In the JournalsPerspective

Immigrant youth face barriers accessing mental health services in outpatient settings

Image of Natasha Saunders
Natasha Ruth Saunders

Results from a population-based study published in CMAJ revealed that refugee and immigrant youth were more likely to present to the ED with a first mental health problem than nonimmigrant youth in Ontario, Canada, with variation by region and time since migration.

These findings indicated immigrant youth may have poor access to timely mental health services from a physician in an outpatient setting, according to the researchers.

“In recent years, we have witnessed increasing rates of ED visits for mental health concerns among youth. We know that this is in part due to increasing prevalence of mental illness, but it is also related to inadequate access to appropriate and timely mental health care in primary care settings,” Natasha Ruth Saunders, MD, MSc, from the Hospital for Sick Children and department of pediatrics at University of Toronto, told Healio Psychiatry. “Understanding which specific populations face some of the largest barriers to outpatient physician mental health care is needed so that targeted interventions that focus on the highest risk populations can be instituted.”

Researchers linked health and demographic administrative data to establish the extent to which 118,851 young immigrants aged 10 to 24 years used the ED as an entryway into mental health services from 2010 to 2014 in Ontario, Canada.

Among participants who presented for the first time to the ED for a mental health-related reason, the investigators determined those who had not seen a primary care practitioner or a psychiatrist for a mental health issue in the previous 2 years before their visit. Participants’ immigrant status (ie, nonimmigrant, nonrefugee immigrant and refugee immigrant) was the main predictor of interest and immigrant-specific predictors included the duration of residence (0 to 5 years, 6 to 10 years and more than 10 years) in Canada and the region/country of origin.

There were 2,194 refugee immigrant, 6,680 nonrefugee immigrant and 109,977 nonimmigrant youth included in the study. Refugees (61.3%) and nonrefugee immigrant youth (57.6%) saw higher rates of first mental health contact in the ED compared with nonimmigrant participants (51.3%), according to results of an analysis using adjusted Poisson models (refugee adjusted RR = 1.17 [95% CI, 1.13-1.21]; nonrefugee immigrant adjusted RR = 1.1 [95% CI, 1.08-1.13]).

Image of upset youth 
Refugee and immigrant youth were more likely to present to the ED with a first mental health problem than nonimmigrant youth in Ontario, Canada, according to results from a population-based study.
Source: Adobe Stock

Refugee youth experienced a higher rate of first mental health contact in the ED compared with nonrefugee immigrants (adjusted RR = 1.06; 95% CI, 1.02-1.11).

In addition, Saunders and colleagues found higher rates among recent compared with long-term immigrants (adjusted RR = 1.1; 95% CI, 1.05-1.16) and immigrant participants who came from Central America (adjusted RR = 1.17; 95% CI, 1.08-1.26) and Africa (adjusted RR = 1.15; 95% CI, 1.06-1.24) compared with those who came from North America and Western Europe.

“When caring for immigrants and refugees, consider personal biases that may contribute to barriers in identifying mental illness early in patients,” Saunders told Healio Psychiatry. “For example, could there be cultural differences between me and my patient that make it more difficult to recognize mental illness? Is my patient afraid to tell me about their experiences due to stigma about mental illness and if so, how can I make them feel more comfortable?”

Without better understanding why marginalized people face a lack of integration and organization of health and mental health services, barriers to access and treatment could increase, David Cawthorpe, PhD, from the departments of psychiatry and community health sciences at Alberta Children’s Hospital Research Institute, University of Calgary, wrote in a related editorial.

“The association of mental disorder with important and apparently intractable social issues, such as homelessness, violence, immigration or refugee status, may serve to further marginalize groups of individuals and increase stigma. The reality is that there is a silent epidemic,” he wrote. “It’s time to recognize the main issues underpinning access and mobilize to address the mental and physical health needs of all Canadian children and youth in the right place at the right time.” – by Savannah Demko

Disclosure: Saunders reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Cawthorpe reports being a shareholder of International Graduate Medical Education Inc. and consulting for Canadian Research and Education for the Advancement of Child Health Trust.

Image of Natasha Saunders
Natasha Ruth Saunders

Results from a population-based study published in CMAJ revealed that refugee and immigrant youth were more likely to present to the ED with a first mental health problem than nonimmigrant youth in Ontario, Canada, with variation by region and time since migration.

These findings indicated immigrant youth may have poor access to timely mental health services from a physician in an outpatient setting, according to the researchers.

“In recent years, we have witnessed increasing rates of ED visits for mental health concerns among youth. We know that this is in part due to increasing prevalence of mental illness, but it is also related to inadequate access to appropriate and timely mental health care in primary care settings,” Natasha Ruth Saunders, MD, MSc, from the Hospital for Sick Children and department of pediatrics at University of Toronto, told Healio Psychiatry. “Understanding which specific populations face some of the largest barriers to outpatient physician mental health care is needed so that targeted interventions that focus on the highest risk populations can be instituted.”

Researchers linked health and demographic administrative data to establish the extent to which 118,851 young immigrants aged 10 to 24 years used the ED as an entryway into mental health services from 2010 to 2014 in Ontario, Canada.

Among participants who presented for the first time to the ED for a mental health-related reason, the investigators determined those who had not seen a primary care practitioner or a psychiatrist for a mental health issue in the previous 2 years before their visit. Participants’ immigrant status (ie, nonimmigrant, nonrefugee immigrant and refugee immigrant) was the main predictor of interest and immigrant-specific predictors included the duration of residence (0 to 5 years, 6 to 10 years and more than 10 years) in Canada and the region/country of origin.

There were 2,194 refugee immigrant, 6,680 nonrefugee immigrant and 109,977 nonimmigrant youth included in the study. Refugees (61.3%) and nonrefugee immigrant youth (57.6%) saw higher rates of first mental health contact in the ED compared with nonimmigrant participants (51.3%), according to results of an analysis using adjusted Poisson models (refugee adjusted RR = 1.17 [95% CI, 1.13-1.21]; nonrefugee immigrant adjusted RR = 1.1 [95% CI, 1.08-1.13]).

Image of upset youth 
Refugee and immigrant youth were more likely to present to the ED with a first mental health problem than nonimmigrant youth in Ontario, Canada, according to results from a population-based study.
Source: Adobe Stock

Refugee youth experienced a higher rate of first mental health contact in the ED compared with nonrefugee immigrants (adjusted RR = 1.06; 95% CI, 1.02-1.11).

In addition, Saunders and colleagues found higher rates among recent compared with long-term immigrants (adjusted RR = 1.1; 95% CI, 1.05-1.16) and immigrant participants who came from Central America (adjusted RR = 1.17; 95% CI, 1.08-1.26) and Africa (adjusted RR = 1.15; 95% CI, 1.06-1.24) compared with those who came from North America and Western Europe.

“When caring for immigrants and refugees, consider personal biases that may contribute to barriers in identifying mental illness early in patients,” Saunders told Healio Psychiatry. “For example, could there be cultural differences between me and my patient that make it more difficult to recognize mental illness? Is my patient afraid to tell me about their experiences due to stigma about mental illness and if so, how can I make them feel more comfortable?”

Without better understanding why marginalized people face a lack of integration and organization of health and mental health services, barriers to access and treatment could increase, David Cawthorpe, PhD, from the departments of psychiatry and community health sciences at Alberta Children’s Hospital Research Institute, University of Calgary, wrote in a related editorial.

“The association of mental disorder with important and apparently intractable social issues, such as homelessness, violence, immigration or refugee status, may serve to further marginalize groups of individuals and increase stigma. The reality is that there is a silent epidemic,” he wrote. “It’s time to recognize the main issues underpinning access and mobilize to address the mental and physical health needs of all Canadian children and youth in the right place at the right time.” – by Savannah Demko

Disclosure: Saunders reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Cawthorpe reports being a shareholder of International Graduate Medical Education Inc. and consulting for Canadian Research and Education for the Advancement of Child Health Trust.

    Perspective
    Brandon Kohrt

    Brandon Kohrt

    As health professionals, we are failing the next generation in assuring that they have access to and engage with treatment for mental illness. Sanders and colleagues report that more than half of youth in a large Canadian study first accessed mental health services through an ED. Although the situation was moderately worse for refugee youth, the researchers’ findings were striking that this problem cuts across all youth populations.

    Early detection and intervention during adolescence leads to better school performance, higher levels of educational completion, less drug and alcohol use, and lower risk-taking behaviors associated with injuries, HIV and other STIs, and legal violations. Early mental health care in adolescents has major personal, communal, and national economic benefits.

    Pediatricians, teachers, coaches and religious leaders can play a vital role in recognizing mental health problems among youth and referring them early for care before problems become so severe that they require going to the ED. As mental health professionals, it is time to reach out more and collaborate with the key people in adolescents’ lives to assure that all youth have access to and seek out community-based and outpatient mental health services. 

    • Brandon Kohrt, MD, PhD
    • Charles and Sonia Akman Professor in Global Psychiatry
      Associate Professor of Psychiatry and Behavioral Sciences and Global Health
      Director, Division of Global Mental Health
      George Washington University

    Disclosures: Kohrt reports no relevant financial disclosures.