Immigrant and refugee mental health during the COVID-19 pandemic: Additional key considerations
COVID-19 and mental health
The COVID-19 pandemic presents unprecedented challenges and stressors on populations around the world. Recent history shows increased rates of PTSD, and psychological distress associated with the SARS epidemic1. By all accounts, the current COVID-19 pandemic has similar and worse preliminary reports1. Disasters are often accompanied by increases in depression, substance use disorder, posttraumatic stress disorder (PTSD), among others, plus problems of child abuse and domestic violence in the general population2. However, it is important to note that such disasters invariably disproportionally affect vulnerable populations, including the poor and patients with serious mental illness3, and the at-risk immigrant and refugee populations.
Mental Health in the Immigrant and Refugee Population
Regardless of the COVID-19 pandemic, immigrants and refugees are, despite experiencing comparable levels of distress, less likely to seek out or be referred to mental health services compared to the general population2. It is hypothesized that this lower rate of mental health services utilization reflects cultural and linguistic barriers, and it is additionally compounded by heightened stigma2. In the current pandemic, it has been already reported that low-income immigrant patients are affected in unique and troubling ways4. For example, high levels of chronic diseases, chronic stress and lower access to preventative health services have increased the risk of immigrants developing more severe infections of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)4. Furthermore, the lack of available translated information about COVID-19, and difficulties navigating the healthcare system leaves immigrants and refugees with limited English proficiency to the vast social media to obtain information and advice that may be inaccurate, stress inducing, and even mythical4. Such difficulties are worsened for patients with mental health problems as many simply do not have access to care, or the outpatient practices are shut down during the pandemic, and virtual care presents a high barrier. While there is no clear literature on how to support immigrants and refugees with mental health issues during the current pandemic, we discuss below some considerations that may help family physicians and other clinicians address the unique needs and challenges that this vulnerable population may face.
Key Considerations
1. Inquire About the Newcomer’s Migration History and Home Country Situations
During this difficult time, a clinician may be tempted to assume that a patient’s current anxieties and stressors may be solely related to COVID-19. However, it is highly important to inquire about the newcomer’s migration history to identify any pre-migration or post-migration stressors that may be contributing to underlying anxiety or mood changes. Pre-migration factors include war, violence, losses due to health and infections, and starvation5. Post-migration stressors may include discrimination, poor housing and language difficulties. Furthermore, concerns about COVID-19 infections in their homelands, often under-resourced, and how it may be affecting their families can be a common stressor.
2. A New Uncertainty Worsening Other Uncertainties
Immigrants and refugees’ post-migration stressors such as uncertainty about immigration or refugee status, health insurance coverage, unemployment, social status and mobility changes, unfamiliarity with hospital admission criteria can all impact mental health2. These uncertainties are very likely worsened by the current uncertainty associated with the COVID-19 pandemic. In general, immigrants and refugees will experience stress and anxiety related to many governmental services slowing or shutting down and transitioning to online services more than the average person. We suggest the importance of asking about these uncertainties, listening empathetically to their concerns, working closely with social workers, and reminding our patients that this is temporary.
3. Watch for the Consequences of Physical Distancing
Physical distancing is one of the critical measures employed to limit the spread of this disease. However, physical distancing can have observable consequences on mental health and well-being in both the short and long term3. Many of these consequences can be attributed to loneliness and its sequalae3. Many immigrants and refugees tend to have poor social support to start with, and therefore, physical distancing may significantly worsen their mental health. Loss of family and community social supports and lack of new social network are commonly known post-migration stressors that affect their mental health2. Therefore, extra efforts should be made by health care providers and community outreach to connect with this marginalized and isolated population3. Health care providers should screen for loneliness and explore for creative alternative approaches in this population to determine the social support that can be provided1.
4. Increased Risk of Domestic Violence
COVID-19 can exacerbate tension between family members and increase risk of domestic violence. High density, close quartered living conditions, debilitating poverty and high expressed emotions communications could be risk factors more commonly found in this population. The risk of family and intimate partner violence is associated with these conditions and is likely to increase due to increased time and contact at home6. Health care providers should be aware of the risk and inquire about needs and concerns. Support can be provided virtually through purposive inquiry, active and empathic listening, and creating a safety plan6.
5. Barriers to Virtual Care
Due to technological and non-technological barriers to virtual care, immigrants and refugees may be unable to benefit from the current virtual care delivered. These barriers include access to digital resources, access to internet, level of education, computer literacy, language barriers and confidentiality concerns7. Telephone call check-ins, collaborated with cultural interpreters or translators, may be a more feasible intervention to support immigrants and refugees.
Conclusion
There are unique and noteworthy considerations when working with immigrants and refugees during this destabilizing pandemic. Research and expert experience show that there are potentially useful additional strategies to mitigate the problems faced by this vulnerable population.
Mr. Weam Sieffien is a third year medical student at the University of Toronto, Faculty of Medicine.
Dr. Samuel Law is a Psychiatrist and Clinical Director, Mount Sinai Hospital Assertive Community Treatment team; Associate Professor, Department of Psychiatry, University of Toronto
Dr. Lisa Andermann is a Psychiatrist, Mount Sinai Hospital; Co-Chair, Equity and Inclusion Council and Associate Professor, Department of Psychiatry, University of Toronto
References
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2. Kirmayer LJ, Narasiah L, Munoz M, et al. Common mental health problems in immigrants and refugees: general approach in primary care. Cmaj. 2011. 183(12), pp.E959-E967.
3. Druss BG. Addressing the COVID-19 pandemic in populations with serious mental illness [published online April 3, 2020]. JAMA psychiatry. doi:10.1001/jamapsychiatry.2020.0894
4. Ross J, Diaz CM, Starrels J.L. The Disproportionate Burden of COVID-19 for Immigrants in the Bronx, New York [published online May 8,2020]. JAMA Internal Medicine. doi:10.1001/jamainternmed.2020.2131
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6. World Health Organization. COVID-19 and violence against women: what the health sector/system can do. https://apps.who.int/iris/bitstream/handle/10665/331699/WHO-SRH-20.04-eng.pdf?sequence=1&isAllowed=y. Accessed June 3, 2020.
7. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of telemedicine and telecare. 2018 Jan;24(1):4-12.