by Dawit Shawel Abebe, Professor of Public Health at the Faculty of Health, Department of Nursing and Health Promotion, Oslo Metropolitan University, Norway
Note from Dr. Bulik: Professor Dawit Abebe is a long-time CEED collaborator who is passionate about the topic of immigrant health and mental health. His work increases awareness in policymakers to improve the health and wellbeing of immigrants and to include them in mental health research. His work also serves to make healthcare systems and mental health research more welcoming to immigrants to improve well-being and increase representation in research.
Migration is a complex phenomenon with profound implications for the mental health of immigrants and their descendants—immigrant children and adolescents. In this blog post, I present the mental health inequalities experienced by these young immigrants, drawing on theoretical frameworks, epidemiological findings, and their unique challenges including critical research gaps that must be addressed.
One of the earliest theoretical models linking migration and mental health is the selection hypothesis, introduced by the Norwegian-American psychiatrist Ørnulv Ødegaard in 1932. He posited that pre-migration factors, particularly the personal characteristics of migrants, could explain the higher incidence of schizophrenia observed among Norwegian migrants in the U.S. compared to those who remained in Norway. Ødegaard suggested that those who chose to migrate were inherently different—perhaps more sensitive, ambitious, or restless—traits that could make them more vulnerable to mental health issues [1]. However, as research evolved, this model was increasingly challenged. Recent studies highlight the limitations of the selection hypothesis, suggesting instead that the stresses and challenges encountered pre/peri-migration (e.g., poverty, war, trauma, or abuse) and post-migration play a more significant role in shaping mental health outcomes. Specifically, this shift in understanding led to the development of the post-migration stress theory, which emphasizes that the mental health of immigrants is more affected by the difficulties they face after arriving in a new country rather than their pre-existing characteristics. Key post-migration stressors include the complexities of navigating immigration laws, financial instability, social isolation, the struggle to adapt to new cultural norms, acculturation stress, and the pervasive impact of discrimination and racism [2, 3]. These stressors create an environment of chronic stress that can severely impact mental health. Building on this, the cumulative disadvantage theory offers a broader perspective by focusing on how the accumulation of multiple disadvantages over time—such as poverty, unemployment, low education, and systemic discrimination—further exacerbates mental health challenges among immigrants [4]. This theory underscores that it is not just individual stressors that are harmful, but the compounded effect of these disadvantages over time that can lead to more severe mental health outcomes. These theories provide a comprehensive framework for understanding the mental health of immigrants.
Research on the mental health of immigrant children and adolescents reveals a heterogeneous picture. Most studies report that these populations are more prone to mental disorders, particularly refugees and those from non-Western countries. In contrast, some studies indicate more similarities or even improved mental health among immigrant children and youth compared with their non-immigrant peers. However, the burden of mental disorders varies based on ethnicity, gender, country of origin, socioeconomic status, parental migration history and types of mental disorders [5-7].
Despite the growing body of research, significant gaps remain in understanding the mental health inequalities among immigrant children and adolescents. A critical gap is the lack of cohort/longitudinal studies that can effectively identify causal mechanisms underlying these inequalities. Most existing research relies on cross-sectional data, which limits the ability to draw definitive conclusions about the pathways leading to mental health disparities. There is a need for more studies that explore the intersectionality of various factors such as ethnicity, migration history, socioeconomic status, and integration parameters, to better understand the nuanced experiences of different immigrant groups. Furthermore, the lack of genetic studies that include immigrant populations is an important research gap. This lack of representation means that we have a limited understanding of how genetic predispositions to general health and mental disorders interact with the unique environmental stressors faced by immigrants.
Another significant challenge in addressing mental health inequalities among immigrants is the treatment gap. Many immigrants do not receive the necessary care, which can lead to prolonged suffering and the worsening of mental health conditions. This can be attributed to various help-seeking barriers at different levels. At the system/macro level, barriers include culturally rooted stigma, a lack of information about the healthcare system, and costs. At the care provider level, barriers involve culturally insensitive healthcare professionals and a mismatch between the needs of the patient and the expectations of the care provider. At the personal level, barriers include self-perceived care needs, language proficiency, mental health literacy, and a lack of trust [8, 9]. These barriers may contribute to broader health disparities and underscore the need for more inclusive and accessible mental health services.
To effectively address the mental health inequalities faced by immigrant children, it is crucial to adopt a holistic approach that considers the multiple interacting social, cultural, and ecological contexts in which these children grow and develop. This includes enhancing the inclusion of immigrant populations in research, developing culturally sensitive recruitment materials, and building trust within immigrant communities. Moreover, there is an ethical responsibility for governments, funding bodies, and research institutions to address these disparities and ensure that immigrant populations are adequately represented in mental health studies, specifically clinical trials and genomic studies.
In conclusion, understanding and addressing mental health inequalities among immigrant children and adolescents requires a multifaceted approach that considers both pre- and post-migration factors, as well as the broader socio-economic and cultural contexts. The significant research gaps in this field must be addressed to develop effective interventions. By acknowledging the diversity of experiences within immigrant populations and working to close the treatment gap, we can better support the mental health and well-being of these vulnerable groups.
References
Ødegaard Ø. Emigration and insanity. Acta Psychiatr Neur Suppl. 1932;4.
Bhugra D. Migration and mental health. Acta Psychiatr Scand. 2004;109(4):243-58.
Hynie M. The social determinants of refugee mental health in the post-migration context: A critical review. Can J Psychiatry. 2018;63(5):297-303.
Seabrook JA, Avison WR. Socioeconomic status and cumulative disadvantage processes across the life course: implications for health outcomes. Can Rev Sociol. 2012;49(1):50-68.
Abebe DS, Lien L, Hjelde KH. What we know and don’t know about mental health problems among immigrants in Norway. J Immigr Minor Health. 2014; 16:60-7.
Close C, Kouvonen A, Bosqui T, Patel K, O’Reilly D, Donnelly M. The mental health and wellbeing of first-generation migrants: a systematic-narrative review of reviews. Glob Health. 2016;12(1):1-13.
Jurado D, Alarcón RD, Martínez-Ortega JM, Mendieta-Marichal Y, Gutiérrez-Rojas L, Gurpegui M. Factors associated with psychological distress or common mental disorders in migrant populations across the world. Rev Psiquiatr Salud Ment. 2017;10(1):45-58.
Abebe DS, Lien L, Elstad JI. Immigrants’ utilization of specialist mental healthcare according to age, country of origin, and migration history: a nationwide register study in Norway. Soc Psychiatry Psychiatr Epidemiol. 2017; 52:679-87.
Derr AS. Mental health service use among immigrants in the United States: A systematic review. Psychiatr Serv. 2016;67(3):265-74.
