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Increased prevalence of anxiety disorders in third-generation migrants in comparison to natives and to first-generation migrants
Journal of Psychiatric Research 102 (2018) 38–43
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Increased prevalence of anxiety disorders in third-generation migrants in comparison to natives and to first-generation migrants
T
Baptiste Pignona,j,∗, Ali Amadb,c, Antoine Pelissoloa,j, Thomas Fovetb, Pierre Thomasb, Guillaume Vaivab, Jean-Luc Roelandtd, Imane Benradiad, Benjamin Rollande,f, Pierre A. Geoffroyg,h,i,j a
AP-HP, DHU PePSY, Hôpitaux universitaires Henri-Mondor, Pôle de Psychiatrie, Inserm, U955, Team 15, UPEC, Université Paris-Est, Faculté de médecine, Créteil, 94000, France b Univ. Lille, CNRS UMR 9193-PsyCHIC-SCALab, CHU Lille, Pôle de Psychiatrie, Unité CURE, F-59000, Lille, France c Fédération régionale de recherche en santé mentale (F2RSM) Nord-Pas-de-Calais, F-59000, Lille, France d EPSM Lille Métropole, Centre Collaborateur de l’Organisation Mondiale de la Santé pour la recherche et la formation en santé mentale, Equipe Eceve Inserm UMR 1123, Lille, France e Service Universitaire d’Addictologie, Pôle UP-MOPHA, CH Le Vinatier, Univ. Lyon, 69500, Bron, France f CRNL Inserm U1028/CNRS UMR5292, CH Le Vinatier, 69678, Bron Cedex, France g Inserm, U1144, Paris, F-75006, France h Université Paris Diderot, Sorbonne Paris Cité, UMR-S 1144, Paris, F-75013, France i AP-HP, GH Saint-Louis, Lariboisière, F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, 75475, Paris Cedex 10, France j Fondation FondaMental, Créteil, 94000, France
A R T I C LE I N FO
A B S T R A C T
Keywords: Migrants Anxiety disorders Panic disorder Social anxiety disorder Generalized anxiety disorder Post-traumatic stress disorder
Introduction: We sought to examine the prevalence of anxiety disorders associated with migration in the first-, second- and third-generation. Methods: The French Mental Health in the General Population cross-sectional survey interviewed 38,694 individuals using the MINI. The prevalence of lifetime anxiety disorders, and comorbidities was compared between migrants and non-migrants and by generation. All analyses were adjusted for age, sex, and income and education levels. Results: In comparison to natives, pooled anxiety disorders were more common among migrants (25.3% vs. 20.7%, OR = 1.24) and among the three studied generations of migrants. Moreover, the prevalence rate of the pooled anxiety disorders was significantly higher in third-generation migrants, in comparison to first-generation (26.7% vs. 22.6%, OR = 1.14). Prevalence rates were higher in migrants for panic disorder (6.6% vs. 5.3%, OR = 1.20), general anxiety disorder (15.0% vs. 12.0%, OR = 1.24), posttraumatic stress disorder (1.0% vs. 0.6%, OR = 1.51), but not for social anxiety disorder. In comparison to natives, migrants with anxiety disorders had higher prevalence rates of suicide attempts (14.0% vs. 12.8% for natives), psychotic disorders (8.3% vs. 5.7%), unipolar depressive disorder (29.5% vs. 25.4%), bipolar disorder (5.0% vs. 4.0%), and addictive disorders (9.6% vs. 6.2% for alcohol use disorder, 8.2% vs. 4.1% for substance use disorders). Conclusion: Migration was associated with a higher prevalence of all anxiety disorders, in the first, second and third generation, and associated with more psychiatric comorbidities. Moreover, the prevalence increased across generations, and was significantly higher among third-generation migrants, in comparison to first-generation.
1. Introduction Anxiety disorders are the most common psychiatric disorders, affecting lifetime between 20 and 40% of the general population (Kessler et al., 2005; Leray et al., 2011). They include panic disorder (PD), social
anxiety disorder (SAD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). Some environmental risk factors of anxiety disorders have already been highlighted, as stressful life events, or history of trauma (Blanco et al., 2014). As migration has been identified as a risk factor for several
∗ Corresponding author. Hôpital Albert Chenevier, Groupe hospitaliers Henri-Mondor, CHU de Créteil, Assistance Publique-Hôpitaux de Paris (AP-HP), 40 rue de Mesly, 94000, Créteil, France. E-mail address: [email protected] (B. Pignon).
https://doi.org/10.1016/j.jpsychires.2018.03.007 Received 3 December 2017; Received in revised form 26 February 2018; Accepted 19 March 2018 0022-3956/ © 2018 Elsevier Ltd. All rights reserved.
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Lifetime comorbidities possibly associated with anxiety disorders were screened: history of suicide attempts, bipolar I disorder (BD), unipolar depressive disorder (UDD), dysthymia, psychotic disorders, alcohol use disorders (AUDs), and SUDs. Details regarding psychiatric disorders assessment in the MHGP survey are available elsewhere (Amad et al., 2013; Pignon et al., 2017a; Rolland et al., 2017; Tebeka et al., 2018).
psychiatric disorders, including psychotic (Bourque et al., 2011) and mood disorders (Mindlis and Boffetta, 2017), it has also been suggested in anxiety disorders. Some studies found higher prevalence rates of anxiety disorders among first-generation migrants than among natives (Beutel et al., 2016), or higher incidence rates in second-generation migrants (Cantor-Graae and Pedersen, 2013). Of note, several studies made the opposite observation, and even described an “healthy migrant effect”, i.e., lower rates of anxiety disorders among first-generation migrant than among natives, e.g., in the USA (Liddell et al., 2016; SalasWright et al., 2014). In addition, several studies found also discrepancies between first- and second-generation migrations, e.g., an increased risk only in the first-generation (Beutel et al., 2016), or only in the second-generation (Cantor-Graae and Pedersen, 2013). For the first time, we have recently studied the third-generation migrants in the Mental Health in General Population (MHGP) survey. The studies showed that the prevalence rates of psychotic, mood and addictive disorders were higher among third-generation migrants than among natives (Amad et al., 2013; Pignon et al., 2017a; Rolland et al., 2017); and it could also be the case for anxiety disorders. Finally, migrants studies are important to replicate in varied cultural countries (Bhugra, 2004), and anxiety disorders have never been studied in France. It is important to note that no previous study has ever explored whether anxiety disorders in migrants were associated with specific clinical characteristics. Yet, this is a major issue since the migrant status could be associated with a specific profile of a disease, e.g., with higher rates of psychiatric comorbidities. Moreover, in a precedent study in the same MHGP survey, we observed that migrants with mood disorders had a more severe profile, with increased rates of comorbid psychotic and substance use disorders (SUDs) (Pignon et al., 2017a). In this context, the present study aimed to examine the prevalence of anxiety disorders (including PD, SAD, GAD, PTSD, pooled anxiety disorders, and comorbid anxiety disorders) in migrant groups, both overall and according to first- (1GM), second- (2GM) and third-generation (3GM), in a large cross-sectional survey, following the same methodology as our precedent work in mood disorders (Pignon et al., 2017a). These prevalences among migrants were compared to the prevalence among natives. We also compared the rate of psychiatric comorbidities of anxiety disorders, including suicide attempts, psychotic disorders, mood disorders and addictive disorders, between migrants and natives. Regarding the higher rate of depression among migrants in our precedent work, our hypothesis was that migrants display more anxiety disorders and that migrants with anxiety disorders displayed more comorbidities than natives.
2.3. Assessment of migrant status As in precedent studies (Amad et al., 2013; Pignon et al., 2018, 2017b; Rolland et al., 2017), the designation of migrant status was based on the country of birth of the subject (1GM), the subject's parents (2GM), and the subject's grandparents (3GM). 2.4. Statistical analyses To examine the associations between anxiety disorders (PD, SAD, GAD, PTSD, pooled anxiety disorders, and comorbid anxiety disorders) and migration status and/or different generations of migration (1GM, 2GM or 3GM), we performed logistic regression analyses adjusting for potential confounding factors: sex, age, income and education levels (Green and Benzeval, 2013; Kessler et al., 2005). Finally, we also assessed several comorbidities according to migrant status using chisquare tests. All statistical analyses were performed using R software (http://www.R-project.org/) version 3.3.1. 3. Results 3.1. Population and sociodemographic characteristics Migrants were younger, with a higher educational level, and a lower income level than natives. There was a significant correlation between age and educational level (average age (standard-deviation) in years by educational level: low: 60.4 (16.5); medium: 41.5 (16.0); high: 36.5 (14.5); p = 0.05). Sex ratio was statistically different (more males among migrants). Sociodemographic characteristics of individuals with anxiety disorders are available in Supplementary Table 1. 3.2. Risk of anxiety disorders according to migrant status Anxiety disorders were diagnosed in 21.9% of the total population, including 5.6% for PD, 4.4% for SAD, 12.8% for GAD, and 0.7% for PTSD. 1.6% of the population displayed two comorbid anxiety disorders, and 0.1% three (none displayed the four). Results of logistic regressions comparing anxiety disorders between natives and migrants are available in Table 1. Pooled anxiety disorders were more common among migrants (25.3% vs. 20.7%, OR = 1.24), as in each of the three generations. Specifically, the prevalence rate of PD was also higher in the whole sample of migrants (6.6% vs. 5.3%, OR = 1.20), and in 2GM and 3GM. The rates were not significantly different in 1GM. We did not observe any significant differences in the prevalence of SAD according to migrant status (4.8% vs. 4.4%), neither in each of the three generation. Concerning GAD, the prevalence rate was significantly higher among the whole sample of migrants (15.0% vs. 12.0%, OR = 1.24), as in each of the three generations. Finally, PTSD was more common among migrants (1.0% vs. 0.6%, OR = 1.51), and in 1GM and 2GM. The rates were not significantly different in 3GM. The prevalence rates of comorbid anxiety disorders were not significantly different according to migrant status (two comorbid anxiety disorders: 1.4% vs. 1.8%, three: 0.1 for both), as well as in the three generation of migrants (except in the first-generation: more three comorbid anxiety disorders than among natives, 0.2% vs. 0.1%, OR = 3.73). The different generations of migrants were also compared with each other (Supplementary Table 2). After statistical adjustment, the prevalence rate of pooled anxiety disorders was higher in 3GM than in
2. Methods 2.1. Mental Health in General Population (MHGP) survey The cross-sectional MHGP survey, conducted by the World Health Organization French Collaborating Centre, interviewed 38,694 subjects in France between 1999 and 2003. The subjects providing consent, speaking French and aged over 18 were selected in 47 sites by a quotasampling method. Methodological details can be found elsewhere (Leray et al., 2011). Legal authorization (number 98.126) was obtained by the ‘Commission Nationale Informatique et Liberté’ (CNIL) and the ‘Comité consultatif sur le traitement de l'information en matière de recherche’ (CCTIRS). 2.2. Assessment of psychiatric disorders The Mini International Neuropsychiatric Interview (MINI, French version 5.0.0) was used to screen for psychiatric disorders, including PD, SAD, GAD, and PTSD, according to ICD-10 criteria. It has been validated in the general population and has good to very good validity, reliability (inter-rater and test-retest), sensitivity and specificity (Sheehan et al., 1997). 39
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3.3. Comorbidities of anxiety disorders associated with migrant status
Table 1 Prevalence and odds ratio (OR) of anxiety disorders comparing natives to different generations of migrants adjusted for age, sex, income level and level of education.
The migrant status in anxiety disorders was associated with more frequent history of suicide attempts (14.0% for migrants vs. 12.8% for natives), more psychotic disorders (8.3% vs. 5.7%), more UDD (29.5% vs. 25.4%), more BD (5.0% vs. 4.0%), and more addictive disorders (9.6% vs. 6.2% for AUD, 8.2% vs. 4.1% for SUDs). There were no significant differences concerning dysthymia. The increased prevalence of suicide attempts history was observed among migrants with PD (20.2% vs. 18.7%) and SAD (17.0% vs. 11.1%) but not in other anxiety disorders. Concerning psychotic disorders, the prevalence was increased in migrants with PD (14.1% vs. 8.2%), SAD (11.9% vs. 6.7%), and GAD (6.1% vs. 4.7%). UDD was more frequent in migrants with each one of the anxiety disorders (38.9% vs. 33.0% for PD, 32.3% vs. 25.6% for SAD, 26.6% vs. 24.0% for GAD, and 35.7% vs. 24.3% for PTSD). Likewise for SUDs (12.3% vs. 5.7% for PD, 10.5% vs. 5.3% for SAD, 6.1% vs. 3.2% for GAD, and 18.4% vs. 6.2% for PTSD). AUDs were more frequent in migrants with PD (12.6% vs. 8.3%) and GAD (8.9% vs. 5.2%) (Table 2).
Panic disorder (N = 2178) Prevalence (%) OR [95%CI] 5.3 6.6 1.20 [1.08–1.32] 6.2 1.20 [0.98–1.45] 6.6 1.19 [1.04–1.36] 6.8 1.20 [1.04–1.38]
p-values* < 0.001 0.065 0.012 0.012
Prevalence (%) OR [95%CI] 4.3 4.8 1.03 [0.92–1.16] 3.8 0.88 [0.69–1.12] 4.7 1.00 [0.85–1.17] 5.5 1.15 [0.98–1.34]
p-values* 0.550 0.327 0.976 0.080
Generalized anxiety disorder (N = 4946) Prevalence (%) OR [95%CI] Natives (N = 3460) 12.0 All generation migrants (N = 1486) 15.0 1.24 [1.16–1.33] First-generation (N = 274) 13.4 1.24 [1.01–1.31] Second-generation (N = 628) 15.3 1.15 [1.13–1.37] Third-generation (N = 584) 15.6 1.30 [1.18–1.43]
p-values* < 0.001 0.048 < 0.001 < 0.001
Post-Traumatic Stress Disorder (N = 275) Prevalence (%) OR [95%CI] Natives (N = 177) 0.6 All generation migrants (N = 98) 1.0 1.51 [1.21–2.00] First-generation (N = 28) 1.4 2.28 [1.49–3.36] Second-generation (N = 44) 1.1 1.54 [1.07–2.15] Third-generation (N = 26) 0.7 1.05 [0.67–1.58]
p-values* 0.001 < 0.001 0.015 0.690
At least one anxiety disorder (N = 8459) Prevalence (%) OR [95%CI] Natives (N = 5939) 20.7 All generation migrants (N = 2520) 25.3 1.24 [1.17–1.31] First-generation (N = 463) 22.6 1.14 [1.02–1.28] Second-generation (N = 1056) 25.4 1.23 [1.14–1.33] Third-generation (N = 1001) 26.7 1.30 [1.20–1.41]
p-values* < 0.001 0.019 < 0.001 < 0.001
Two comorbid anxiety disorders (N = 615) Prevalence (%) OR [95%CI] Natives (N = 409) 1.4 All generation migrants (N = 183) 1.8 1.18 [0.99–1.41] First-generation (N = 35) 1.7 1.30 [0.91–1.81] 1.9 1.17 [0.91–1.50] Second-generation (N = 78) Third-generation (N = 70) 1.9 1.13 [0.86–1.46]
p-values* 0.067 0.129 0.202 0.358
Natives (N = 1520) All generation migrants (N = 658) First-generation (N = 127) Second-generation (N = 274) Third-generation (N = 257) Social anxiety disorder (N = 1698) Natives (N = 1221) All generation migrants (N = 477) First-generation (N = 77) Second-generation (N = 194) Third-generation (N = 206)
Three comorbid anxiety disorders (N = 23) Prevalence (%) OR [95%CI] Natives (N = 15) 0.1 All generation migrants (N = 8) 0.1 1.20 [0.48–2.78] First generation (N = 4) 0.2 3.73 [1.06–10.42] Second-generation (N = 3) 0.1 0.98 [0.22–2.99] Third-generation (N = 1) 0.0 0.38 [0.02–1.90]
4. Discussion The present study found that migrant status was associated with a higher prevalence rate of anxiety disorders. When examining the different generations, the risk effect appeared significant in the three generations. Interestingly, this risk increased across the three migrant generations for SAD and GAD, while remained stable for PD and decreased for PTSD. Considering the high risk of psychotic disorders among migrants (Bourque et al., 2011), we repeated the analysis adjusting on psychotic disorders. The associations between migrants and the different anxiety disorders remained significant. The differences between generations of migrants were significant for 3GM in comparison of 1GM for the pooled anxiety disorders. Finally, the migrant status in individuals presenting with anxiety disorders was also associated with a higher rate of psychiatric comorbidities. The prevalence rate found in our study for all anxiety disorders (21.9%) was consistent with other figures from the literature (28.8% in the USA (Kessler et al., 2005), 21% in Europe (Wittchen and Jacobi, 2005)). Prevalence rates of PD, GAD, and SAD were higher than in a meta-analysis of European studies (5.6% in our study vs. 2.3% for PD, 12.8% vs. 1.5% for GAD, 4.4% vs. 2.0% for SAD) (Wittchen and Jacobi, 2005). Concerning GAD, the gap may be related to the use of MINI in the MHGP survey, and to the focus on somatic symptoms rather than cognitive symptoms, as discussed by Leray et al. (2011). Finally, the prevalence rate of PTSD (0.7%) was lower than in previous literature (between 2.0% and 4.0%) (Vaiva et al., 2008). Of note, PTSD does not belong to anxiety disorders according to ICD-10. However, its classification as anxiety disorders is debated (Friedman et al., 2011), and we chose to study the large spectrum of anxiety disorders. Previous studies that investigated the prevalence of whole anxiety disorders in migrants and ethnic minority groups found conflicting results. Contrary to the present study, several prevalence and incidence studies of anxiety disorders did not find any significant differences between 1GM and natives, e.g., in Austria or Netherlands (de Wit et al., 2008; Kerkenaar et al., 2013). Several other studies found a healthy migrant effects for whole anxiety disorders (Liddell et al., 2016; SalasWright et al., 2014; Szaflarski et al., 2017). In the study in Danish population, as in the present study, the 2GM with one foreign-born parent (i.e., the majority of 2GM) displayed higher incidence rate of anxiety and somatoform disorders (Cantor-Graae and Pedersen, 2013). In a 2011 meta-analysis on primary care patients, Tarricone et al. (2012) did not find any difference between ethnic minorities, natives and ethnic majorities for prevalence of anxiety disorders (RR = 1.01, 95% CI [0.76–1.32]). Interestingly, to our knowledge, the present study is the first to explore the 3GM. Some of the previous findings specifically regarding PD in migrants
p-values* 0.684 0.020 0.970 0.353
*Results from logistic regression. NB: No subject displayed the four considered anxiety disorders.
1GM (26.7% vs. 22.6%, OR = 1.14); the prevalence rate of PTSD was higher in 1GM than in 3GM (1.4% vs. 0.7%, OR = 2.16); and the prevalence rate of three comorbid anxiety disorders was higher in 1GM than in 3GM (0.2% vs. 0.1%, OR = 9.76). The proportion of migrants from different regions of origin did not differ between the overall sample of migrants and migrants with each anxiety disorder and each generation, except for PTSD in 1GM (more migrants from Maghreb in the sample with PTSD) and in 3GM (more migrants from Sub-Saharan Africa in the sample with PTSD) (Supplementary Table 3).
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Table 2 Comorbidities of subjects with anxiety disorders in natives and three generations of migrants (N, %). Natives
All-generation of migrants
p-values*
First-generation
Second-generation
Third-generation
Pooled anxiety disorders (N = 8459) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 5939 761 (12.8) 340 (5.7) 1508 (25.4) 238 (4.0) 328 (5.5) 367 (6.2) 244 (4.1)
N = 2520 354 (14.0) 210 (8.3) 744 (29.5) 126 (5.0) 135 (5.4) 243 (9.6) 206 (8.2)
0.018 < 0.001 < 0.001 0.040 0.503 < 0.001 < 0.001
N = 463 48 (10.3) 46 (9.9) 163 (35.2) 23 (5.0) 19 (4.1) 43 (9.6) 18 (3.9)
N = 1056 140 (13.3) 78 (7.4) 324 (30.7) 52 (4.9) 49 (4.6) 84 (8.0) 94 (8.9)
N = 1001 166 (16.6) 86 (8.6) 257 (25.7) 51 (5.1) 67 (6.7) 116 (11.6) 94 (9.4)
Panic disorder (N = 2178) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 1520 284 (18.7) 124 (8.2) 501 (33.0) 128 (8.4) 117 (7.7) 126 (8.3) 86 (5.7)
N = 658 133 (20.2) 93 (14.1) 256 (38.9) 62 (9.4) 55 (8.4) 83 (12.6) 81 (12.3)
0.018 < 0.001 0.007 0.447 0.599 0.002 < 0.001
N = 127 24 (18.9) 21 (16.5) 62 (48.8) 12 (9.4) 8 (6.3) 20 (15.7) 9 (7.1)
N = 274 54 (19.7) 38 (13.9) 109 (39.8) 25 (9.1) 21 (7.7) 31 (11.3) 32 (11.7)
N = 257 55 (21.4) 34 (13.2) 85 (33.1) 25 (9.7) 26 (10.1) 32 (12.4) 40 (15.6)
Social anxiety disorders (N = 1698) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 1221 135 (11.1) 82 (6.7) 312 (25.6) 66 (5.4) 80 (6.6) 84 (6.9) 65 (5.3)
N = 477 81 (17.0) 57 (11.9) 154 (32.3) 36 (7.5) 31 (6.5) 46 (9.6) 50 (10.5)
< 0.001 < 0.001 0.005 0.095 0.968 0.054 < 0.001
N = 77 17 (22.1) 14 (18.2) 35 (45.5) 6 (7.8) 7 (9.1) 9 (11.7) 5 (6.5)
N = 194 28 (14.4) 22 (11.3) 67 (34.5) 18 (9.3) 12 (6.2) 15 (7.7) 22 (11.3)
N = 206 36 (17.5) 21 (10.2) 52 (25.2) 12 (5.8) 12 (5.8) 22 (10.7) 23 (11.2)
Generalized anxiety disorder (N = 4946) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 3460 395 (11.4) 163 (4.7) 829 (24.0) 84 (2.4) 163 (4.7) 181 (5.2) 111 (3.2)
N = 1486 181 (12.2) 91 (6.1) 395 (26.6) 47 (3.2) 63 (4.2) 132 (8.9) 90 (6.1)
0.152 0.039 0.050 0.140 0.467 < 0.001 < 0.001
N = 274 18 (6.6) 18 (6.6) 81 (29.6) 8 (2.9) 8 (2.9) 18 (6.6) 7 (2.6)
N = 628 72 (11.5) 31 (4.9) 172 (27.4) 18 (2.9) 21 (3.3) 41 (7.0) 42 (6.7)
N = 584 91 (15.6) 42 (7.2) 142 (24.3) 21 (3.6) 34 (5.8) 70 (12.0) 41 (7.0)
Post-Traumatic Stress Disorder (N = 275) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 177 43 (24.3) 15 (8.5) 43 (24.3) 11 (6.2) 10 (5.6) 20 (11.3) 11 (6.2)
N = 98 23 (23.5) 13 (13.3) 35 (35.7) 11 (11.2) 8 (8.2) 18 (18.4) 18 (18.4)
0.699 0.208 0.044 0.142 0.420 0.103 0.002
N = 28 6 (21.4) 3 (10.7) 13 (46.4) 3 (10.7) 3 (10.7) 5 (17.9) 4 (14.3)
N = 44 10 (22.7) 5 (11.4) 14 (31.8) 6 (13.6) 3 (6.8) 6 (13.6) 9 (20.5)
N = 26 7 (26.9) 5 (19.2) 8 (30.8) 2 (7.7) 2 (7.7) 7 (26.9) 5 (19.2)
*Comparisons between all generations of migrants and non-migrants using chi-squared test.
The increased prevalence rates of anxiety disorders among migrant populations could be explained by several factors; and these factors might be variable according to both the considered host country and the migrant population, explaining some of the discrepancies between the present study and previous studies. For example, trauma or stressful life events might be involved in developing anxiety disorders (Hovens et al., 2010; Tebeka et al., 2016), and may occur in pre-migration, permigration and post-migration periods. Concerning 2GM and 3GM, transmission of pre-migration trauma psychiatric disorders have been suggested, with several studies on Shoah survivor families supporting this hypothesis (Baider et al., 2000; Baranowsky et al., 1998). The gap between cultural backgrounds related to both country of origin and host country, that involve acculturation issues, may also be implicated both in the increased prevalence rates in the present study, and in the discrepancies with precedent studies (Lewis-Fernández et al., 2016). Other hypotheses address migrants' socio-economic conditions (post-migration factors), as anxiety disorders have been previously found to be associated with psychosocial and economic adversities (Green and Benzeval, 2013). The fact that, in the MHGP sample, migrants with anxiety disorders had a higher educational level and a lower income level is consistent with this hypothesis. This fact could be due to discrimination phenomena. Specifically, the increased prevalence in 3GM in comparison to 1GM could be related to the ethnic density effect
and ethnic minority groups were conflicting with our observations of increased prevalence rates in 2GM and 3GM and non-significant differences for the 1GM. Indeed, several studies found a healthy migrant effect for PD among 1GM and 2GM or ethnic minorities in the USA (Blanco et al., 2014; Salas-Wright et al., 2014). On the other hand, in Spain, the rate of PD among Latin American-born patients consulting in a primary health care for PD was significantly higher than Spanish-born patients (20.5% vs. 15.3%) (Salinero-Fort et al., 2015). Regarding SAD, as in the present study, Beutel et al. (2016) did not find any significant difference in the prevalence rates within 1GM and 2GM in Germany. As for the other anxiety disorders analysed in Salas-Wright et al. (2014) study, there was a healthy migrant effect in SAD for both 1GM and 2GM in the USA. Moreover, few studies have investigated the prevalence rate of GAD in migrant populations. Confirming our results, an Indian study found that Kashmiri migrants in a refugees camp displayed higher rate of GAD than native controls (Banal et al., 2010). Several studies on ethnic minority groups in the USA did not find significant differences in prevalence rates (Brenes et al., 2008; Hoppe et al., 1989). Concerning PTSD among migrants and ethnic minority groups, several studies reported high prevalence rates in 1GM, specifically in non-voluntary and refugee migrants (Rasmussen et al., 2012; Schweitzer et al., 2006). To our knowledge, the present study is the first to compare prevalence rates of PTSD in 2GM and 3GM to natives. 41
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References
related phenomena (Shaw et al., 2012). Indeed, 1GM may live in neighbourhoods with higher ethnic density, which has been shown to be a protective factor against psychiatric disorders, including anxiety disorders. In comparison to psychotic disorders, which has been showed consistently as associated to the migrant status, the increased prevalence rates of anxiety disorders in the 2GM and 3GM for PD and GAD (OR between 1.15 and 1.25) were lower (OR = 2.3 for 1GM and OR = 2.1 for 2GM) (Bourque et al., 2011). However, as anxiety disorders are more prevalent than psychotic disorders (21.9% in the present study vs. 0.46% for psychotic disorders in a recent French study (Szöke et al., 2015)), the burden of anxiety disorders in migrants may be higher. Regarding comorbidities, migrants with anxiety disorders suffered from more psychiatric comorbidities than natives with anxiety disorders. They displayed higher rates of psychotic, mood and addictive disorders, which is consistent with previous findings from the MHGP regarding the effect of migration on the prevalence of these outcomes (Amad et al., 2013; Tebeka et al., 2018; Pignon et al., 2017a, 2018). Thus, these associated psychiatric comorbidities appear to be nonspecific to migrants with anxiety disorders, but rather common in all migrants suffering from psychiatric disorders. Concerning addictive disorders, different explanatory models could explain this phenomenon. Indeed, the increased prevalences of AUDs and SUDs among migrants could imply that anxiety disorders are more severe clinically. However, as addictive disorders are associated with anxiety disorder (Kessler et al., 2005), it could also reflect the involvement of addictive disorders as causal factors of anxiety disorders on the migrant populations. Likewise, cannabis use disorder could explain the higher rate of suicide attempts among migrants (Serafini et al., 2012). Furthermore, methodological issues may also affect the results of the different migrant studies on anxiety disorders and explain the discrepancies with the present study. For instance, studies based on medical registers and census figures, e.g. Cantor Graae and Pedersen (2013), may underestimate the number of migrants (i.e., in the denominator) in these data (e.g., undocumented or recently moved), and therefore overestimate the risk of psychiatric disorders (Bourque et al., 2011). Moreover, migrant studies may be affected by cultural biases (and the MINI has not been assessed cross-culturally) (Zandi et al., 2008). Regarding the sampling method, as it was done by quotas within regions, and thus non probabilistic, we can't assume that our sample was representative of the general population. However, quota sampling method warrant same socio-demographic characteristics of the general population. The other limitations of this study, as the French language in inclusion criterion, the absence of data concerning the subjects that refused to participate, have already been discussed in other papers on MHGP survey (Pignon et al., 2018; Rolland et al., 2017). In conclusion, the prevalence of whole anxiety disorders was increased in 1GM, 2GM and 3GM. Migration led to a profile of anxiety disorders with higher rates of psychiatric comorbidities, i.e., of psychotic, mood and addictive disorders. Clinicians and public authorities should take account of this fact to prevent, identify, and rapidly care of the affected subjects.
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Conflicts of interest The Authors have declared that there are no conflicts of interest in relation to the subject of this study.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx. doi.org/10.1016/j.jpsychires.2018.03.007.
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Journal of Psychiatric Research journal homepage: www.elsevier.com/locate/jpsychires
Increased prevalence of anxiety disorders in third-generation migrants in comparison to natives and to first-generation migrants
T
Baptiste Pignona,j,∗, Ali Amadb,c, Antoine Pelissoloa,j, Thomas Fovetb, Pierre Thomasb, Guillaume Vaivab, Jean-Luc Roelandtd, Imane Benradiad, Benjamin Rollande,f, Pierre A. Geoffroyg,h,i,j a
AP-HP, DHU PePSY, Hôpitaux universitaires Henri-Mondor, Pôle de Psychiatrie, Inserm, U955, Team 15, UPEC, Université Paris-Est, Faculté de médecine, Créteil, 94000, France b Univ. Lille, CNRS UMR 9193-PsyCHIC-SCALab, CHU Lille, Pôle de Psychiatrie, Unité CURE, F-59000, Lille, France c Fédération régionale de recherche en santé mentale (F2RSM) Nord-Pas-de-Calais, F-59000, Lille, France d EPSM Lille Métropole, Centre Collaborateur de l’Organisation Mondiale de la Santé pour la recherche et la formation en santé mentale, Equipe Eceve Inserm UMR 1123, Lille, France e Service Universitaire d’Addictologie, Pôle UP-MOPHA, CH Le Vinatier, Univ. Lyon, 69500, Bron, France f CRNL Inserm U1028/CNRS UMR5292, CH Le Vinatier, 69678, Bron Cedex, France g Inserm, U1144, Paris, F-75006, France h Université Paris Diderot, Sorbonne Paris Cité, UMR-S 1144, Paris, F-75013, France i AP-HP, GH Saint-Louis, Lariboisière, F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, 75475, Paris Cedex 10, France j Fondation FondaMental, Créteil, 94000, France
A R T I C LE I N FO
A B S T R A C T
Keywords: Migrants Anxiety disorders Panic disorder Social anxiety disorder Generalized anxiety disorder Post-traumatic stress disorder
Introduction: We sought to examine the prevalence of anxiety disorders associated with migration in the first-, second- and third-generation. Methods: The French Mental Health in the General Population cross-sectional survey interviewed 38,694 individuals using the MINI. The prevalence of lifetime anxiety disorders, and comorbidities was compared between migrants and non-migrants and by generation. All analyses were adjusted for age, sex, and income and education levels. Results: In comparison to natives, pooled anxiety disorders were more common among migrants (25.3% vs. 20.7%, OR = 1.24) and among the three studied generations of migrants. Moreover, the prevalence rate of the pooled anxiety disorders was significantly higher in third-generation migrants, in comparison to first-generation (26.7% vs. 22.6%, OR = 1.14). Prevalence rates were higher in migrants for panic disorder (6.6% vs. 5.3%, OR = 1.20), general anxiety disorder (15.0% vs. 12.0%, OR = 1.24), posttraumatic stress disorder (1.0% vs. 0.6%, OR = 1.51), but not for social anxiety disorder. In comparison to natives, migrants with anxiety disorders had higher prevalence rates of suicide attempts (14.0% vs. 12.8% for natives), psychotic disorders (8.3% vs. 5.7%), unipolar depressive disorder (29.5% vs. 25.4%), bipolar disorder (5.0% vs. 4.0%), and addictive disorders (9.6% vs. 6.2% for alcohol use disorder, 8.2% vs. 4.1% for substance use disorders). Conclusion: Migration was associated with a higher prevalence of all anxiety disorders, in the first, second and third generation, and associated with more psychiatric comorbidities. Moreover, the prevalence increased across generations, and was significantly higher among third-generation migrants, in comparison to first-generation.
1. Introduction Anxiety disorders are the most common psychiatric disorders, affecting lifetime between 20 and 40% of the general population (Kessler et al., 2005; Leray et al., 2011). They include panic disorder (PD), social
anxiety disorder (SAD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). Some environmental risk factors of anxiety disorders have already been highlighted, as stressful life events, or history of trauma (Blanco et al., 2014). As migration has been identified as a risk factor for several
∗ Corresponding author. Hôpital Albert Chenevier, Groupe hospitaliers Henri-Mondor, CHU de Créteil, Assistance Publique-Hôpitaux de Paris (AP-HP), 40 rue de Mesly, 94000, Créteil, France. E-mail address: [email protected] (B. Pignon).
https://doi.org/10.1016/j.jpsychires.2018.03.007 Received 3 December 2017; Received in revised form 26 February 2018; Accepted 19 March 2018 0022-3956/ © 2018 Elsevier Ltd. All rights reserved.
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Lifetime comorbidities possibly associated with anxiety disorders were screened: history of suicide attempts, bipolar I disorder (BD), unipolar depressive disorder (UDD), dysthymia, psychotic disorders, alcohol use disorders (AUDs), and SUDs. Details regarding psychiatric disorders assessment in the MHGP survey are available elsewhere (Amad et al., 2013; Pignon et al., 2017a; Rolland et al., 2017; Tebeka et al., 2018).
psychiatric disorders, including psychotic (Bourque et al., 2011) and mood disorders (Mindlis and Boffetta, 2017), it has also been suggested in anxiety disorders. Some studies found higher prevalence rates of anxiety disorders among first-generation migrants than among natives (Beutel et al., 2016), or higher incidence rates in second-generation migrants (Cantor-Graae and Pedersen, 2013). Of note, several studies made the opposite observation, and even described an “healthy migrant effect”, i.e., lower rates of anxiety disorders among first-generation migrant than among natives, e.g., in the USA (Liddell et al., 2016; SalasWright et al., 2014). In addition, several studies found also discrepancies between first- and second-generation migrations, e.g., an increased risk only in the first-generation (Beutel et al., 2016), or only in the second-generation (Cantor-Graae and Pedersen, 2013). For the first time, we have recently studied the third-generation migrants in the Mental Health in General Population (MHGP) survey. The studies showed that the prevalence rates of psychotic, mood and addictive disorders were higher among third-generation migrants than among natives (Amad et al., 2013; Pignon et al., 2017a; Rolland et al., 2017); and it could also be the case for anxiety disorders. Finally, migrants studies are important to replicate in varied cultural countries (Bhugra, 2004), and anxiety disorders have never been studied in France. It is important to note that no previous study has ever explored whether anxiety disorders in migrants were associated with specific clinical characteristics. Yet, this is a major issue since the migrant status could be associated with a specific profile of a disease, e.g., with higher rates of psychiatric comorbidities. Moreover, in a precedent study in the same MHGP survey, we observed that migrants with mood disorders had a more severe profile, with increased rates of comorbid psychotic and substance use disorders (SUDs) (Pignon et al., 2017a). In this context, the present study aimed to examine the prevalence of anxiety disorders (including PD, SAD, GAD, PTSD, pooled anxiety disorders, and comorbid anxiety disorders) in migrant groups, both overall and according to first- (1GM), second- (2GM) and third-generation (3GM), in a large cross-sectional survey, following the same methodology as our precedent work in mood disorders (Pignon et al., 2017a). These prevalences among migrants were compared to the prevalence among natives. We also compared the rate of psychiatric comorbidities of anxiety disorders, including suicide attempts, psychotic disorders, mood disorders and addictive disorders, between migrants and natives. Regarding the higher rate of depression among migrants in our precedent work, our hypothesis was that migrants display more anxiety disorders and that migrants with anxiety disorders displayed more comorbidities than natives.
2.3. Assessment of migrant status As in precedent studies (Amad et al., 2013; Pignon et al., 2018, 2017b; Rolland et al., 2017), the designation of migrant status was based on the country of birth of the subject (1GM), the subject's parents (2GM), and the subject's grandparents (3GM). 2.4. Statistical analyses To examine the associations between anxiety disorders (PD, SAD, GAD, PTSD, pooled anxiety disorders, and comorbid anxiety disorders) and migration status and/or different generations of migration (1GM, 2GM or 3GM), we performed logistic regression analyses adjusting for potential confounding factors: sex, age, income and education levels (Green and Benzeval, 2013; Kessler et al., 2005). Finally, we also assessed several comorbidities according to migrant status using chisquare tests. All statistical analyses were performed using R software (http://www.R-project.org/) version 3.3.1. 3. Results 3.1. Population and sociodemographic characteristics Migrants were younger, with a higher educational level, and a lower income level than natives. There was a significant correlation between age and educational level (average age (standard-deviation) in years by educational level: low: 60.4 (16.5); medium: 41.5 (16.0); high: 36.5 (14.5); p = 0.05). Sex ratio was statistically different (more males among migrants). Sociodemographic characteristics of individuals with anxiety disorders are available in Supplementary Table 1. 3.2. Risk of anxiety disorders according to migrant status Anxiety disorders were diagnosed in 21.9% of the total population, including 5.6% for PD, 4.4% for SAD, 12.8% for GAD, and 0.7% for PTSD. 1.6% of the population displayed two comorbid anxiety disorders, and 0.1% three (none displayed the four). Results of logistic regressions comparing anxiety disorders between natives and migrants are available in Table 1. Pooled anxiety disorders were more common among migrants (25.3% vs. 20.7%, OR = 1.24), as in each of the three generations. Specifically, the prevalence rate of PD was also higher in the whole sample of migrants (6.6% vs. 5.3%, OR = 1.20), and in 2GM and 3GM. The rates were not significantly different in 1GM. We did not observe any significant differences in the prevalence of SAD according to migrant status (4.8% vs. 4.4%), neither in each of the three generation. Concerning GAD, the prevalence rate was significantly higher among the whole sample of migrants (15.0% vs. 12.0%, OR = 1.24), as in each of the three generations. Finally, PTSD was more common among migrants (1.0% vs. 0.6%, OR = 1.51), and in 1GM and 2GM. The rates were not significantly different in 3GM. The prevalence rates of comorbid anxiety disorders were not significantly different according to migrant status (two comorbid anxiety disorders: 1.4% vs. 1.8%, three: 0.1 for both), as well as in the three generation of migrants (except in the first-generation: more three comorbid anxiety disorders than among natives, 0.2% vs. 0.1%, OR = 3.73). The different generations of migrants were also compared with each other (Supplementary Table 2). After statistical adjustment, the prevalence rate of pooled anxiety disorders was higher in 3GM than in
2. Methods 2.1. Mental Health in General Population (MHGP) survey The cross-sectional MHGP survey, conducted by the World Health Organization French Collaborating Centre, interviewed 38,694 subjects in France between 1999 and 2003. The subjects providing consent, speaking French and aged over 18 were selected in 47 sites by a quotasampling method. Methodological details can be found elsewhere (Leray et al., 2011). Legal authorization (number 98.126) was obtained by the ‘Commission Nationale Informatique et Liberté’ (CNIL) and the ‘Comité consultatif sur le traitement de l'information en matière de recherche’ (CCTIRS). 2.2. Assessment of psychiatric disorders The Mini International Neuropsychiatric Interview (MINI, French version 5.0.0) was used to screen for psychiatric disorders, including PD, SAD, GAD, and PTSD, according to ICD-10 criteria. It has been validated in the general population and has good to very good validity, reliability (inter-rater and test-retest), sensitivity and specificity (Sheehan et al., 1997). 39
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3.3. Comorbidities of anxiety disorders associated with migrant status
Table 1 Prevalence and odds ratio (OR) of anxiety disorders comparing natives to different generations of migrants adjusted for age, sex, income level and level of education.
The migrant status in anxiety disorders was associated with more frequent history of suicide attempts (14.0% for migrants vs. 12.8% for natives), more psychotic disorders (8.3% vs. 5.7%), more UDD (29.5% vs. 25.4%), more BD (5.0% vs. 4.0%), and more addictive disorders (9.6% vs. 6.2% for AUD, 8.2% vs. 4.1% for SUDs). There were no significant differences concerning dysthymia. The increased prevalence of suicide attempts history was observed among migrants with PD (20.2% vs. 18.7%) and SAD (17.0% vs. 11.1%) but not in other anxiety disorders. Concerning psychotic disorders, the prevalence was increased in migrants with PD (14.1% vs. 8.2%), SAD (11.9% vs. 6.7%), and GAD (6.1% vs. 4.7%). UDD was more frequent in migrants with each one of the anxiety disorders (38.9% vs. 33.0% for PD, 32.3% vs. 25.6% for SAD, 26.6% vs. 24.0% for GAD, and 35.7% vs. 24.3% for PTSD). Likewise for SUDs (12.3% vs. 5.7% for PD, 10.5% vs. 5.3% for SAD, 6.1% vs. 3.2% for GAD, and 18.4% vs. 6.2% for PTSD). AUDs were more frequent in migrants with PD (12.6% vs. 8.3%) and GAD (8.9% vs. 5.2%) (Table 2).
Panic disorder (N = 2178) Prevalence (%) OR [95%CI] 5.3 6.6 1.20 [1.08–1.32] 6.2 1.20 [0.98–1.45] 6.6 1.19 [1.04–1.36] 6.8 1.20 [1.04–1.38]
p-values* < 0.001 0.065 0.012 0.012
Prevalence (%) OR [95%CI] 4.3 4.8 1.03 [0.92–1.16] 3.8 0.88 [0.69–1.12] 4.7 1.00 [0.85–1.17] 5.5 1.15 [0.98–1.34]
p-values* 0.550 0.327 0.976 0.080
Generalized anxiety disorder (N = 4946) Prevalence (%) OR [95%CI] Natives (N = 3460) 12.0 All generation migrants (N = 1486) 15.0 1.24 [1.16–1.33] First-generation (N = 274) 13.4 1.24 [1.01–1.31] Second-generation (N = 628) 15.3 1.15 [1.13–1.37] Third-generation (N = 584) 15.6 1.30 [1.18–1.43]
p-values* < 0.001 0.048 < 0.001 < 0.001
Post-Traumatic Stress Disorder (N = 275) Prevalence (%) OR [95%CI] Natives (N = 177) 0.6 All generation migrants (N = 98) 1.0 1.51 [1.21–2.00] First-generation (N = 28) 1.4 2.28 [1.49–3.36] Second-generation (N = 44) 1.1 1.54 [1.07–2.15] Third-generation (N = 26) 0.7 1.05 [0.67–1.58]
p-values* 0.001 < 0.001 0.015 0.690
At least one anxiety disorder (N = 8459) Prevalence (%) OR [95%CI] Natives (N = 5939) 20.7 All generation migrants (N = 2520) 25.3 1.24 [1.17–1.31] First-generation (N = 463) 22.6 1.14 [1.02–1.28] Second-generation (N = 1056) 25.4 1.23 [1.14–1.33] Third-generation (N = 1001) 26.7 1.30 [1.20–1.41]
p-values* < 0.001 0.019 < 0.001 < 0.001
Two comorbid anxiety disorders (N = 615) Prevalence (%) OR [95%CI] Natives (N = 409) 1.4 All generation migrants (N = 183) 1.8 1.18 [0.99–1.41] First-generation (N = 35) 1.7 1.30 [0.91–1.81] 1.9 1.17 [0.91–1.50] Second-generation (N = 78) Third-generation (N = 70) 1.9 1.13 [0.86–1.46]
p-values* 0.067 0.129 0.202 0.358
Natives (N = 1520) All generation migrants (N = 658) First-generation (N = 127) Second-generation (N = 274) Third-generation (N = 257) Social anxiety disorder (N = 1698) Natives (N = 1221) All generation migrants (N = 477) First-generation (N = 77) Second-generation (N = 194) Third-generation (N = 206)
Three comorbid anxiety disorders (N = 23) Prevalence (%) OR [95%CI] Natives (N = 15) 0.1 All generation migrants (N = 8) 0.1 1.20 [0.48–2.78] First generation (N = 4) 0.2 3.73 [1.06–10.42] Second-generation (N = 3) 0.1 0.98 [0.22–2.99] Third-generation (N = 1) 0.0 0.38 [0.02–1.90]
4. Discussion The present study found that migrant status was associated with a higher prevalence rate of anxiety disorders. When examining the different generations, the risk effect appeared significant in the three generations. Interestingly, this risk increased across the three migrant generations for SAD and GAD, while remained stable for PD and decreased for PTSD. Considering the high risk of psychotic disorders among migrants (Bourque et al., 2011), we repeated the analysis adjusting on psychotic disorders. The associations between migrants and the different anxiety disorders remained significant. The differences between generations of migrants were significant for 3GM in comparison of 1GM for the pooled anxiety disorders. Finally, the migrant status in individuals presenting with anxiety disorders was also associated with a higher rate of psychiatric comorbidities. The prevalence rate found in our study for all anxiety disorders (21.9%) was consistent with other figures from the literature (28.8% in the USA (Kessler et al., 2005), 21% in Europe (Wittchen and Jacobi, 2005)). Prevalence rates of PD, GAD, and SAD were higher than in a meta-analysis of European studies (5.6% in our study vs. 2.3% for PD, 12.8% vs. 1.5% for GAD, 4.4% vs. 2.0% for SAD) (Wittchen and Jacobi, 2005). Concerning GAD, the gap may be related to the use of MINI in the MHGP survey, and to the focus on somatic symptoms rather than cognitive symptoms, as discussed by Leray et al. (2011). Finally, the prevalence rate of PTSD (0.7%) was lower than in previous literature (between 2.0% and 4.0%) (Vaiva et al., 2008). Of note, PTSD does not belong to anxiety disorders according to ICD-10. However, its classification as anxiety disorders is debated (Friedman et al., 2011), and we chose to study the large spectrum of anxiety disorders. Previous studies that investigated the prevalence of whole anxiety disorders in migrants and ethnic minority groups found conflicting results. Contrary to the present study, several prevalence and incidence studies of anxiety disorders did not find any significant differences between 1GM and natives, e.g., in Austria or Netherlands (de Wit et al., 2008; Kerkenaar et al., 2013). Several other studies found a healthy migrant effects for whole anxiety disorders (Liddell et al., 2016; SalasWright et al., 2014; Szaflarski et al., 2017). In the study in Danish population, as in the present study, the 2GM with one foreign-born parent (i.e., the majority of 2GM) displayed higher incidence rate of anxiety and somatoform disorders (Cantor-Graae and Pedersen, 2013). In a 2011 meta-analysis on primary care patients, Tarricone et al. (2012) did not find any difference between ethnic minorities, natives and ethnic majorities for prevalence of anxiety disorders (RR = 1.01, 95% CI [0.76–1.32]). Interestingly, to our knowledge, the present study is the first to explore the 3GM. Some of the previous findings specifically regarding PD in migrants
p-values* 0.684 0.020 0.970 0.353
*Results from logistic regression. NB: No subject displayed the four considered anxiety disorders.
1GM (26.7% vs. 22.6%, OR = 1.14); the prevalence rate of PTSD was higher in 1GM than in 3GM (1.4% vs. 0.7%, OR = 2.16); and the prevalence rate of three comorbid anxiety disorders was higher in 1GM than in 3GM (0.2% vs. 0.1%, OR = 9.76). The proportion of migrants from different regions of origin did not differ between the overall sample of migrants and migrants with each anxiety disorder and each generation, except for PTSD in 1GM (more migrants from Maghreb in the sample with PTSD) and in 3GM (more migrants from Sub-Saharan Africa in the sample with PTSD) (Supplementary Table 3).
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Table 2 Comorbidities of subjects with anxiety disorders in natives and three generations of migrants (N, %). Natives
All-generation of migrants
p-values*
First-generation
Second-generation
Third-generation
Pooled anxiety disorders (N = 8459) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 5939 761 (12.8) 340 (5.7) 1508 (25.4) 238 (4.0) 328 (5.5) 367 (6.2) 244 (4.1)
N = 2520 354 (14.0) 210 (8.3) 744 (29.5) 126 (5.0) 135 (5.4) 243 (9.6) 206 (8.2)
0.018 < 0.001 < 0.001 0.040 0.503 < 0.001 < 0.001
N = 463 48 (10.3) 46 (9.9) 163 (35.2) 23 (5.0) 19 (4.1) 43 (9.6) 18 (3.9)
N = 1056 140 (13.3) 78 (7.4) 324 (30.7) 52 (4.9) 49 (4.6) 84 (8.0) 94 (8.9)
N = 1001 166 (16.6) 86 (8.6) 257 (25.7) 51 (5.1) 67 (6.7) 116 (11.6) 94 (9.4)
Panic disorder (N = 2178) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 1520 284 (18.7) 124 (8.2) 501 (33.0) 128 (8.4) 117 (7.7) 126 (8.3) 86 (5.7)
N = 658 133 (20.2) 93 (14.1) 256 (38.9) 62 (9.4) 55 (8.4) 83 (12.6) 81 (12.3)
0.018 < 0.001 0.007 0.447 0.599 0.002 < 0.001
N = 127 24 (18.9) 21 (16.5) 62 (48.8) 12 (9.4) 8 (6.3) 20 (15.7) 9 (7.1)
N = 274 54 (19.7) 38 (13.9) 109 (39.8) 25 (9.1) 21 (7.7) 31 (11.3) 32 (11.7)
N = 257 55 (21.4) 34 (13.2) 85 (33.1) 25 (9.7) 26 (10.1) 32 (12.4) 40 (15.6)
Social anxiety disorders (N = 1698) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 1221 135 (11.1) 82 (6.7) 312 (25.6) 66 (5.4) 80 (6.6) 84 (6.9) 65 (5.3)
N = 477 81 (17.0) 57 (11.9) 154 (32.3) 36 (7.5) 31 (6.5) 46 (9.6) 50 (10.5)
< 0.001 < 0.001 0.005 0.095 0.968 0.054 < 0.001
N = 77 17 (22.1) 14 (18.2) 35 (45.5) 6 (7.8) 7 (9.1) 9 (11.7) 5 (6.5)
N = 194 28 (14.4) 22 (11.3) 67 (34.5) 18 (9.3) 12 (6.2) 15 (7.7) 22 (11.3)
N = 206 36 (17.5) 21 (10.2) 52 (25.2) 12 (5.8) 12 (5.8) 22 (10.7) 23 (11.2)
Generalized anxiety disorder (N = 4946) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 3460 395 (11.4) 163 (4.7) 829 (24.0) 84 (2.4) 163 (4.7) 181 (5.2) 111 (3.2)
N = 1486 181 (12.2) 91 (6.1) 395 (26.6) 47 (3.2) 63 (4.2) 132 (8.9) 90 (6.1)
0.152 0.039 0.050 0.140 0.467 < 0.001 < 0.001
N = 274 18 (6.6) 18 (6.6) 81 (29.6) 8 (2.9) 8 (2.9) 18 (6.6) 7 (2.6)
N = 628 72 (11.5) 31 (4.9) 172 (27.4) 18 (2.9) 21 (3.3) 41 (7.0) 42 (6.7)
N = 584 91 (15.6) 42 (7.2) 142 (24.3) 21 (3.6) 34 (5.8) 70 (12.0) 41 (7.0)
Post-Traumatic Stress Disorder (N = 275) Suicide attempt Psychotic disorder Unipolar depressive disorder Bipolar disorder Dysthymia Alcohol use disorders Substance use disorders
N = 177 43 (24.3) 15 (8.5) 43 (24.3) 11 (6.2) 10 (5.6) 20 (11.3) 11 (6.2)
N = 98 23 (23.5) 13 (13.3) 35 (35.7) 11 (11.2) 8 (8.2) 18 (18.4) 18 (18.4)
0.699 0.208 0.044 0.142 0.420 0.103 0.002
N = 28 6 (21.4) 3 (10.7) 13 (46.4) 3 (10.7) 3 (10.7) 5 (17.9) 4 (14.3)
N = 44 10 (22.7) 5 (11.4) 14 (31.8) 6 (13.6) 3 (6.8) 6 (13.6) 9 (20.5)
N = 26 7 (26.9) 5 (19.2) 8 (30.8) 2 (7.7) 2 (7.7) 7 (26.9) 5 (19.2)
*Comparisons between all generations of migrants and non-migrants using chi-squared test.
The increased prevalence rates of anxiety disorders among migrant populations could be explained by several factors; and these factors might be variable according to both the considered host country and the migrant population, explaining some of the discrepancies between the present study and previous studies. For example, trauma or stressful life events might be involved in developing anxiety disorders (Hovens et al., 2010; Tebeka et al., 2016), and may occur in pre-migration, permigration and post-migration periods. Concerning 2GM and 3GM, transmission of pre-migration trauma psychiatric disorders have been suggested, with several studies on Shoah survivor families supporting this hypothesis (Baider et al., 2000; Baranowsky et al., 1998). The gap between cultural backgrounds related to both country of origin and host country, that involve acculturation issues, may also be implicated both in the increased prevalence rates in the present study, and in the discrepancies with precedent studies (Lewis-Fernández et al., 2016). Other hypotheses address migrants' socio-economic conditions (post-migration factors), as anxiety disorders have been previously found to be associated with psychosocial and economic adversities (Green and Benzeval, 2013). The fact that, in the MHGP sample, migrants with anxiety disorders had a higher educational level and a lower income level is consistent with this hypothesis. This fact could be due to discrimination phenomena. Specifically, the increased prevalence in 3GM in comparison to 1GM could be related to the ethnic density effect
and ethnic minority groups were conflicting with our observations of increased prevalence rates in 2GM and 3GM and non-significant differences for the 1GM. Indeed, several studies found a healthy migrant effect for PD among 1GM and 2GM or ethnic minorities in the USA (Blanco et al., 2014; Salas-Wright et al., 2014). On the other hand, in Spain, the rate of PD among Latin American-born patients consulting in a primary health care for PD was significantly higher than Spanish-born patients (20.5% vs. 15.3%) (Salinero-Fort et al., 2015). Regarding SAD, as in the present study, Beutel et al. (2016) did not find any significant difference in the prevalence rates within 1GM and 2GM in Germany. As for the other anxiety disorders analysed in Salas-Wright et al. (2014) study, there was a healthy migrant effect in SAD for both 1GM and 2GM in the USA. Moreover, few studies have investigated the prevalence rate of GAD in migrant populations. Confirming our results, an Indian study found that Kashmiri migrants in a refugees camp displayed higher rate of GAD than native controls (Banal et al., 2010). Several studies on ethnic minority groups in the USA did not find significant differences in prevalence rates (Brenes et al., 2008; Hoppe et al., 1989). Concerning PTSD among migrants and ethnic minority groups, several studies reported high prevalence rates in 1GM, specifically in non-voluntary and refugee migrants (Rasmussen et al., 2012; Schweitzer et al., 2006). To our knowledge, the present study is the first to compare prevalence rates of PTSD in 2GM and 3GM to natives. 41
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References
related phenomena (Shaw et al., 2012). Indeed, 1GM may live in neighbourhoods with higher ethnic density, which has been shown to be a protective factor against psychiatric disorders, including anxiety disorders. In comparison to psychotic disorders, which has been showed consistently as associated to the migrant status, the increased prevalence rates of anxiety disorders in the 2GM and 3GM for PD and GAD (OR between 1.15 and 1.25) were lower (OR = 2.3 for 1GM and OR = 2.1 for 2GM) (Bourque et al., 2011). However, as anxiety disorders are more prevalent than psychotic disorders (21.9% in the present study vs. 0.46% for psychotic disorders in a recent French study (Szöke et al., 2015)), the burden of anxiety disorders in migrants may be higher. Regarding comorbidities, migrants with anxiety disorders suffered from more psychiatric comorbidities than natives with anxiety disorders. They displayed higher rates of psychotic, mood and addictive disorders, which is consistent with previous findings from the MHGP regarding the effect of migration on the prevalence of these outcomes (Amad et al., 2013; Tebeka et al., 2018; Pignon et al., 2017a, 2018). Thus, these associated psychiatric comorbidities appear to be nonspecific to migrants with anxiety disorders, but rather common in all migrants suffering from psychiatric disorders. Concerning addictive disorders, different explanatory models could explain this phenomenon. Indeed, the increased prevalences of AUDs and SUDs among migrants could imply that anxiety disorders are more severe clinically. However, as addictive disorders are associated with anxiety disorder (Kessler et al., 2005), it could also reflect the involvement of addictive disorders as causal factors of anxiety disorders on the migrant populations. Likewise, cannabis use disorder could explain the higher rate of suicide attempts among migrants (Serafini et al., 2012). Furthermore, methodological issues may also affect the results of the different migrant studies on anxiety disorders and explain the discrepancies with the present study. For instance, studies based on medical registers and census figures, e.g. Cantor Graae and Pedersen (2013), may underestimate the number of migrants (i.e., in the denominator) in these data (e.g., undocumented or recently moved), and therefore overestimate the risk of psychiatric disorders (Bourque et al., 2011). Moreover, migrant studies may be affected by cultural biases (and the MINI has not been assessed cross-culturally) (Zandi et al., 2008). Regarding the sampling method, as it was done by quotas within regions, and thus non probabilistic, we can't assume that our sample was representative of the general population. However, quota sampling method warrant same socio-demographic characteristics of the general population. The other limitations of this study, as the French language in inclusion criterion, the absence of data concerning the subjects that refused to participate, have already been discussed in other papers on MHGP survey (Pignon et al., 2018; Rolland et al., 2017). In conclusion, the prevalence of whole anxiety disorders was increased in 1GM, 2GM and 3GM. Migration led to a profile of anxiety disorders with higher rates of psychiatric comorbidities, i.e., of psychotic, mood and addictive disorders. Clinicians and public authorities should take account of this fact to prevent, identify, and rapidly care of the affected subjects.
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Conflicts of interest The Authors have declared that there are no conflicts of interest in relation to the subject of this study.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx. doi.org/10.1016/j.jpsychires.2018.03.007.
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