Meryam Schouler-Ocak

EPA guidance mental health care of migrants.

Migration is an increasingly commonplace phenomenon for a number of reasons. People migrate from rural to urban areas or across borders for reasons including economic, educational or political. There is increasing recent research evidence from many countries in Europe that indicates that migrants are more prone to certain psychiatric disorders. Because of their experiences of migration and settling down in the new countries, they may also have special needs such as lack of linguistic abilities which must be taken into account using a number of strategies at individual, local and national policy levels. In this guidance document, we briefly present the evidence and propose that specific measures must be taken to improve and manage psychiatric disorders experienced by migrants and their descendants. This improvement requires involvement at the highest level in governments. This is a guidance document and not a systematic review.

Patienten mit Migrationshintergrund in stationär-psychiatrischen Einrichtungen

The work group on psychiatry and migration of the Conference of Directors of Psychiatric Hospitals in Germany conducted a study on the use of inpatient psychiatric services by migrants in 12 psychiatric and psychotherapeutic hospitals and hospital departments. In contrast to previous studies the proportion of migrants in psychiatric hospitals (17.4%) equaled that of migrants in the general population. However there still was a high rate of diagnostic and treatment problems resulting from cultural differences and, to a lesser extent, from language problems. A high proportion of migrants suffered from delusional and schizophrenic disorders, while there were considerable differences in the distribution of diagnoses between different groups of migrants, e.g. those from Turkey and eastern Europe, respectively. Roughly half of all migrants studied had German citizenship. Among the migrants of Turkish background, a high proportion was born in Germany. The number of asylum seekers and refugees was disproportionately high.

[Patients of immigrant origin in outpatient psychiatric facilities: a comparison between Turkish, eastern European and German patients].

OBJECTIVE Nationwide representative survey of the use of psychiatric outpatient services in Germany. METHODS Every fifth patient of several psychiatric outpatient services was surveyed on one index day (27 (th) of May 2008) with respect to sociodemographic characteristics, ICD-10 diagnoses, difficulties in communication, treatment duration, and number of sickness certificates. RESULTS Patients with immigrant background comprised 32.5 % of all patients. Compared to German patients, patients with immigrant background received significantly more neurotic, stress-related and somatoform disorders (F4). Turkish patients received significantly more mood (affective) disorders diagnoses (F3), compared to German and Eastern Europe patients. Immigrants had shorter treatment duration and a higher number of sickness certificates. Eastern European patients had a significantly higher education, compared to patients with Turkish background. Patients with immigrant background were younger compared to German patients and had significantly more children. CONCLUSIONS The utilization of outpatient psychiatric services by patients with a migratory background is high. This suggests that immigrants benefit from the multiprofessional team and the low-treshold service offered by outpatient units.

EPA guidance on cultural competence training

The stress of migration as well as social factors and changes related to the receiving society may lead to the manifestation of psychiatric disorders in vulnerable individuals after migration. The diversity of cultures, ethnicities, races and reasons for migration poses a challenge for those seeking to understand how illness is experienced by immigrants whose backgrounds differ significantly from their clinicians. Cultural competence represents good clinical practice and can be defined as such that a clinician regards each patient in the context of the patients own culture as well as from the perspective of the clinicians cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. It points out that cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment. To reach these aims, both individual and organizational competence are needed, as well as teaching competence in terms of educational leadership. The WPA Guidance on Mental Health and Mental Health Care for Migrants and the EPA Guidance on Mental Health Care for Migrants list a series of recommendations for policy makers, service providers and clinicians; these are aimed at improving mental health care for immigrants. The authors of this paper would like to underline these recommendations and, focusing on cultural competency and training, believe that they will be of positive value.

Transkulturelle Aspekte der Depression

ZusammenfassungLange Zeit wurde angenommen, dass depressive Erkrankungen ein klassisch westliches, für die Industriestaaten spezifisches Problem seien. Jedoch zeigte eine Untersuchung der Weltbank bereits 1993, dass die Depression in Entwicklungsländern bereits an fünfter Stelle in der Liste der Erkrankungen stand, die den stärksten Teil zum Global Burden of Disease (GBD) beitragen. Affekt- und Verhaltensstörungen sowie somatische Beschwerden stellen die 3 zentralen Symptomkategorien der Depression dar. In westlichen Kulturen gilt die Störung des Affektes als Hauptmerkmal einer Depression, in anderen Kulturen können andere Symptome im Vordergrund stehen. Für eine optimale Behandlung ist es wichtig, dass die Behandelnden den kulturellen Hintergrund ihrer Patienten bei Diagnostik und Therapie beachten. Zu den Zielen der transkulturellen Psychiatrie und Psychotherapie zählt nicht nur die Entwicklung kulturadäquater Behandlungskonzepte und Einrichtungen, sondern auch die Erweiterung des Wissens über die Psychopathologie und Epidemiologie psychischer Erkrankungen in Migrantengruppen sowie die Untersuchung der Nutzung von Versorgungsmöglichkeiten durch diese.AbstractFor many decades it was assumed that depressive disorders are mainly a problem of Western societies. However, a World Bank report published in 1993 revealed that Major Depression is already the fifth leading contributor to the Global Burden of Disease (GBD) among women in developmentally disadvantaged countries. The core symptoms of depression are disorders of affect, conduct and somatic complaints. In Western societies, the key symptom of depression is regarded to be a disorder of affect. However, in other cultural settings, different symptoms may be more central for depression. Nowadays mental health specialists have regular contact with patients from different cultural backgrounds. In order to achieve optimal results in diagnosing and treating mental disorders, it is important to consider the cultural background of a patient and her or his explanatory model of the disease. Transcultural psychiatry and psychotherapy aims at developing culturesensitive concepts for treatment and mental health services and tries to increase insight in culture-related psychopathology and epidemiology.

Der Zusammenhang zwischen Migrationsstatus und depressiven Symptomen in der älteren Bevölkerung in Deutschland

OBJECTIVE To assess the association between migrant status and depressive symptoms among the older population in Germany. METHODS In a cross-sectional study with the German subsample of the Survey of Health, Ageing and Retirement in Europe (SHARE), a population-based sample of 2890 German residents aged 50 years or older (mean age 65 years, 55 % women), the association between migrant status (defined as being born outside of, and having immigrated to Germany) and depressive symptoms (≥ 4 points on the EURO-D scale) was examined by multiple logistic regression analysis. RESULTS A total of 539 respondents (19 %) were migrants. Prevalence of depressive symptoms was higher in migrants (28 %) than in non-migrants (19 %, p < 0.001). Migrant status remained associated with depressive symptoms (odds ratio 1.50, 95 % confidence interval 1.11-2.01) in logistic regression analysis adjusting for sociodemographic factors, indicators of physical health, and cognitive function. CONCLUSIONS The results suggest an association between migrant status and depressive symptoms in the older population in Germany that was independent of other predictors of late-life depression included in this analysis.

Socio-economic status and emotional distress of female Turkish immigrants and native German women living in Berlin

BACKGROUND Many immigrants face more economic strains and hardship than non-immigrants. Income inequality and an increasing social gap between immigrants and non-immigrants in Europe warrant further studies on the impact of socioeconomic factors on health in immigrant groups. The purpose of this study was to examine the association of socioeconomic status (SES) and emotional distress in women of Turkish descent and in women of German descent. METHODS AND SUBJECTS A total of 405 women of German or Turkish descent residing in Berlin were interviewed. Emotional distress was assessed by the General Health Questionnaire-28 (GHQ-28), and SES was examined by level of education, employment status, and income. The associations of emotional distress and SES were estimated in multivariate linear regression analyses. RESULTS Unemployment was associated with increased levels of emotional distress in all women, with the highest level of distress in the group of unemployed Turkish women. The overall SES level was related to a greater level of emotional distress in Turkish women, but not in German women (-3.2, 95%CI -5.9 - -.5; p=.020 vs. -.8, 95%CI -2.7 - 1.2; p=.431). Further stratified analyses by relationship status revealed that the association of SES and emotional distress only remained significant among single women. CONCLUSION The impact of socioeconomic hardship appears to be complicated by social roles and expectations related to these. Further in-depth study of the complex nature of the interaction of social roles and socioeconomic position in female Turkish immigrants in Germany is needed to better understand differing risk patterns for emotional distress.

Suicide attempt rates and intervention effects in women of Turkish origin in Berlin

PURPOSE Ethnic minority groups show elevated suicide attempt rates across Europe. Evidence suggests a similar trend for women of Turkish origin in Germany, yet data on suicidal behaviour in minorities in Germany is scarce. The objective was to examine rates of suicidal behaviour, underlying motives, and to explore the effectiveness of an intervention program. METHODS From 05/2009-09/2011, data on all suicide attempts among women of Turkish origin who presented at a hospital-based emergency unit in Berlin, Germany, were collected. A multi-modal intervention was conducted in 2010 and the effects of age, generation and the intervention on suicide attempt rates were examined. RESULTS At the start, the highest rate was found in women aged 18-24years with 225.4 (95% CI=208.8-242.0)/100,000. Adjustment disorder was the most prevalent diagnosis with 49.7% (n=79), being more common in second-generation women (P=.004). Further analyses suggested an effect of the intervention in the youngest age group (trend change of ß=-1.25; P=.017). CONCLUSION Our findings suggest a particularly high rate of suicide attempts by 18-24-year-old, second-generation women of Turkish origin in Berlin. Furthermore, our results suggest a trend change in suicide attempts in women aged 18-24years related to a population-based intervention program.

Mental health of Turkish women in Germany: resilience and risk factors

BACKGROUND The purpose of the present study was to examine the protective and risk factors of mental distress among Turkish women living in Germany. METHOD 105 Turkish immigrant women living in Berlin were investigated with measures of extraversion/neuroticism (NEO-FFI), general self-efficacy (GSE), social support (BSSS), social strain (F-SOZU) and mental distress (GHQ-28). Interrelations between psychosocial variables were assessed using simple Pearson correlations. RESULTS In all subjects, social strain (Pearsons r=.26(**), p=.008) and neuroticism (r=.34(**), p<.001) were positively associated with mental distress. In contrast, perceived self-efficacy (r=-.38(**), p<.001) and extraversion (r=-.36(**), p<.001) were negatively associated with mental distress. CONCLUSION Protective factors such as extraversion and self-efficacy seem to have a buffering effect on the process of migration. However, in addition to neuroticism, social strain seems to be positively associated with mental distress.

Cultural Factors in the Diagnosis and Treatment of Traumatised Migrant Patients from Turkey

The process of migration may be associated not only with great hope, but also with distressing experiences that can lead to trauma and posttraumatic stress disorders. Although some of the symptoms induced by trauma are common across cultures, the strategies used to deal with them are often culture-specific. In the following paper, we consider the unique aspects of trauma-focused psychotherapy in patients with a history of migration. We discuss a variety of culture-specific factors with the help of two case histories.