrants (52.9%) and natives (46.9%).
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Discussion |
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Our findings suggest that the rates of use of psychiatric emergency and hospitalization services by immigrants are lower than the rates of use of psychiatric emergency and hospitalization services by natives. This may mean that immigrants under-use psychiatric services. Immigrants also had a smaller rate of repetition than natives. This supports previous research which indicated that ethnic minorities tend to under-use psychiatric services.5,6 The fact that immigrants were admitted from the PER to the PHU in a smaller proportion than natives could mean that they are less willingly hospitalized than natives. However, the length of stay was similar in immigrants and natives. This does not support the hypothesis that immigrants have a significantly lower number of care days than natives, which has been defended in other studies.8
Notwithstanding, other studies disagree with our findings. They affirm that there is a greater number of psychiatric admissions among immigrants.2,3 For example, several studies have linked the Afro-Caribbean ethnic group to a higher rate of psychoses and psychiatric admissions in England.4
Regarding the pathway to care, a greater proportion of natives than immigrants came to the PER by their own free will, and a greater proportion of immigrants than natives were brought to the PER by an ambulance.
Motives for demanding emergency psychiatric care and hospitalization were also different in immigrants and natives. Immigrants suffered more neuroses and suicide attempts, and fewer psychoses, organic mental disorders, and affective disorders than natives. These differences might be explained by the stress caused by the migration process. This supports the stress-related theory which has been proposed to explain the psychiatric conditions suffered by immigrants who have been exposed to stresses associated with migration, settlement, or acculturation.9
The rates of mandatory admission were similar in immigrants and natives. This contradicts several previous studies,10–12 in which the rate of mandatory admissions was much higher in immigrants.
Concerning the continuity of care, similar proportions of natives and immigrants got a follow-up psychiatric appointment after being released from the psychiatric facilities. The lack of a National Health Care identification number did not seem to affect the continuity of care.
Our study has several limitations. First, the number of cases in some groups is very small. Second, immigrant populations in the catchment area may be much bigger than the theoretical numbers, due to high rates of illegal immigration (i.e. Moroccans). In other cases, most of the patients admitted to the ER may be tourists, thus not registered as living in the catchment area (i.e. UK individuals). Third, we cannot avoid misunderstandings due to cultural differences between the patient and the researcher. Finally, the situation of immigrants in Spain may also be different from that of other countries, because most immigrants come from countries of similar cultures (i.e. Latin America). This fact could explain why some of our results differ so much from those of other studies carried out in other countries with more multicultural immigration patterns.
Further research is needed to compare the different pathways of access to psychiatric care in immigrants and natives. We are currently working on a bigger study, introducing new variables and increasing the sample size.
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Conclusion |
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Our findings suggest that immigrants under-use psychiatric emergency and hospitalization services in comparison with natives.
In addition, it seems that they do not consult because of psychosis or affective disorders, but mainly because of reactive conditions related to the stress of migration.
Key points
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References |
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1 Dein S. ABC of mental health: mental health in a multiethnic society. Br Med J 1997;315:473–6.
2 Ödegaard O. Emigration and insanity. A study of mental disease among Norwegian-born population in Minnesota. Acta Psychiatr Neurol Scand 1932 Suppl 4 1–206.
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7 Concejalía de Gobierno de Hacienda y Administración Pública. Dirección de Estadística. Población Extranjera en el Municipio de Madrid. Padrón Municipal de Habitantes a 1 de Julio de 2003. [Foreign Population in the city of Madrid. Municipal Population Census (1 July 2003)]. Available at: http://www.munimadrid.es/Principal/menus/Publicaciones/PobExt/pobext112003.pdf
8 Johansson LM, Sundquist J, Johansson S-E, Bergman B. Immigration, moving house and psychiatric admissions. Acta Psychiatr Scand 1998;98:105–11.[Web of Science][Medline]
9 Murphy HBM. Migration, culture and mental health. Psychol Med 1977;7:677–84.[Web of Science][Medline]
10 Davies S, Thornicroft G, Leese M, et al. Ethnic differences in risk of compulsory admission among representative cases of psychosis in London. Br Med J 1996;312:533–7.
11 Flannigan CB, Glover GR, Feeney ST, et al. Inner London collaborative audit of admissions in two health districts I: Introduction, methods and preliminary findings. Br J Psychiatry 1994;165: 734–42.
12 Thomas CS, Stone K, Osborn M, et al. Psychiatric morbidity and compulsory admission among UK-born Europeans, Afro-Caribbeans and Asians in Central Manchester. Br J Psychiatry 1993;163:91–9.
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