Migration and its Impact on Mental Health

INTRODUCTION The term migrant comes from the Latin word migrant-, migrants, and migrare and is designed as an umbrella term that reflects the common understanding of a person who moves away from their usual place of residence, whether within a country or across international borders, temporarily or permanently, for various reasons.[1] Sir Thomas Browne, in late 1600, first used this term. World Health Organization defined the term migration as the movement of a person or a group of persons, either across an international border or within a State. This term encompasses various well-defined legal categories, such as migrant workers, as well as those whose movements are less clearly defined, such as smuggled migrants and international students. Reverse migration refers to the movement of people from their place of employment back to their native places.[2] Different synonyms for migrants included were emigrant, immigrant, and refugee. A refugee resides outside their country of origin due to fear of persecution based on race, religion, nationality, membership in a particular social group, or political opinion. Similarly, an asylum seeker is a person who has left their country for any reason and has applied for shelter and protection in another country. A person forced to leave their home or region due to unfavorable conditions, political, social, or environmental, without crossing any borders comes under the category of an internally displaced person.[3,4] Migrant workers in any society are at a crossroads of immense vulnerability due to their economic and social status as a cheap workforce, which brings various mental health implications throughout the migration process. Losing familiar support structures can lead to feelings of isolation, while difficulties in integrating into a new environment and community further exacerbate their challenges. Many work in the informal economy, where job security is limited, adding to their considerable stress and burden. As a result, they often need help in coping with these pressures and may develop various coping strategies to manage their situations. However, unhealthy coping mechanisms can adversely affect their overall functioning. Tragically, the migrant population has frequently been neglected and often ignored by mental health professionals, which highlights the urgent need for targeted support and resources to address their mental health needs.[5] Migrant workers play an important role in the labor market, keeping our cities running despite their existence often is hardly acknowledged. According to the National Sample Survey conducted in 2007–2008, 28.3% of the workforce comprises the migrant population. Census data reveal a significant increase in this demographic over the years: the 1991 census recorded 220 million migrants, the 2001 census noted 315 million, and the 2011 census recorded 454 million, representing a hike of 139 million and nearly doubling figures in just 20 years.[6] This narrative review has included a marginalized population and an often overlooked problem. Hence, our review helps to shed more light on the issues faced by migrants for better mental healthcare services. This review includes the first-hand experience of the author while working in a rural shelter home for migrants on ground levels. METHODS An electronic database search was carried out using the search words Migrants, Migration, and Mental health in PubMed, Psych INFO, and Google Scholar. A manual search and review of journals for relevant articles were also conducted. The manuscripts irrespective of their types (editorial, review, original research articles, letters to editor, and commentaries) discussing mental health issues of migrants as the major themes were considered in this narrative review. RESULTS Prevalence The prevalence of mental health problems among migrants was reported differently in various research studies conducted in India and abroad. He and Wong[7] reported that 24% of the migrated working women staying in cities were found to be mentally unhealthy. In another risk assessment observation study, 3.4% of migrants were reported in the high-risk category, 23.4% were in the moderate category, and 73% were found in the low-risk category for the development of psychiatric disorders.[8] Bhugra and Gupta reported that admission rates for schizophrenia were at a peak among migrants after 10–12 years of migration.[9] In a comparative study regarding psychiatric morbidity among migrants, the figures were higher (7%) among migrants (33.66%) as compared to the nonmigrant local population, which was 26%.[10] Firdaus analyzed the social environmental issues for the psychological well-being of migrants in an urban center of India.[11] Factors related to migration that affect mental health[2,3,5,9,11] Table 1 depicts the migration trajectory components, which can be divided into three components: (a) premigration, (b) migration, and postmigration resettlement. In the premigration component, the economic, educational, and occupational status of the migrant in the country of origin were important indicators of their mental health status. The disruption of social support, roles and networks, trauma, and political involvement indicators also play crucial roles in mental health during the premigration stages. During migration, the route of travel, duration, exposure to harsh living conditions, violence, uncertainty, and disruption of family and community networks.Table 1: Factors affecting the mental health of adults in migrationMigrants represent a vulnerable population that faces numerous challenges contributing to mental health implications. Table 2 depicts different factors which were involved in different stages of migration that affect the mental health of the migrant at three points of the migration trajectory. Migrant workers face numerous challenges that significantly impact their well-being. Key risk factors included in premigration were age and development stage at migration, disruption of education, and separation from extended family and peer networks. The migration factors were loss and grief, often stemming from leaving family and familiar environments, and separation from caregivers, poor nutrition, economic instability, as many work in precarious jobs and social isolation, which can lead to feelings of loneliness. The postmigration factors were language barriers further complicated their ability to communicate and integrate into new communities, while discrimination and racism can exacerbate their vulnerabilities and hinder access to resources. Other risk factors included poverty, inequality, financial debt, and demographics such as being single, unskilled, and illiterate.Table 2: List of factors of migration-related with mental healthStudies have found that stigma and discrimination lead to a high level of negative impact on mental health, with a positive association with common mental disorders. These factors contribute to higher rates of depression, stress, and an elevated risk of suicide. They often experience social exclusion based on language and appearance and are frequently perceived as threats to local jobs. Many reside in unauthorized colonies, where they lack access to essential services, including public distribution, free education, and even basic health and mental health services. The absence of proper registration and documentation, often limited to their place of origin, exacerbates their marginalization. Effect of COVID-19 on migrants The COVID-19 pandemic has had a profound impact on migrants, representing a humanitarian and healthcare crisis, particularly in developing countries like India.[12–18] The pandemic acted as a “time bomb,” leading to a significant migrant crisis following the lockdown, which has been described as an invisible mental health tsunami.[13] A cross-sectional survey conducted by Kumar et al.[14] revealed a high level of negative impact on mental health among migrant workers. The study involved 98 participants with a mean age of 32.7 years (standard deviation: 10.1) and utilized two brief screening instruments: the Patient Health Questionnaire-2 and the Generalized Anxiety Disorder-2, along with the Perceived Stress Scale-4. The findings were alarming, with 73.5% screening positive for depression, 50% for anxiety, and 51% for both conditions. Severe anxiety and depressive symptoms were particularly prevalent, primarily due to the loss of livelihood, financial insecurity, and excessive worries about their future and the well-being of family members. Feelings of isolation compounded their distress. The study recommends routine screening for mental morbidity and planning for psychological aid to address these critical needs. Notably, the National Crime Records Bureau reported that 22.4% of suicides in states like Maharashtra, Tamil Nadu, West Bengal, Madhya Pradesh, and Karnataka occurred among migrants during the COVID-19 pandemic. Increased rates of mood disorders, psychotic disorders, and posttraumatic stress disorders are prevalent in migrants during the COVID-19 pandemic.[11–15] Experience of working in rural Shelter Home during the COVID-19 pandemic for migrants The Government of India, through the Ministry of Health and Family Welfare,[16] established a nodal agency to run a shelter home for the migrants at Village Maloya, Chandigarh, from April 2 to April 17, 2020. This initiative included a dedicated mental health team comprising a consultant psychiatrist and a clinical psychologist, who provided psychosocial services three times a week. The team supervised the basic needs and safety of residents, addressing mental health concerns while coordinating with various Chandigarh administrative, police, and health agencies. The migrants were provided basic needs like food, hygiene, cleanliness, recreational items, toys for children, nutritious food, safety masks, sanitizer, and sanitation in these shelter homes. They also assisted migrants in arranging transportation back to their place of origin. The research efforts at the shelter home have resulted in many research publications in national and international journals and some multicentric studies related to mental health issues of migrants.[13,17–21] In addition, a Chandigarh Psychosocial Model was developed to enhance the stay of the migrant population in the shelter home, focusing on their mental health and overall psychosocial well-being.[21] Mental healthcare strategies Several key strategies can be implemented to improve migrants’ access to mental health care.[21–23] First, providing clear information on mental health entitlements and how to access mental health services is crucial. Outreach efforts should target high-risk groups, such as migrants, unaccompanied children, and persons with disabilities; ensuring affordable and nondiscriminatory access to care is essential, along with facilitating communication by engaging interpreters and cultural mediators. Person-centered care that respects cultural differences is vital, as is integrating mental health services into primary health care, making them more easily accessible and cost-effective. Ensuring continuity of care will help build trust and improve health outcomes for migrants. Enhancing coping mechanisms and resilience building, community support, and social networks are coping mechanisms and positive strategies.[4,13,21–23] Cultural adaptation and resilience-building strategies are important methods to break the barriers to receiving mental health care for migrants. Basic mental healthcare services, telemental health services, and eSanjivani outdoor services needed to be prioritized at district and primary health center levels so that migrants could benefit from these basic mental healthcare services.[16–18] The migrant population needs optimal mental health care to minimize mental health implications. Combined efforts of mental health professionals, policy planners, industrialists, researchers, and social scientists for psychosocial intervention for mental health care of migrant population are needed. Limitations In this narrative review, only recent research work was included. We tried to do an exhaustive review but it is difficult to rule out bias as we have tried to include first-hand experience. The other relevant mental health issues from various zones of India might be addressed in future studies. CONCLUSION There is an urgent need for health systems that are sensitive to the unique needs and languages of migrants. Strengthening social inclusion and cohesion between host communities and migrants is essential to fostering a supportive environment. In addition, efforts should aim for universal health coverage to ensure all individuals can access necessary services. The term “migrant” can be a misnomer, as these individuals are an integral part of our society. The prevalence of psychiatric morbidity among migrants was alarmingly high, highlighting the need for the attention of mental health professionals, health administrators, and policy planners. Establishing special community clinics dedicated to their mental health needs is imperative for addressing these critical issues. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.