Position statement Euromed Network on Mental Health and Migration

Introduction/contextMigration is one of the most important challenges ofthe XXIst century. Europe in particular has seen a dra-matic rise in migration over the past decade, and allindications suggest that this increase will continue wellinto the future.It is becoming increasingly clear that the mentalhealth needs of migrants require specific attention.Recent reports indicate that migrants are underrepre-sented in mental health care centers, are subject tomore diagnostic error, more coercive measures andinvoluntary treatment, less psychotherapy and less sec-ond generation medication [1,2]. The specific relation-ship between migration and mental health remainsunclear, although a number of protective and risk fac-tors have been identified [3]. What would appear to beclear is that there is a robust relationship betweenmigration and schizophrenia, with odds rations varyingfrom 2 to 8 for individuals from the European commu-nity for the former and Afrocaribbean migrants for thelatter [4]. In addition, research indicates that the chil-dren of immigrants-second generation citizens-also havehigher odds ratios for the development of psychotic andaffective disorders.All of this has implications for psychology and psy-chiatry as a whole. The field of transcultural psychiatryovertly emphasizes the biopsychosocial model: thatmigration overwhelmingly impacts the incidence of schi-zophrenia emphasizes that experience itself, and notsimply biological structure or genetics is involved. Diffi-culties with diagnosis demand reconsideration of exist-ing nosological systems, as reflected, for example, inthe pathway towards the DSM-V and the ICD-11,and treatment issues, be they psychotherapeutic orpharmacological indicate that treatments may need tobe adapted given the cultural and/or ethnic backgroundand migratory experience of the patient [5,6].A clear conclusion is thatthe mental health needs ofimmigrants are not being met [7]. This can be seen atthe two levels identified above and are related to bothprevention and treatment. To that end the Euromednetwork calls for the development of both clinical andinstitutional cultural competence by attending toresearch, training, and advocacy. This human rightsissue which involves considerable suffering implicates alllevels of stakeholders, from individuals to their families,from clinicians to the institutions they work for, tohealth care systems, professional associations, and pro-fessional training programs.ResearchMost all of what we know about migration and mentalhealth comes from research. Although considerablestrides have been made in this area, it is clear that thereremains much to be done. We call for more research tobe facilitated and carried out in this area. It is note-worthy that the vast bulk of psychological and psychia-tric research uses a“gold standard” that is notrepresentative of more than 80% of the world’spopula-tion, which means that much of what we know may beof questionable applicability to the latter, which is parti-cularly true of clinical trials.Indeed, the field of ethnopsychopharmacology clearlydemonstrates that pharmacokinetics and pharmacody-namics are not“universal” but rather vary with thegenetic makeup [6]. Thus treatment, be it pharmacologi-cal or psychological, needs to be investigated at morepopulation specific levels in order to ensure that allpatients receive an optimal quality of care.

pharmacological indicate that treatments may need to be adapted given the cultural and/or ethnic background and migratory experience of the patient [5,6].
A clear conclusion is that the mental health needs of immigrants are not being met [7]. This can be seen at the two levels identified above and are related to both prevention and treatment. To that end the Euromed network calls for the development of both clinical and institutional cultural competence by attending to research, training, and advocacy. This human rights issue which involves considerable suffering implicates all levels of stakeholders, from individuals to their families, from clinicians to the institutions they work for, to health care systems, professional associations, and professional training programs.

Research
Most all of what we know about migration and mental health comes from research. Although considerable strides have been made in this area, it is clear that there remains much to be done. We call for more research to be facilitated and carried out in this area. It is noteworthy that the vast bulk of psychological and psychiatric research uses a "gold standard" that is not representative of more than 80% of the world's population, which means that much of what we know may be of questionable applicability to the latter, which is particularly true of clinical trials.
Indeed, the field of ethnopsychopharmacology clearly demonstrates that pharmacokinetics and pharmacodynamics are not "universal" but rather vary with the genetic makeup [6]. Thus treatment, be it pharmacological or psychological, needs to be investigated at more population specific levels in order to ensure that all patients receive an optimal quality of care.
It is essential that research is carried out on all aspects related to the improvement of care of migrants, from pharmacological intervention to psychotherapy to the participation of intercultural mediators and medical interpreters. In addition, research needs to examine institutional and administrative characteristics to determine what maximizes access and quality of care. All of this is necessary to improve the overall cultural competence of the mental health care system.
One of the big questions facing researchers has to do with the degree to which immigration in and of itself constitutes a risk factor for common mental disorders, on the one hand, and what best explains the relationship between immigration and schizophrenia [4]. In addition to requiring further exploration, these areas of research all thematize the complexity of applying research methodology and instrumentation developed in one particular cultural, social, and political context in another. Psychometrics are clearly influenced by cultural differences, to the extent that leading experts agree that there is no such thing as a "culture free" or even "culture fair" test [8]. This means that how research is carried out needs to be rethought, with, perhaps, more emphasis given to qualitative approaches.
The area of prevention also warrants attention. Clearly, the optimal way of improving the mental health of a population is to prevent mental health problems and promote mental health. How to do this, however, demands a better understanding of the risk and protective factors related to the migratory process. Research in this area is growing and needs to be further developed and then made relevant to mental health promotion and prevention and treatment on psychopathology.

Training and education
In today's increasingly diverse world, it is arguable that culture and difference play a role in most every sort of patient contact. To that end, it is, in our opinion, an ethical requirement that all mental health professionals receive training in cultural competence. The very notion of professional competence is predicated on a combination of practical experience along with theory and research [9]. Whereas many clinicians have ample experience working with migrants, they all too often lack a scientific basis on which to frame and further develop their work.
Training should be focused on promotion of mental health, prevention of psychopathology, and diagnosis and treatment, and should be provided not only to clinicians but also to administrators, researchers, as well as all clinical staff.
We need to have a better understanding of the effectiveness of training. Many models exist; however, there exists minimal research that evaluates the clinical impact. We need to know what sorts of training initiatives have a real world impact on the sort of care imparted by trainees.

Advocacy
As things stand, it is clear tha migrants are not having their best interests attended to. It is essential that those with the means to do so advocate on behalf of this more vulnerable population ranging from advocacy at the community to that of the individual level.
In a related vein, we call upon national and international associations to organize or promote sections or special interest groups related to migration and mental health/transcultural psychiatry as a means of identifying and needs and developing appropriate responses. Such special interest groups can then network in order to further share ideas, experiences, and research findings, with an eye to improving the mental health of migrants.

The Euromed Network on Migration and Mental Health
One of the central objectives of the Euromed Network on Migration and Mental Health is the development of a forum in which local and relevant research, experiences, and initiatives can be shared, compared, and contrasted with the objective of contributing to an overall improvement in the mental health of migrants.