Abstract
Background and aim:
Lack of cultural adaptation may risk or worsen mental illness among immigrants, and interfere with assessment and treatment. Language proficiency (LP) seems essential for access to foreign environments, and the limited research concerning its effects on mental health care encouraged this preliminary study.
Methods:
We reviewed clinical records of all immigrant psychiatric patients hospitalized at the University of Foggia in 2004–09 (N = 85), and compared characteristics of patients with adequate versus inadequate LP.
Results:
Subjects (44 men, 41 women; aged 35.7±10.0 years) represented 3.62±0.94% of all hospitalizations in six years. (2004–09). Most (60.0%) had emigrated from other European countries. Many were diagnosed with a DSM-IV unspecified psychosis (40.0%) or adjustment disorder (18.8%), and 45.9% were in first-lifetime episodes. Average comprehension and spoken LP was considered adequate in 62.4% and inadequate in 37.6%. In multivariate modelling, adequate LP was more prevalent among women, emigration from another European country, receiving more psychotropic drugs at hospitalization, and having entered Italy legally.
Conclusion:
Findings support an expected importance of LP among immigrant psychiatric inpatients, and encourage language assessment and training as part of the comprehensive support of such patients, especially men.
Background
The number of migrants in the world has been increasing in recent decades, more than doubling in Europe since the 1990s, and was approximately 56 million persons in 2002 (UN, 2002). Moreover, European countries host more undocumented immigrants than neighbouring, less developed countries, probably owing to the availability of relatively favourable, publicly supported social and medical services, although most asylum seekers and undocumented immigrants fall outside the existing health and social services (Carta, Bernal, Hardoy & Haro, 2005; Lindert, Schouler-Ocak, Heinz & Priebe, 2008).
Immigrants face many challenges, including changes in language, diet, social relations, cultural status, religion, and climate (Carta et al., 2005). Their experience includes reactions to losses and changes that parallel the grief process (Lube Puerto, 2002). A proposed model for migration, based closely on grief and loss, has proposed seven relevant factors: (1) family and friends; (2) language; (3) culture; (4) homeland; (5) change (typically loss) of status; (6) loss of contact with a familiar ethnic group; and (7) exposure to physical risks (Achotegui, 2002). In addition, difficulties in coping with losses may lead to psychological and substance-abuse problems, as well as an increased risk of suicide, especially when immigration occurs abruptly and under adverse conditions (Bhugra & Gupta, 2011; Cartaet al., 2005). In addition to adverse conditions or reasons for migration, impacts at the level of family and the social community may also produce a collective trauma (Bhugra & Gupta, 2011). Overall, the concept of acculturative stress has been employed to describe mental health problems experienced by migrants to a new culture (Oberg, 1960). Although migration is often associated with losses and stress, elements of post-traumatic psychological growth are also likely to be important in the process of adapting to a new culture (Bhugra & Gupta, 2011; Teodorescu et al., 2012).
It is unwise to consider immigrants as a uniform group with respect to risk of mental illness, and particular cultural changes involved seem relevant to the adaptation process (Carta, Coppo, Reda, Hardoy & Carpiniello, 2001; Murphy, 1977). Many studies concerning mental health among ethnic minorities have used an acculturative stress theory as an explanatory model (Berry, 1976, 1990). However, this plausible theory remains poorly empirically verified (Koch et al., 2004). Since mental health treatment relies heavily on verbal communication, language skills are particularly important, especially as the clinicians, patients and interpreters involved may hold different explanatory views of problems that are presented by immigrant patients, and non-clinician interpreters are frequently viewed as having limited value in mental health settings (Bhugra & Gupta, 2011; Sentell, Shumway & Snowden, 2007). In general, lack of language fluency has been associated with low satisfaction with medical services and poor adherence to recommended treatments (Bhugra & Gupta, 2011). Limitations and benefits of working with an interpreter in mental health settings need to be considered and balanced (BPS, 2013). An important consideration is that even an accurate interpretation of words between languages may not capture the rich and subtle complexities of coded emotions and meanings, and can lead to miscommunication, ineffective advice, and less successful adaptation than might otherwise be possible (Bhugra & Gupta, 2011; Kim et al., 2011).
The substantial remaining uncertainties concerning the impact of particular characteristics of immigant patients encouraged the present study. We report on preliminary assessments of the relationships of language proficiency (LP) to demographic and clinical factors in immigrant psychiatric patients admitted to an inpatient university psychiatric service in Italy who are considered to have adequate versus inadequate proficiency in the Italian language.
Methods
We reviewed medical and pharmacy records of all 85 immigrant psychiatric patients hospitalized at the University of Foggia Medical Centre in 2004 (n = 19), 2005 (n = 8), 2006 (n = 14), 2007 (n = 16), 2008 (n = 9) and 2009 (n = 19), and tested associations of demographic and clinical factors between those considered to have adequate versus inadequate proficiency in the Italian language.
LP was considered inadequate when index clinical examinations had been conducted in a language other than Italian, when a patient needed translation for the majority of verbal interactions, or when they required the service of an interpreter.
We recorded age, sex, social and demographic information, DSM-IV-TR consensus, discharge diagnoses, as well as clinical presentation at hospitalization, including suicide attempts within 90 days, and days in hospital. We also gathered data on the presence of co-morbid clinical conditions, treatments given (and doses), as well as adverse events associated with prescribed treatments. In addition, functional (Global Assessment of Functioning [GAF]), clinical (Clinical Global Impression [CGI]) and psychopathological (Brief Psychiatric Rating Scale [BPRS]) ratings were extracted from medical records and scored by investigator consensus, with estimated percentage change in these ratings between hospital admission and discharge.
To facilitate comparisons, antipsychotic doses (total mg/day) were converted to chlorpromazine equivalents (CPZ-eq mg/day); Baldessarini 2013; Gardner, Murphy & Baldessarini 2010), and mood-stabilizer doses to approximate lithium carbonate equivalents (Li-eq mg/day; Baldessarini, 2013; Centorrino et al., 2006). We also computed initial, maximum and discharge total daily drug doses during hospitalization.
Statistical analyses employed commercial microcomputer programs (Statview, SAS Corp., Cary, NC; Stata, Stata Corp., College Station, TX). Data are presented as means ± standard deviations (SD) or percentages (%), unless stated otherwise. Continuous data were compared by analysis of variance (ANOVA) methods (F), and categorical data by contingency tables (χ2). Multivariate logistic regression modelling of association of selected factors to LP status (yielding odds ratios (OR) and their 95% confidence intervals (CIs)), by stepwise inclusion of factors in order of their strength (p value) of preliminary, bivariate association with LP status was carried out. Findings were considered statistically significant with two-tailed p ≤ .05.
Results
Subjects (44 men, 41 women; aged 35.7±10.0 years) were immigrant psychiatric patients hospitalized at the study site for an average of 10.0±6.79 days; they represented 3.62±0.94% of all admissions over the six years considered (2004–09), without significant differences in rates by year. Patients had emigrated from: other European countries (60.0%) > Africa (22.3%) > Latin America (9.42%) > Asia (8.23%); 69.4% (n = 59/85) had entered Italy illegally and were undocumented, but information regarding status as an ‘asylum seeker’ was available for only for 8/85 patients. DSM-IV diagnoses ranked: unspecified (NOS) psychoses (40%) > adjustment (18.8%) > substance use (14.1%) > mood (9.41%) > anxiety (7.05%) > somatoform (5.94%) > personality disorder (4.70%); 45.9% represented first-lifetime episodes. Average Italian-LP (comprehension and spoken) was rated good or moderate in 62.4% of patients, and low or inadequate (needing an interpreter) in 37.6%.
Initial bivariate comparisons identified factors preliminarily associated with LP status (Table 1). Factors significantly associated (p ≤ .05) with inadequate LP were: (1) sex (men > women); (2) having entered Italy illegally (being undocumented); (3) fewer psychotropic drugs/person prescribed at hospitalization; (4) younger age; (5) first-lifetime episode; (6) unemployed; and (7) non-EU country of origin.
Bivariate comparison of factors in 85 hospitalized immigrant patients with adequate or inadequate Italian language proficiency.
Factors not significantly associated with LP included: socio-demographic factors (marital status, education, religion); DSM-IV-TR diagnoses, co-morbid psychiatric or medical conditions including substance abuse; admission or change in clinical ratings (BPRS, CGI, GAF) during hospitalization; days in hospital; involuntary hospital commitment, CPZ-eq or Li-eq daily drug doses and adverse effects; length of hospitalization (not shown).
Of the factors preliminarily associated with inadequate LP, those significantly and independently remaining associated in subsequent logistic multivariate modeling were (in descending order of statistical significance): (1) men > women; (2) non-EU country of origin; (3) fewer psychotropic drugs at hospitalization; and (4) having entered Italy illegally (Table 2).
Multivariate logistic regression model of factors associated with proficiency in Italian by 85 hospitalized immigrant psychiatric patients.
Factors are in descending order of significance of independent contribution to greater LP.
Discussion
Language deficits probably limit cultural and social adaptation among immigrants and may also contribute to risk for, or manifestations of, psychiatric disorders (Berry, 1976, 1990; Carta et al., 2005; Kim et al., 2010). LP is especially important for mental health care based greatly on interpersonal verbal communication, and access to health services is significantly associated with language skills (Kim et al., 2010; Sentell et al., 2007). Nevertheless, immigrants with psychiatric disorders remain remarkably little-studied for relationships of LP to their illnesses or access and responses to treatment.
Our preliminary bivariate analyses suggest that men had lower LP in Italian than women, perhaps reflecting gender differences in acquisition rates for new languages (Wallentin, 2009). Inadequate LP also was associated with being an undocumented immigrant or having entered Italy illegally. This association is not surprising, since illegal immigration is frequently associated with socially disadvantaged conditions and limited access to foreign cultural environments (Carta et al., 2005). Patients with poor or inadequate LP were also more likely to be unemployed and to have come from a non-EU country, possibly in part reflecting lack of benefits of efforts at social, cultural and economic exchanges between EU countries (Carta et al., 2005). The only clinical factors associated with poorer LP were greater incidence of first-episode disorders, and prescription of fewer psychotropic drugs at hospitalization. Lack of LP can lead to higher distress levels and poorer cultural adaptation among immigrant patients, and these factors may contribute to risk of first-episode psychiatric disorders severe enough to require hospitalization, in particular (Carta et al., 2001; Carta et al., 2005). In addition, given that mental health treatment relies greatly on verbal communication, LP may be especially important in psychiatric care settings, and patients with poorer language skills are probably under-diagnosed or at least less accurately diagnosed. This conclusion is suggested by the high observed prevalence of unspecified (NOS), adjustment disorder and anxiety disorder diagnoses in the present cohort. Consequently, the accuracy and precision of treatment of such patients may also be limited (Sentell et al., 2007). In this regard, the greater number of psychotropic drugs received at hospitalization by patients with good LP suggests that better communication skills increased access to treatment.
Limitations
Limitations of this study include moderate numbers of subjects, sampling from one institution, as well as lack of comparisons of hospitalized and ambulatory patients – all of which may limit generalization. Nevertheless, it is our clinical impression that most immigrant patients do not seek treatment in outpatient clinics, but instead are treated at hospitals when acutely ill. In addition, reliable data about total time in Italy and of exposure to the Italian language were not available in most cases, nor were detailed reasons for immigration, perhaps reflecting the high proportion (69.4%) of undocumented immigrants, with a lack of medical information and availability of family members.
Conclusion
In conclusion, the present preliminary findings support the expected importance of LP among immigrant psychiatric inpatients, with poorer proficiency among men, those from non-EU countries, illegal immigrants, the unemployed, and those with a first-episode illness. The findings encourage additional studies and consideration of language assessment and training as part of the comprehensive support of psychiatric patients, and especially men.
Footnotes
Declaration of conflicting interests
Drs Ventriglio, Baldessarini, Iuso, La Torre, D’Onghia, La Salandra and Mazza have no potential conflicts of interest based on financial relationships with commercial organizations. Dr Bellomo has recently served as a consultant to Bristol-Myers Squibb, and has been a speakers’ bureau member with AstraZeneca, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen-Cilag and Lundbeck corporations. No author or any immediate family member holds equity positions in biomedical or pharmaceutical corporations.
Funding
This study was supported, in part, by a grant from the Bruce J. Anderson Foundation and by the McLean Private Donors Psychiatric Research Fund (Dr Baldessarini).