Mental health in different groups of migrants and ethnic minority within Europe and beyond: Regional and cross-national challenges and approaches in research, practice and training

Mental health and migration are two issues of increasing importance for health care systems and services regarding prevention, promotion and the quality of delivery of care. Immigration and emigration are as old as mankind, however, new forms of mobility [5,10], the effects and consequences of war and demographic changes (to name just a few) created a new quality of migration in recent years that affects European health care systems and services. A great variety of lifestyles, everyday realities and diverse cultural repertoires are interwoven and compete with each other. Migratory milieus and cross-cultural relationships create new spaces, in which individuals from different cultural backgrounds experience diversity and develop their identity and their conception of the self and their environment. The so called globalisation creates new challenges and demands and promotes new competences [24] – also in the health sector [20].

The number of migrants in the world has more than doubled since 1975, with most migrants living in Europe (56 million), Asia (50 million) and Northern America (41 millions) [8].

In Europe, approximately 27% of the population between 18 and 65 years of age are affected by at least one mental disorder, and roughly a quarter of these individuals are in treatment [23]. Mental disorders belong to the group of diseases with the highest proportion of “Disability Adjusted Life Years” (DAYLs), as demonstrated by the Global Burden of Disease Study conducted by the WHO [25]. The economic burden caused by mental diseases is the highest compared with other diseases [3]. Nevertheless, migrants and people suffering from mental health problems are among those subjects who experience the strongest barriers to access the health care systems in Europe [7] and the opening of mental health care institutions to migrants remains a widely neglected topic.

Barriers preventing migrants to access the health care system are often attributed to cultural differences and misunderstandings. However, “culture” is a multifaceted term that is often (mis-)used as a putative politically correct expression of “ethnical differences”, thus reifying social differences and neglecting discrimination. Misinterpretation of social differences as cultural can therefore result in inappropriate culturalisation and lead to new stigmatisation and exclusion. On the other hand, clinical practice is often characterized by a lack of basic provisions to cope with cultural and social diversity, as indicated e.g. by the failure to provide translators in clinical settings. Therefore, we would like to emphasize that our use of the term “culture” does not refer to a homogenous, “ethnic” category but rather to diverse aspects of a web of meanings that embeds people in various contexts [9]. Individuals develop as well as participate in diverse systems that order the available knowledge and actions with meaning. Culture is thus constituted by actions in the social and physical world and can be named as just one aspect of differentiation besides historical, social and economical features.

Reflection on culture includes a reflection on European prejudices and implicit assumptions about mental health and its impairment. Therefore, our articles address the historical and cultural roots of basic clinical and psychological concepts of the body, soul, emotions and self. We also discuss explanatory models of diseases and their context-specific expressions, e.g. the individual adoption of global discourses of disease in locally specific ways [13,21].

In 2008 we had the chance to publish a first supplement on the topic “Transcultural Psychiatry in Europe” in the European Psychiatry [22] and discussed epidemiological data regarding mental disorders in migrants, barriers in communication, limited access to treatment and attempts to improve the situation by competence trainings. In the meantime, several lines of funding (European Commission, the German BMBF, VW-Foundation) provided ressources to deepen those approaches and findings, particularly with respect to major migrant communities in different parts of Europe.

In the first part of the supplement, social and individual factors determining mental health of migrants in Europe are addressed with a special focus on gender aspects and stress factors resulting from social exclusion. Today, epidemiological studies of mental health in migrants are often limited by the low response rate of contacted individuals in the chosen sample. Therefore Demet Dingoyan and colleagues [6] conducted focus groups to assess ressources and barriers in the attendance at scientific studies. Marion Aichberger and colleagues [1] examined the impact of socioeconomic factors on emotional distress in women with and without Turkish migratory background living in Germany. Zohra Bromand and co-workers [4] describe risk and resilience factors contributing to mental distress and highlight the advantages and challenges of close family ties for female migrants. The effects of social stigma on the manifestation of affective disorders and somatization in women with migratory background are reported by Amanda Heredia and others [12], who challenge the hypothesis that somatization rather than depressive symptoms are displayed in women with a Mediterranean background.

Diagnostic instruments for the assessment of mental disorders in migrants and problems of classification are discussed in the second part of the supplement. Fidan Mammadova [16] present a cultural and lingual adaptation of standardised depression ratings in Azerbaijan and discuss differences between Russian and Azerbaijani speaking women. Andreas Heinz and colleagues [11] describe historical and intercultural differences in the construction of the self, address (post-)colonial distortions of the respective concepts and describe their relevance for the diagnosis of mental disorders. Fatima Napo and co-workers [18] assess whether key diagnostic symptoms of schizophrenia can be found among patients suffering from acute psychoses in Mali and among West-African migrants in Europe. Finally, Azra Vardar and colleagues [26] describe differences and similarities in explanatory models of mental disorders depending with respect to diverse factors such as education, gender and migratory background.

In the third section of this supplement, studies address challenges for the health care system when it is geared towards the needs of migrants in Europe. Ulrike Kluge and colleagues [15] describe diverse health care systems in Europe and focus on service use, diversity of staff members in health care services and the provision of translators. Simone Penka and co-workers [19] introduce an assessment tool that measures the degree of “intercultural openess” of community mental health services. Sofie Bäärnhielm and Mike Mösko [2] give an overview over cross-cultural training programms and discuss the advantages and limitations of such interventions. Inge Missmahl and colleagues [17] describe basic diagnostic tools for the assessment of mental disorders and their implementation in training programs for medical practitioners, students and psychosocial counsellors based on experiences in Afghanistan.

Finally, Arthur Kleinman [14] discusses challenges and perspectives for the organisation of mental health care systems oriented towards the diverse needs of patients in a globalized world.

Altogether, the studies presented in this supplement illustrate the diverse approaches required in research, practice and training to improve the promotion, access, delivery and quality of health services for migrants and ethnic minorities. As discussed in the articles of this supplement, a wider view on cultural, social, gender and age differences is necessary to meet the needs of the respective groups. Human diversity clearly transcends cultural differences and requires flexible responses to different needs. To address these diverse settings and experiences, the integration of quantitative and qualitative research is warranted to promote comprehensive approaches in the area of mental health. Besides increased epidmiological research, studies on the improvement of communication in the respective settings and a fight against discrimination within the health care system are important tasks for a health care system that is geared towards inclusion of patients, relatives and professionals with diverse backgrounds and experiences.