Psychosis Risk Linked to Age-at-Migration and Ethnicity

The intricate relationship between migration and the heightened risk of psychosis is well documented in the literature. A comprehensive meta-analysis conducted by Selten et al. (2020) indicates that migrants are approximately twice as likely to experience psychosis compared to non-migrants. Various blogs from Mental Elf have further elaborated on how individuals who migrate are not only more susceptible to developing psychosis but also face a higher likelihood of requiring inpatient care than their non-migrant peers (Chilman, 2021; Dengu, 2021; Fazel, 2016).

Several risk factors have been identified that elucidate this connection between migration and psychosis, including social class, childhood trauma, perceived psychosocial power, and ethnicity (Jongsma et al., 2020; Kirkbride et al., 2008; Termorshuizen et al., 2020). Interestingly, the age at migration appears to play a significant role, with younger individuals showing a higher propensity to develop psychosis later in life. However, existing studies have often been limited by their small sample sizes, which calls for more robust research in this area.

In order to build upon existing knowledge, Andleeb and colleagues initiated a comprehensive European case-control study. As someone who migrated during my adolescent years, I was particularly interested in exploring how the age of migration influences the risk of developing psychosis.

Comprehensive Study Methods to Assess Psychosis Risk

This investigation utilized a case-control study design involving participants drawn from the European Network of National Schizophrenia Networks Studying Gene-Environment Interaction (EU-GEI, 2008). The research encompassed data collected from five diverse countries: England, France, Italy, the Netherlands, and Spain between the years 2010 and 2015.

• Study Locations: 17 research sites across five countries
• Total Participants: 2,132 individuals, including 937 cases diagnosed with First Episode Psychosis and 1,195 control participants
• Age Range of Participants: 18 to 64 years
• Psychosis Diagnosis: Classified according to ICD-10 (WHO, 2004)
• Control Group: Random and quota sampling of white non-migrant participants to represent specific subgroup characteristics
• Independent Variable: Age-at-migration categorized into infancy, childhood, adolescence, and adulthood.

To ensure that the risk of developing psychosis was accurately linked to age-at-migration, researchers took into account multiple confounding factors, including ethno-racial identity, social class, parental history of mental health issues, and childhood trauma.

Advanced statistical analyses were applied, utilizing regression analysis to determine the impact of various variables on the rates of psychosis (Sarstedt & Mooi, 2018).

Key Findings on Migration and Psychosis

• Migration at any age was linked to an increased likelihood of experiencing first episode psychosis.
• Migration during adolescence significantly heightened the odds of developing psychosis, with a risk factor of 3.72 (2.08 to 6.64, unadjusted model).
• Adolescents hailing from Black and North African ethnic backgrounds faced the greatest risk.

Despite these findings, considerable uncertainty persists regarding the results. Many associations appeared diminished when adjusted for other confounding factors, and all showed wide confidence intervals.

Understanding the Adolescent Migration Experience and Psychosis Vulnerability

The authors concluded that migration during adolescence, a critical developmental phase for identity formation, may expose these individuals to unique stressors associated with the migration process. Young migrants may struggle more than younger children to adapt to new cultures, often facing language barriers (Sebastian-Galles & Santolin, 2020). Additionally, they are likely to have encountered various pre-migration risk factors due to spending more years in their country of origin (Arango et al., 2021). Furthermore, adolescents are at a stage where they begin to establish social networks, increasingly relying on friendships over family connections. This disruption in development can have detrimental effects on their social functioning (Verelst et al., 2022).

Evaluating the Strengths and Limitations of the Study

The strengths of this study lie in its extensive data collection, which enhances its applicability across different regions of Europe. The confounding variables were gathered through insights from individuals with lived migration experiences, and the data underwent stringent adjustments. Although 28.5% of participants had at least one variable missing, established statistical methods were employed for imputation. However, the process of imputing substantial amounts of missing data could diminish the reliability of the findings.

On the flip side, one limitation of the study pertains to its participant count. While the authors assert that the sample size was considerable, the multitude of confounding variables they controlled for may have led to issues with statistical power (Blackford, 2006). Specifically, the number of participants from certain ethno-racial identities, such as North African, was small, resulting in uncertainty regarding the psychosis risk strength. Furthermore, the findings cannot necessarily be applied to migrants in non-European nations or any refugee populations due to differences in stressors faced. Although childhood trauma was considered a pre-migration risk factor, it was difficult to ascertain whether it occurred before or after migration, which may have resulted in inappropriate data adjustments.

Additionally, notable differences existed between the case and control groups regarding key confounding variables such as age, sex, race, and ethnicity, complicating comparisons between the two groups.

Practical Implications for Healthcare and Future Research

The authors highlighted the significance of understanding that being an adolescent during migration could lead to an increased risk of psychosis, particularly for individuals from minority ethnic groups. As someone who navigated migration during my teenage years, I resonate with these findings. The experience of packing one’s belongings and relocating to a new country, leaving cherished friends and memories behind, evokes a mix of confusion and hope as parents promise a new, promising future. Yet, upon arrival, the anticipated utopia often proves to be elusive. Instead, families confront poverty, educational setbacks, and bullying in a language that remains unfamiliar (based on my own experience). This underscores the urgent need for further research aimed at mitigating mental health issues among migrants and fostering improved mental well-being.

The findings of this study serve as crucial information for healthcare professionals, enabling them to develop targeted interventions for adolescent migrants, especially those belonging to ethnic minorities. However, this specific demographic often faces significant barriers to accessing psychosis-related services (Schlief et al., 2023). The challenges encountered when integrating into a new country—including securing financial stability, gaining access to education, building community connections, and ensuring the presence of anti-discriminatory policies—are highly relevant for adolescent migrants. Additional research is essential to understand the outcomes experienced by young migrants and the efficacy of various interventions.

A myriad of factors contribute to the resilience of young individuals facing stressors. While models exist to predict stress reactions, adolescent migrants may be particularly vulnerable due to the adversities they endure, such as socioeconomic deprivation, childhood trauma, and discrimination, alongside a lack of protective factors like extended family and community support (Del Giudice et al., 2011).

Issues surrounding the validity of psychosis diagnoses have been raised. A review by Castagnini and Fusar-Poli (2017) indicated that the absence of neurobiological evidence and low predictability undermine the diagnostic validity. Cultural differences must also be taken into account when diagnosing psychosis. For instance, what may be perceived as delusions—an essential symptom of psychosis—could be interpreted differently across cultures. This discrepancy may pose significant challenges for migrants adapting to a new cultural environment (Ghanem et al., 2023).

I must emphasize that this paper may underestimate the impact of overdiagnosis and systemic racism on these findings, even though the authors hint at it. In the study, the only adolescents exhibiting a statistically significant increased risk of psychosis were those from Black and North African backgrounds when ethno-racial identity was included as a confounding factor. Therefore, it is crucial for future research to explore the elevated risk of psychosis through the lens of structural discrimination (Misra et al., 2022).

Insights from University of Glasgow MSc Students

This blog was crafted by a student from the University of Glasgow.

We periodically feature blogs authored by individual students or student groups from universities that are affiliated with the National Elf Service. If you would like to learn more about how this collaboration can benefit your university, please reach out to us.

Key References and Further Reading

Primary Research Article

Andleeb, H., Moltrecht, B., Gayer-Anderson, C., Arango, C., Arrojo, M., D’Andrea, G., Bernardo, M., Del-Ben, C. M., De Haan, L., Ferraro, L., La Barbera, D., La Cascia, E., Llorca, P., Menezes, P. R., Quattrone, D., Sanjuán, J., Selten, J., Szöke, A., Tarricone, I., . . . Kirkbride, J. B. (2024). Age-at-migration, ethnicity and psychosis risk: Findings from the EU-GEI case-control study. PLOS Mental Health, 1(5), e0000134. https://doi.org/10.1371/journal.pmen.0000134

Additional References

Arango, C., Dragioti, E., Solmi, M., Cortese, S., Domschke, K., Murray, R. M., Jones, P. B., Uher, R., Carvalho, A. F., Reichenberg, A., Shin, J. I., Andreassen, O. A., Correll, C. U., & Fusar‐Poli, P. (2021). Risk and protective factors for mental disorders beyond genetics: an evidence‐based atlas. World Psychiatry, 20(3), 417–436. https://doi.org/10.1002/wps.20894

Blackford, J. U. (2006). Statistical issues in developmental epidemiology and developmental disabilities research: confounding variables, small sample size, and numerous outcome variables. In International review of research in mental retardation (pp. 93–120). https://doi.org/10.1016/s0074–7750(06)33005–4

Castagnini, A., & Fusar-Poli, P. (2017). Diagnostic validity of ICD-10 acute and transient psychotic disorders and DSM-5 brief psychotic disorder. European Psychiatry, 45, 104–113. https://doi.org/10.1016/j.eurpsy.2017.05.028

Chilman, N. (2021, October 18). Migrants with psychosis are more likely to receive inpatient care. National Elf Service. https://www.nationalelfservice.net/mental–health/psychosis/migrants–psychosis–inpatient–care/

Del Giudice, M., Ellis, B. J., & Shirtcliff, E. A. (2011). The Adaptive Calibration Model of stress responsivity. Neuroscience & Biobehavioral Reviews, 35(7), 1562–1592. https://doi.org/10.1016/j.neubiorev.2010.11.007

Dengu, Z. (2021, March 19). Migration and the risk of compulsory psychiatric admission for psychosis. National Elf Service. https://www.nationalelfservice.net/mental–health/psychosis/migrants–compulsory–admissionpsychosis/

EU-GI. (2008). Schizophrenia aetiology: Do gene-environment interactions hold the key? Schizophrenia Research, 102(1–3), 21–26. https://doi.org/10.1016/j.schres.2008.04.003

Fazel, M. (2016, March 16). Increased vulnerability of migrants. National Elf Service. https://www.nationalelfservice.net/mental–health/psychosis/increased–vulnerability–of–migrants–non–affectivepsychosis–in–sweden/

Ghanem, M., Evangeli‐Dawson, C., & Georgiades, A. (2023). The role of culture on the phenomenology of hallucinations and delusions, explanatory models, and help‐seeking attitudes: A narrative review. Early Intervention in Psychiatry, 17(9), 843–863. https://doi.org/10.1111/eip.13449

Jongsma, H. E., Gayer-Anderson, C., Tarricone, I., Velthorst, E., Van Der Ven, E., Quattrone, D., Di Forti, M., Menezes, P. R., Del-Ben, C. M., Arango, C., Lasalvia, A., Berardi, D., La Cascia, C., Bobes, J., Bernardo, M., Sanjuán, J., Santos, J. L., Arrojo, M., De Haan, L., . . . Kirkbride, J. B. (2020). Social disadvantage, linguistic distance, ethnic minority status and first-episode psychosis: results from the EU-GEI case–control study. Psychological Medicine, 51(9), 1536–1548. https://doi.org/10.1017/s003329172000029x

Kirkbride, J. B., Barker, D., Cowden, F., Stamps, R., Yang, M., Jones, P. B., & Coid, J. W. (2008). Psychoses, ethnicity and socio-economic status. The British Journal of Psychiatry, 193(1), 18–24. https://doi.org/10.1192/bjp.bp.107.041566

Marsman, A., Van Den Heuvel, M. P., Klomp, D. W. J., Kahn, R. S., Luijten, P. R., & Pol, H. E. H. (2011). Glutamate in Schizophrenia: A Focused Review and Meta-Analysis of 1H-MRS Studies. Schizophrenia Bulletin, 39(1), 120–129. https://doi.org/10.1093/schbul/sbr069

Misra, S., Etkins, O. S., Yang, L. H., & Williams, D. R. (2022). Structural racism and inequities in incidence, course of illness, and treatment of psychotic disorders among Black Americans. American Journal of Public Health, 112(4), 624–632. https://doi.org/10.2105/ajph.2021.306631

Sarstedt, M., & Mooi, E. (2018). Regression analysis. In Springer texts in business and economics (pp. 209–256). https://doi.org/10.1007/978–3–662–56707–4_7

Schlief, M., Rich, N., Rains, L. S., Baldwin, H., Rojas-Garcia, A., Nyikavaranda, P., Persaud, K., Dare, C., French, P., Lloyd-Evans, B., Crawford, M., Smith, J., Kirkbride, J. B., & Johnson, S. (2023). Ethnic differences in receipt of psychological interventions in Early Intervention in Psychosis services in England – a cross-sectional study. Psychiatry Research, 330, 115529. https://doi.org/10.1016/j.psychres.2023.115529

Sebastian-Galles, N., & Santolin, C. (2020). Bilingual acquisition: the early steps. Annual Review of Developmental Psychology, 2(1), 47–68. https://doi.org/10.1146/annurev-devpsych-013119-023724

Selten, J., Van Der Ven, E., & Termorshuizen, F. (2020). Migration and psychosis: a meta-analysis of incidence studies. Psychological Medicine, 50(2), 303–313. https://doi.org/10.1017/s0033291719000035

Termorshuizen, F., Van Der Ven, E., Tarricone, I., Jongsma, H. E., Gayer-Anderson, C., Lasalvia, A., Tosato, S., Quattrone, D., La Cascia, C., Szöke, A., Berardi, D., Llorca, P., De Haan, L., Velthorst, E., Bernardo, M., Sanjuán, J., Arrojo, M., Murray, R. M., Rutten, B. P., . . . Selten, J. (2020). The incidence of psychotic disorders among migrants and minority ethnic groups in Europe: findings from the multinational EU-GEI study. Psychological Medicine, 52(7), 1376–1385. https://doi.org/10.1017/s0033291720003219

Verelst, A., Spaas, C., Pfeiffer, E., Devlieger, I., Kankaapää, R., Peltonen, K., Vänskä, M., Soye, E., Watters, C., Osman, F., Durbeej, N., Sarkadi, A., Andersen, A., Primdahl, N. L., & Derluyn, I. (2022). Social determinants of the mental health of young migrants. European Journal of Health Psychology, 29(1), 61–73. https://doi.org/10.1027/2512-8442/a000097

World Health Organization. (2004). ICD-10: International Statistical Classification of Diseases and Related Health Problems: Tenth revision. https://iris.who.int/handle/10665/42980

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