Pitfalls of studying immigrant people

There are considerable difficulties in studying immigrant and ethnic populations. In addition to personal factors intrinsic to being a new immigrant (Box 1), we should consider the effect of the new country of residence on immigrants. There is little explicit consideration of the changes that occur when immigrants live in a new culture. It is often assumed that they remain unaffected by the experience. In fact, immigrants interact and adapt to their new environment, undergoing a degree of acculturation and sometimes assimilation. Furthermore, the meaning of the move, the welcome (or lack of it) on arrival and the age and stage of life at which people move make for different experiences, even when people originate from the same culture. Much of the research into the effect of immigration focuses on increased vulnerability rather than on the resilience and protection that may be afforded by, for example, close social groups.

Defining race and ethnicity

The definition of race and ethnicity (Box 2) as research variables is contentious. An ‘ethnic group’ may share geographical origins, culture, religious traditions and language. ‘Culture’ is the network of shared ideas, meaning and rules, a lens through which a person perceives and understands the world (Reference HelmanHelman, 2000: p. 2). ‘Ethnicity’ therefore refers to a self-described identity. As people see themselves in different ways at different times, it is not a fixed concept. When immigrants’ children are subjects of research, the study of ethnicity becomes more difficult, as classification becomes even less clear. People from ethnic minorities are also increasingly likely to marry people from the indigenous population or those from a different ethnic minority. Ethnicity can also refer to imposed categories such as those in the 1991 UK census, which has been used for much of the UK research but did not allow a mixed ethnicity category. Many people found it difficult to classify themselves. ‘Race’ is a term implying genetic homogeneity, and racial distinctions are generally based on physical appearance – largely skin colour. It gives little information about immigrant status or ethnic group.

As immigrant groups establish themselves, they may wish to continue a lifestyle based on cultural or religious traditions from their country of origin and hope to pass this on to the next generation. Tensions may arise if children do not want to adopt the way of life preferred by their parents. This can become particularly apparent at important times in the life cycle, such as marriage and childbirth, which are traditionally times when families come together. There may also be problems as older immigrants become more frail and dependent.

Assessing dementia (Box 3)

Cross-cultural assessment of dementia in older people has specific pitfalls related to language and literacy skills. In particular, the use of culturally biased screening instruments that rely on language recognition and familiarity with test situations may be inappropriate or misleading for people with cognitive impairment (Reference LindesayLindesay, 1998). Culturally appropriate norms are also important in the evaluation of dementia. Immigrants may be literate in a different language or functionally illiterate. Recent immigrants from rural areas may have had little need for the concept of complex maps and exact dates. As a result, interpreting cognitive testing without a knowledge of education and background is likely to lead to errors in diagnosis. It may be important, therefore, to validate and modify instruments for examining cognitive function in different ethnic groups. One report of validation of the Mini-Mental State Examination (MMSE) in South Asians in the UK found that cut-offs varied when judged against a diagnostic instrument for the detection of dementia (Rait et al, 2000). A new normative test battery for cognitive function in African–Caribbean elders in the UK shows that, compared with normative data for the African American population, scores on verbal fluency were lower but scores on memory tests were comparable (Reference Stewart, Richards and BrayneStewart et al, 2001b ).

Despite these caveats, a 1-year follow-up of a multi-cultural community sample of people with a diagnosis of dementia found that stability of diagnosis did not vary according to ethnic background (Reference Schofield, Tang and MarderSchofield et al, 1995). Similarly, a small study of Gujarati people diagnosed with dementia found that the diagnosis was stable at follow-up (Reference Shah, Lindesay and JaggerShah et al, 1998).

Assessing depression

Depression may present with different patterns of symptoms in different cultures. People of some cultures commonly present with predominant symptoms of sadness and low mood during depression, whereas others present with pain and somatic symptoms. The language of distress used, for example, by African Americans differs from that on which structured diagnoses are made and may lead to an underestimate of distress and anxiety levels. When screening for depression in older people, lower cut-points have been found to be appropriate for older Black people living in the UK (Reference Abas, Phillips and CarterAbas et al, 1998).

Current research evidence

Much of our current knowledge of mental illness in immigrant elders relies on research carried out in the USA, where the experience of immigration may differ from that in the UK. The USA sees itself as a melting pot and it is proud of the idea that economic migrants come to strive for, and find, success. In contrast, the term ‘economic migrant’ is used in Britain as a term of abuse, with implications in parts of the media that people are coming here to live off the state. Conversely, African Americans are descendants of an extremely oppressed population, subject to overt racism. The studies from the USA are therefore of a population that is different from that in the UK, and comparable studies between the two countries may have different results.

Dementia in older immigrants

Depression (Box 4)

In most studies in the USA, Black and White elders show no difference in rates of depression (e.g. Reference Blazer, Hays and SaliveBlazer et al, 1996). In the UK, rates of depression and anxiety have been found to be the same (e.g. Reference Lindesay, Jagger and HibbettLindesay et al, 1997) or slightly higher in Black African elders (Reference McCracken, Boneham and CopelandMcCracken et al, 1997). The latter study found that Black Africans with depression were less likely to see relatives, and the authors considered that this was significantly associated with depression. In east London, older people of Bengali and Somalian ethnicity were found to have a surprisingly high but varying prevalence of depression (77% and 25%, respectively) when compared with two different control populations of White people (5% and 25%) (Reference Silveira and EbrahimSilveira & Ebrahim, 1998a Silveira & Ebrahim, 1998b). However, the populations were sampled in very different ways: the Somali population was from a lunch club, the Whites from an age–gender register. The same study found that Gujaratis had a lower prevalence of depression (2%). When adjusted for age, income, physical health and social problems, ethnicity was no longer a significant risk factor for high depression scores.

Another study of older people of South Asian origin estimated a 20% prevalence of depression (Reference Bhatnagar and FrankBhatnagar & Frank, 1997). A study in north London showed that the mental health of Hindu grandmothers was associated with family structure, with those coming from nuclear rather than extended families being more susceptible to depression (Reference Guglani, Coleman and Sonuga-BarkeGuglani et al, 2000).

For African–Caribbean elders, in particular, rates based on community screening using instruments with cut-offs validated on predominantly White populations have been found to be underestimates (Reference Abas, Phillips and CarterAbas et al, 1998). The Irish population in general, although not older people in particular, has been shown to have poorer mental and physical health than other ethnic minority groups. They have the highest rates of hospital admissions for mental illness and high rates of suicide and attempted suicide (Reference Merril and OwensMerril & Owens, 1988).

Our own recent study found an excess of depression in Cypriots but not in other groups, including African–Caribbean and Irish groups. This excess occurred despite the fact that they were less likely to live alone and were no more likely to be physically ill. They did, however, have increased subjective ill health and were much less likely to speak English or have had a secondary education and so were possibly less able to access help when required (Reference Livingston, Leavey and KitchenLivingston et al, 2002). Cypriots with depression were likely to present to many services but not to complain of psychological symptoms. They often presented with prominent somatic symptoms. This is likely to be due to a different idiom of distress. Similar patterns of presentation were found in a study of immigrants to Israel from the former Soviet Union, with somatisation being more common in those who were older, currently single and female.

The vascular hypothesis of depression suggests that new depression in older age groups may be caused by cerebrovascular pathology (Reference Hickie and ScottHickie & Scott, 1998) and therefore could be increased in the African–Caribbean population in the West. Older African–Caribbean people living in the West might therefore represent a population particularly at risk of depression from vascular causes and stroke. One recent study of older African–Caribbean people living in south London found an expected association of stroke and depression but no association with vascular risk factors in those who had not had a stroke (Reference Stewart, Prince and MannStewart et al, 2001a ). The conclusion was that it is stroke itself that causes depression rather than experiencing vascular risk factors.

The wide variation in rates of depression in those from the Indian subcontinent might reflect a complex picture. Any increased rates may be a result of comparing populations that differ in important confounding characteristics, such as physical ill health and social disadvantage. It might also be related to the use of inappropriate screening instruments. The results in studies on the prevalence of depressive disorders are therefore unsurprisingly inconsistent and inconclusive.

Psychosis

The issue of the overrepresentation in hospital of younger Black people with a diagnosis of schizophrenia has been studied extensively. This contrasts with the situation for older people, partly because there is less literature on psychosis and schizophrenia in this group. Depression and dementia in elders are more common and more studied than is schizophrenia. One study of paranoid symptoms in older people in the community reported that being Black was a risk factor (Reference Blazer, Hays and SaliveBlazer et al, 1996) but we did not find this in our study (Reference Livingston, Kitchen and ManelaLivingston et al, 2001b ).

Suicide

Despite the high rate of completed suicide in older people, in particular older men, there has been little research considering the role of immigration and ethnicity as risk factors. Existing evidence is somewhat contradictory. In the UK, one study of suicide rates according to age and ethnicity found that all suicides in the over-75 age group were of Asian women and Whites of either gender and that there were no suicides from any other ethnic group (Reference Neeleman, Mak and WesselyNeeleman et al, 1997). This contrasts with another report from the UK showing that suicide rates in elderly first-generation immigrants from the Indian subcontinent are low compared with those of the indigenous elderly population (Reference Soni Raleigh, Bulusu and BalarajanSoni Raleigh et al, 1990). Although younger Asian women are more likely to self-harm than their White counterparts, this is clearly not so for the older Asian population (Reference Bhugra, Desai and BaldwinBhugra et al, 1999). In the USA, the highest suicide rates were found to be among elderly White men (Reference CattellCattell, 2000). It has been suggested that older African Americans have surmounted more threats to their self-esteem than older Whites and are thereby better adapted to new challenges associated with ageing. However, older immigrants in Sweden have an increased rate of suicide (Reference Johansson, Sundquist and JohanssonJohansson et al, 1997).

Service utilisation

The factors which influence service utilisation are complex and include accessibility, perception of usefulness, availability of alternative help, stigma and beliefs about racism. Thus, it is unclear how immigration will affect the use of services.

Studies of immigrant Asian and Black elders showed that, in general, they were more likely to consult their general practitioner than their British-born counterparts. This contrasts with the picture of consultation in social service and secondary care. In general, the studies report findings on small numbers of older people and they are based on referrals. In the main, they suggest that ethnic elders are referred less (or have increased untreated morbidity) to secondary care health and social services, in particular psychiatric services, than their White UK-born counterparts (e.g. Reference Shah and Dighe-DeoShah & Dighe-Deo, 1997). Recent studies, one comparing Asian and White referral to secondary care and one comparing service use by community-dwelling ethnic elders and by White counterparts, were unable to confirm this (e.g. Reference Odutoye and ShahOdutoye & Shah, 1999; Reference Livingston, Leavey and KitchenLivingston et al, 2002).

A variety of reasons has been suggested for any lack of utilisation, for example interpreting symptoms as a spiritual problem rather than as a depressive or physical illness. In addition, there have been reports of a reluctance in ethnic elders to accept referral to secondary mental health services (Reference Shah, Lindesay and JaggerShah et al, 1998) and of perceptions by Black people of racism in health workers (Reference Hutchinson and GilvarryHutchinson & Gilvarry, 1998). It might be that the medical profession is less able to recognise the presentation of psychological distress by people from other cultures.

A recent qualitative study in London compared Black elders with and without depression with White counterparts. They found that Black elders often chose not to use medical services, as they perceived them to be irrelevant and stigmatising. There was, however, little evidence of perceived racism (Reference Marwaha and LivingstonMarwaha & Livingston, 2003).

Carers for those with dementia

Caring for people with dementia is known to be stressful and associated with distress and depression, particularly in female and spouse caregivers. The meaning of caring and ways of coping may vary between ethnic and immigrant groups although the demands may be similar. Immigrants may have left their families and therefore their traditional sources of support. A review of 12 studies comparing White and non-White caregivers of people with dementia showed non-White caregivers to be less likely to be a spouse and more likely to be an adult child, friend or other family member. Non-White caregivers reported lower levels of caregiver stress, burden and depression. They endorsed more strongly held beliefs about filial support and were more likely to use prayer, faith or religion as a coping mechanism (Reference Connell and GibsonConnell & Gibson, 1997). This contrasts with a study comparing Hispanic and White non-Hispanic primary caregivers for dementia. This found that Hispanic caregivers were more likely to have depression, but the most robust risk factors were female gender and spouse status (Reference Harwood, Barker and CantillonHarwood et al, 1998).

Multiple choice questions

1. 1 With regard to the mental health of ethnic elders:

   1. a immigrant elders are concentrated in rural areas

   2. b 15% of older people in the UK are immigrants

   3. c ethnicity is self-defined

   4. d ethnicity is fixed

   5. e the number of immigrant elders is increasing.

2. 2 With regard to the diagnosis of dementia in immigrant ethnic elders:

   1. a diagnosis is both difficult and less stable than in White counterparts

   2. b there is evidence of a higher prevalence of dementia in Black African–Caribbean immigrants

   3. c there is evidence of a higher prevalence of dementia in older people living in Nigeria

   4. d the APOE 4 allele frequency varies between Black and White Americans

   5. e ethnic status affects the mortality rate in dementia.

3. 3 With regard to depression in immigrant elders:

   1. a depression presents with different patterns of symptoms in different cultures

   2. b when screening for depression, higher cut-points are appropriate for older Black people in the UK

   3. c depression in older Black people is associated with vascular risk factors apart from stroke

   4. d Irish older people have higher rates of depression

   5. e reported prevalence rates of depression in older people from the Indian subcontinent vary widely.

4. 4 Concerning elderly immigrants:

   1. a non-White carers are more likely to be a spouse than White carers

   2. b there are higher levels of carer stress and depression in the Hispanic population

   3. c carers rarely use religion/prayer as a source of support

   4. d older immigrants in Sweden have an increased risk of suicide

   5. e elderly Asian women living in the UK show a consistently higher rate of suicide than their indigenous counterparts.

5. 5 The following reasons may account for immigrant elders’ underutilisation of psychiatric services:

   1. a symptom interpreted as a spiritual problem

   2. b lower rates of illness

   3. c decreased utilisation of primary care services

   4. d perceived racism in services

   5. e symptoms perceived as a physical problem.