The relationship between migration and psychosis risk is well established. A meta-analysis by Selten et al., (2020) found that migrants are twice as likely to experience psychosis. Other Mental Elf blogs have highlighted how migrants are both more vulnerable to psychosis and more likely to receive inpatient care than their non-migrant counterparts (Chilman, 2021; Dengu, 2021; Fazel, 2016).
There are some known risk factors that can also explain this relationship between psychosis and migration such as social class, childhood trauma, perceived psychosocial power and ethnicity (Jongsma et al., 2020; Kirkbride et al., 2008; Termorshuizen et al., 2020). The age at which someone migrates may also increase the risk of later developing psychosis with younger people being at greatest risk, but studies to date have been limited by their small sample sizes.
Andleeb and colleagues set out to build on the evidence in a European case-control study. As someone who migrated as an adolescent, I was personally eager to learn about how age of migration contributed to risk of psychosis.
The relationship between migration and later risk of psychosis is well established but studies have been limited by small sample sizes
Methods
This was a case-control study using participants from the European Network of National Schizophrenia Networks Studying Gene-Environment Interaction study (EU-GEI, 2008), with data from five countries (England, France, Italy, the Netherlands and Spain) between 2010 and 2015.
- Location: 17 sites across five countries
- 2,132 participants: 937 cases with First Episode Psychosis and 1,195 controls
- Age of participants: 18 to 64
- Diagnosis of psychosis as classified by ICD-10 (WHO, 2004)
- Control group: random and quota sampling (the sample representing specific subgroup characteristics based on a quota) of white non-migrant participants
- Independent variable: age-at-migration divided into the categories of infancy, childhood, adolescence, adulthood.
Multiple confounding factors were considered to make sure the risk of psychosis was directly linked to age-at-migration instead of other variables such as ethno-racial identity, social class, parental history of mental illness, or childhood trauma.
Statistical tests were conducted using regression analysis to estimate which variables have an impact on the psychosis rates (Sarstedt & Mooi, 2018).
Data were included about people who migrated to five European countries – England, France, Italy, the Netherlands and Spain.
Results
- Migration at any age was associated increased odds of first episode psychosis risk.
- Migration at adolescence was associated with significantly increased odds of psychosis: 3.72 (2.08 to 6.64, unadjusted model)
- Adolescents from Black and North African backgrounds had the highest risk of all.
However, there remains a lot of uncertainty about these results. Many associations were attenuated when adjusted for other confounders, and all had wide confidence intervals.
Conclusions
The authors concluded that migration during adolescence when people are developing their sense of self, may be particularly vulnerable to stressors of migration. Adolescents may have a harder time adjusting to the new culture compared to their younger counter-parts, perhaps due to language barriers (Sebastian-Galles & Santolin, 2020). They may also have been exposed to more pre-migration risk factors, due to spending more time in their country of origin (Arango et al., 2021). Adolescents are also at the age where they need to be developing their social networks as they grow closer with their friends than their families. Consequently, this disruption in development may be detrimental in terms of social functioning (Verelst et al., 2022).
People migrating during adolescence may be particularly vulnerable to stressors.
Strengths and Limitations
The strengths of the study include that a diverse range of data was collected to make the study applicable around Europe. The confounders for the study were collected through people with lived experience of migration and the data was rigorously adjusted. Although 28.5% of the participants had at least one variable missing, the missing data were imputed using recognised statistical methods. However, imputing such large amounts of missing data across the sample may reduce the reliability of findings.
The limitations of the study include the number of participants. Although the authors claim this was a large pool of participants, the high number of confounding variables they were controlling for may have caused power issues (Blackford, 2006). Specifically, participant numbers were low for some ethno-racial identities like North African, which caused uncertainty about the strength of the psychosis risk. The findings also cannot be generalised to migrants in non-European countries or any refugee population due to difference in stressors. Childhood trauma was considered as a pre-migration risk factor. However, there was no actual way to distinguish if it happened before or after migration, this may have caused inappropriate adjustment of data.
Finally, there were also important differences between the case and control groups in key confounding variables, including age, sex, race and ethnicity, which makes comparison between groups harder.
Large amounts of missing data were imputed, which may reduce the reliability of findings.
Implications for practice
The authors were able to demonstrate that being an adolescent (a difficult period in most people’s lives) during migration, may result in higher risk of psychosis, especially if the individual is from a minority ethnic group. As someone who was an adolescent during migration these results are on par my own experiences. Packing your bags and moving to a country, leaving behind your precious friends and memories. Being half confused, half hopeful, as your parents promise you a new life full of greatness. However, realising that the moment you arrive, the utopia you were hoping for does not exist. Instead, your family fights poverty, you are suddenly behind in all the classes and the kids are bullying you in a language you don’t understand (at least in my experience). Further research into these factors is needed to prevent mental health problems developing in migrants and to promote better mental health.
The authors suggest the findings can be used by healthcare professionals to create targeted interventions for adolescent migrants, especially those from ethnic minorities. However, this specific population also faces direct barriers to accessing psychosis services in the first place (Schlief et al., 2023). The barriers faced when integrating into a new country, such as being financially stable, accessing education, having a community, having anti-discriminatory policies in place, can also be highly relevant for adolescent migrants. Further research is also needed to understand the outcomes for young migrants and the effects of interventions.
There can be a lot of factors that affect the resilience of young people to stressors. While models exist to predict stress responses, adolescent migrants may be more vulnerable as they experience adversities such as socioeconomic deprivation, childhood trauma and discrimination, whilst lacking many of the protective factors such as extended family and wider community support (Del Giudice et al., 2011).
When it comes to the diagnosis of psychosis there have been issues regarding validity. A review by Castagnini and Fusar-Poli (2017) stated that the lack of neurobiological findings and low predictability do undermine the validity of the diagnosis. There are cultural differences that need to be considered when making the diagnosis. For example, what constitutes delusions, a key symptom of psychosis, may not be strictly pathogenic in some cultures, however, for a migrant that is living in a different culture this might be an issue (Ghanem et al., 2023).
One point I would like to raise is that this paper may be downplaying how much of a role overdiagnosis and racism are factoring into these results, although in the paper the authors allude to it. In the study, when ethno-racial identity was added as a confounding factor, the only adolescents with statistically significant heightened risk of psychosis were Black and North African people. It is therefore important that future research consider the increased risk of psychosis through the prism of structural discrimination (Misra et al., 2022).
Future research should consider this increased risk of psychosis in Black and North African migrants through the prism of structural discrimination.
University of Glasgow MSc Students
This blog has been written by a student from the University of Glasgow.
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Links
Primary paper
Andleeb, H., Moltrecht, B., Gayer-Anderson, C., Arango, C., Arrojo, M., D’Andrea, G., Bernardo, M., Del-Ben, C. M., De Haan, L., Ferraro, L., La Barbera, D., La Cascia, E., Llorca, P., Menezes, P. R., Quattrone, D., Sanjuán, J., Selten, J., Szöke, A., Tarricone, I., . . . Kirkbride, J. B. (2024). Age-at-migration, ethnicity and psychosis risk: Findings from the EU-GEI case-control study. PLOS Mental Health., 1(5), e0000134. https://doi.org/10.1371/journal.pmen.0000134
Other references
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