This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.


Why Do Some Nonnative People Who Migrate to Another Country Have Better Health Status Than Their Native-Born Counterparts?

Mario Cruz, MD

Published: September 28, 2016

See article by Chiu et al

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Why Do Some Nonnative People Who Migrate to Another Country Have Better Health Status Than Their Native-Born Counterparts?

It is well known that racial and ethnic differences exist in the utilization of mental health services.1-10 These differences have been posited to be secondary to a various array of factors such as different mental health beliefs among ethnic groups that act as barriers to or facilitators of mental health services11,12; barriers to mental health care access secondary to low socioeconomic status,8,10 lack of health insurance,8,10 discrimination,13,14 institutional racism,10 lack of culturally sensitive and appropriate services,10 racial/ethnic and cultural mismatches between providers and patients,10 and shame and stigma10; and social differences in the path chosen for patients of different ethnic groups to mental health.15-18

Immigration status is another factor influencing utilization of mental health services. Immigration status plays a role in the health and mental health status of racial and ethnic groups. Recent migration status has been linked to better health status in nonnative compared to Canadian and US populations.19 The positive association between recent migration and better health status has not been clearly shown in people who have migrated to European countries.20 In addition, immigrants with mental illnesses who live in areas that are densely populated by individuals (ethnic density hypothesis) from the same ethnic group have been shown to be associated with reduced illness severity.21-23

Global migration is estimated at 200 million individuals per year.19 With the recent migration of millions of individuals from war-torn Syria, Afghanistan, and Iraq, this number will surely continue to rise. Understanding how immigration status influences the mental health status of different racial/ethnic groups and understanding the sociocultural barriers to and facilitators of mental service utilization for different immigration groups would be helpful in terms of future global and national health policy.

Maria Chiu and colleagues’ article "Ethnic Differences in Mental Illness Severity: A Population-Based Study of Chinese and South Asian Patients in Ontario, Canada"24 addresses an important mental health care service delivery question: How does immigration status and ethnicity influence psychiatric presentations that lead to inpatient psychiatric hospitalization for mainland Chinese and South Asian populations?

Canada is one of the key destinations for many immigrants. Twenty percent of the Canadian population is foreign-born. As the authors point out, many of these immigrants are from the Republic of China and South Asia (ie, India, Pakistan, Bangladesh, Sri Lanka).

The health status of Chinese and South Asian immigrants appears to be better than that of native Canadians for the first 10 years after their arrival.19 Thereafter, the health status of these immigrant groups becomes consistent with the general population. The health trajectory of Chinese and South Asian immigrants is consistent with the healthy immigrant hypothesis.20,25 That is, individuals who travel great distances to migrate from their country of origin are healthier than the native population in the country they migrate to. One limitation of the health status data on Canadian immigrants is that they do not thoroughly address the mental health status of immigrant groups.

As the authors point out, our knowledge of the mental health presentation of Chinese and South Asian populations for inpatient psychiatric admission is limited by small sample sizes and inconsistent findings in the published studies on these population groups.

The objective of their study24 was to enhance our understanding of how sociocultural factors such as race/ethnicity and immigration status influence the clinical presentation and treatment decision making of providers regarding inpatient psychiatric admission.

To achieve their objective, the authors’ investigated whether a population-based sample of Chinese and South Asian patients aged from 19 to 105 years who were hospitalized for psychiatric reasons between April 1, 2006, and March 31, 2014, in Ontario, the most populous province within Canada’s single-payer universal health care system, differed from the general hospitalized population on 4 measures of disease severity: involuntary admissions, aggressive behaviors, and the number and frequency of positive symptoms. In addition, they examined the role of sex, diagnosis, and immigration status on the relationship between Chinese and South Asian ethnicities and disease severity.

Pooling data from several large health (Ontario Mental Health Reporting System and the Canadian Institute for Health Information’s Discharge Abstract Database) and citizenship databases (the Registered Persons database and the Immigration, Refugees and Citizenship Canada Permanent Resident database), the authors captured patient-level sociodemographic characteristics, diagnoses, clinical ratings on aggressive behaviors, the number and frequency of positive psychotic symptoms, prior psychiatric hospitalizations, age, sex, area-level income, rurality of residence, and immigration status. Using a novel surnames algorithm the authors created and validated,26 they were able to classify all patients within the study time period into Chinese, South Asian, or general population groups. Thereafter, the authors employed appropriate statistical measures to identify relationships between sociocultural characteristics and the clinical presentation and type (voluntary or involuntary) of inpatient psychiatric admission.

The authors identified 133,588 unique patients, with 2,582 being Chinese, 2,452 being South Asian, and 128,554 being the general population. Important study findings were that Chinese and South Asian patients were younger, more likely to be immigrants, more likely to be admitted involuntarily because they were a threat to others (ie, exhibiting severe aggressive behaviors as measured by the Resident Assessment Instrument-Mental Health [RAI-MH]27,28 Aggressive Behavior scale29) or unable to care for themselves, and significantly more likely to be diagnosed with schizophrenia than the general population. In terms of positive psychotic symptoms, a disproportionately large number of Chinese and South Asians exhibited 3 or more positive symptoms (ie, hallucinations, command hallucinations, delusions, abnormal thought process or form) compared to the general population on the RAI-MH. In summary, Chinese and South Asian patients who were psychiatrically admitted were younger, were more often admitted involuntarily, and exhibited severe aggressive behaviors as well as psychotic symptoms compared to the general admitted population in Ontario, Canada. The authors aptly rule out ethnic differences in disease prevalence and propose that delays in treatment seeking explain these findings. They then discuss several of the previously mentioned patient/family and health system/provider barriers to accessing mental health services as potential causes.

An interesting additional finding was that Chinese patients’ illness severity was greater than the general population regardless of immigration status while Canadian-born South Asian patients had greater illness severity for most severity measures than their immigrant peers compared to the general population. These findings do not support the healthy immigrant hypothesis, for illness severity was greater for Chinese patients than the general population irrespective of immigrant status, while illness severity was greater for Canadian-born South Asians.

I propose these findings could be explained by the ethnic density hypothesis if there are variations in ethnic density between Chinese patients and Canadian-born South Asian patients. If we posit that Chinese populations, irrespective of immigration status, reside in more Chinese-dense areas while Canadian-born South Asian patients reside in less South Asian-dense areas compared to their immigrant peers, according to the ethnic density hypothesis, illness severity would be significantly greater for the South Asian Canadian-born group compared to their immigrant group peers. Future studies should assess the influence of ethnic density on illness severity at the time of psychiatric admission.

In conclusion, Chiu and colleagues’ study24 is a thoughtful, well-designed, and important contribution to our understanding of the influence of sociocultural factors, particularly immigration status, on clinical presentation and provider admission decision making of Chinese and South Asian psychiatric patients.

Submitted: September 21, 2015; accepted September 24, 2015.

Potential conflicts of interest: Dr Cruz has no conflicts of interest to disclose.

Funding/support: None.


1. Bansal N, Bhopal R, Netto G, et al. Disparate patterns of hospitalisation reflect unmet needs and persistent ethnic inequalities in mental health care: the Scottish health and ethnicity linkage study. Ethn Health. 2014;19(2):217-239. PubMed doi:10.1080/13557858.2013.814764

2. Chen AW, Kazanjian A, Wong H, et al. Mental health service use by Chinese immigrants with severe and persistent mental illness. Can J Psychiatry. 2010;55(1):35-42. PubMed

3. Lê Cook B, McGuire TG, Zuvekas SH. Measuring trends in racial/ ethnic health care disparities. Med Care Res Rev. 2009;66(1):23-48. PubMed doi:10.1177/1077558708323607

4. McGuire TG, Miranda J. New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Aff (Millwood). 2008;27(2):393-403. PubMed doi:10.1377/hlthaff.27.2.393

5. Blanco C, Patel SR, Liu L, et al. National trends in ethnic disparities in mental health care. Med Care. 2007;45(11):1012-1019. PubMed doi:10.1097/MLR.0b013e3180ca95d3

6. Hasnain-Wynia R, Baker DW, Nerenz D, et al. Disparities in health care are driven by where minority patients seek care: examination of the hospital quality alliance measures. Arch Intern Med. 2007;167(12):1233-1239. PubMed doi:10.1001/archinte.167.12.1233

7. Ojeda VD, McGuire TG. Gender and racial/ethnic differences in use of outpatient mental health and substance use services by depressed adults. Psychiatr Q. 2006;77(3):211-222. PubMed doi:10.1007/s11126-006-9008-9

8. Zimmerman FJ, Katon W. Socioeconomic status, depression disparities, and financial strain: what lies behind the income-depression relationship? Health Econ. 2005;14(12):1197-1215. PubMed doi:10.1002/hec.1011

9. Snowden LR, Cheung FK. Use of inpatient mental health services by members of ethnic minority groups. Am Psychol. 1990;45(3):347-355. PubMed doi:10.1037/0003-066X.45.3.347

10. Cruz M, Pincus HA, Harman JS, et al. Barriers to care-seeking for depressed African Americans. Int J Psychiatry Med. 2008;38(1):71-80. PubMed doi:10.2190/PM.38.1.g

11. Patel M, Chawla R, Krynicki CR, et al. Health beliefs and carer burden in first episode psychosis. BMC Psychiatry. 2014;14(1):171. PubMed doi:10.1186/1471-244X-14-171

12. Snowden LR, Yamada A-M. Cultural differences in access to care. Annu Rev Clin Psychol. 2005;1(1):143-166. PubMed doi:10.1146/annurev.clinpsy.1.102803.143846

13. Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med. 2009;32(1):20-47. PubMed doi:10.1007/s10865-008-9185-0

14. Ashton CM, Haidet P, Paterniti DA, et al. Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication? J Gen Intern Med. 2003;18(2):146-152. PubMed doi:10.1046/j.1525-1497.2003.20532.x

15. Anderson KK, Flora N, Archie S, et al. A meta-analysis of ethnic differences in pathways to care at the first episode of psychosis. Acta Psychiatr Scand. 2014;130(4):257-268. PubMed doi:10.1111/acps.12254

16. Bruce M, Cobb D, Clisby H, et al. Violence and crime among male inpatients with severe mental illness: attempting to explain ethnic differences. Soc Psychiatry Psychiatr Epidemiol. 2014;49(4):549-558. PubMed doi:10.1007/s00127-013-0760-5

17. Unick GJ, Kessell E, Woodard EK, et al. Factors affecting psychiatric inpatient hospitalization from a psychiatric emergency service. Gen Hosp Psychiatry. 2011;33(6):618-625. PubMed doi:10.1016/j.genhosppsych.2011.06.004

18. Vinkers DJ, de Vries SC, van Baars AW, et al. Ethnicity and dangerousness criteria for court ordered admission to a psychiatric hospital. Soc Psychiatry Psychiatr Epidemiol. 2010;45(2):221-224. PubMed doi:10.1007/s00127-009-0058-9

19. Gushulak BD, Pottie K, Hatcher Roberts J, et al; Canadian Collaboration for Immigrant and Refugee Health. Migration and health in Canada: health in the global village. CMAJ. 2011;183(12):E952-E958. PubMed doi:10.1503/cmaj.090287

20. Rivera B, Casal B, Currais L. The Healthy Immigrant Effect on Mental Health: Determinants and Implications for Mental Health Policy in Spain. Adm Policy Ment Health. 2015. PubMed doi:10.1007/s10488-015-0668-3

21. Termorshuizen F, Braam AW, van Ameijden EJ. Neighborhood ethnic density and suicide risk among different migrant groups in the four big cities in the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2015;50(6):951-962. PubMed doi:10.1007/s00127-014-0993-y

22. Mezuk B, Li X, Cederin K, et al. Ethnic enclaves and risk of psychiatric disorders among first- and second-generation immigrants in Sweden. Soc Psychiatry Psychiatr Epidemiol. 2015;50(11):1713-1722. PubMed doi:10.1007/s00127-015-1107-1

23. Veling W, Susser E, van Os J, et al. Ethnic density of neighborhoods and incidence of psychotic disorders among immigrants. Am J Psychiatry. 2008;165(1):66-73. PubMed doi:10.1176/appi.ajp.2007.07030423

24. Chiu M, Lebenbaum M, Newman AM, et al. Ethnic differences in mental illness severity: a population-based study of Chinese and South Asian patients in Ontario, Canada. J Clin Psychiatry. 2016;77(9):e1108-e1116.

25. Moullan Y, Jusot F. Why is the ‘ healthy immigrant effect’ different between European countries? Eur J Public Health. 2014;24(suppl 1):80-86. PubMed doi:10.1093/eurpub/cku112

26. Shah BR, Chiu M, Amin S, et al. Surname lists to identify South Asian and Chinese ethnicity from secondary data in Ontario, Canada: a validation study. BMC Med Res Methodol. 2010;10(1):42. PubMed doi:10.1186/1471-2288-10-42

27. Hirdes JP, Ljunggren G, Morris JN, et al. Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system. BMC Health Serv Res. 2008;8(1):277. PubMed doi:10.1186/1472-6963-8-277

28. Hirdes JP, Smith TF, Rabinowitz T, et al; Resident Assessment Instrument-Mental Health Group. The Resident Assessment Instrument-Mental Health (RAI-MH): inter-rater reliability and convergent validity. J Behav Health Serv Res. 2002;29(4):419-432. PubMed doi:10.1007/BF02287348

29. Perlman CM, Hirdes JP. The Aggressive Behavior Scale: a new scale to measure aggression based on the minimum data set. J Am Geriatr Soc. 2008;56(12):2298-2303. PubMed doi:10.1111/j.1532-5415.2008.02048.x

aDepartment of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque

*Corresponding author: Mario Cruz, MD, Department of Psychiatry and Behavioral Health Sciences, MSC09 5030, 1 University of New Mexico School of Medicine, Albuquerque, New Mexico 87131-0001 (

J Clin Psychiatry 2016;77(9):e1146-e1148

© Copyright 2016 Physicians Postgraduate Press, Inc.

Related Articles

Volume: 77

Quick Links: