Depression, anxiety and suicidal ideation among 1^st and 2^nd generation migrants - results from the Gutenberg health study

Migration is currently reaching a record high on a global level [1]. The proportion of migrants in Germany has risen to about 20.3 % in 2014 according to Federal census statistics [2], and keeps growing strongly. Migration is a complex process which may be voluntary or involuntary. The migratory process is generally regarded as a stressful life event [3], consisting of a stage of decision and planning (pre-migration), followed by the physical transition (migration), often characterized by multiple losses, e.g., of neighborhoods, homes, work and social ties. Even if the destination promises safety from violence and political or ethnical prosecution, escape may pose many imponderables including threats to the lives of the migrant, separation from his or her next-to kin and unforeseen losses. Described as post-migration, migrants need to adjust to new social and cultural contexts including learning a new language. Acculturation requires reconciling the culture of origin with the new culture. This often lengthy process is fraught with multiple stressors, e.g., uncertain approval by the authorities, lack of employment and social recognition. As a fourth stage, sub-standard living and minority discrimination are discussed as possible long-term outcomes [1].

While international studies have demonstrated mental and physical strains among migrants, it has remained an issue of debate if migration is associated with stress and compromised physical and mental health in the long run. In a population- based German survey, Glaesmer et al. [4] found no evidence for increased mental disorders in migrants. However, their sample of immigrants was small. In their systematic review of 34 studies, Lindert et al. [5] found increased rates of depression (44 %), respectively anxiety (44 %) only among compelled refugees; prevalence rates of labor migrants were in the range of German population samples (20 % depression; 21 % anxiety). In the WHO/EURO Multicentre Study on Suicidal Behavior, the largest available European database, suicide attempt rates were higher in about half the immigrant groups studied, and rarely lower compared to the host populations. Turks also showed higher rates despite low suicide rates in their home country [6]. Suicide attempts in women of Turkish origin in Germany were much higher compared to native German women [7], however, German data are scarce [8].

In order to determine the risk of mental disorders in migrants, risk factors such as female sex, low income and poor neighborhoods [9], time since migration [1] and ethnic group need to be taken into account. In the state of Rhineland-Palatinate the proportion of migrants has been estimated at 20.3 %. As in Germany, Turkish were the largest, mostly Muslim group of migrants. Studies have compared Turkish to Polish migrants, the largest group from Eastern Europe with a Christian background. A small study by Mewes at al. [10] showed no differences between the mental health of migrants from Turkey, the largest group of migrants in Germany, from Eastern Europe and the former Soviet Union. Wittig et al. [11], however, reported increased anxiety, depression and somatization as well as less mental health care utilization in Vietnamese and Polish migrants compared to the German population. Morawa and Erim [9] found that 109 Turkish migrants recruited from the community reported more depression and lower quality of life than a random sample of Polish migrants, who were comparable to reference values from the German population. In a primary care sample Turkish patients reported higher depression and somatoform complaints compared to German natives (when adjusted for age and sex; [12]). Comparatively strong perceived discrimination, i.e., an unequal, disadvantaging or segregating treatment, was identified as one factor which might be responsible for low mental health among Turkish migrants in a German representative sample [13]. As Turkish migrants are experienced as more culturally different than other groups, e.g., Polish migrants, they may sustain more discrimination and hence less subjective mental [14, 15].

Overall, mental health has been understudied in German migrants. Due to difficult access for physical, cultural or language reasons, studies are usually small, often based on non-random samples (e.g., patients from a certain medical practice). Different definitions of migration were used and sometimes detailed inquiries were avoided for fear of stigmatizing clients. Measures have usually been developed and validated in different populations. Migration as a risk factor turned out to be hard to disentangle from macroeconomic conditions and resulting individual opportunities [5].

The purpose of this study was to determine (1) if 1^st and 2^nd generation migrants differ from native Germans and (2) if Turkish and Polish 1^st generation migrants as the two largest migrant groups from single countries in our sample differ from non-migrants regarding mental health in a large and population-based survey. As indicators for mental health we used a range of brief and validated self-report measures of depression, generalized anxiety, panic, social phobia, suicidal ideation and distressed personality (Type D).

In the population-based sample, almost one fourth of participants had a migration background, slightly exceeding official estimates of the proportion of migrants in the state of Rhineland Palatinate with 20.3 % [30]. With 10.6 %, there were slightly less 1^st generation migrants who had immigrated since 1949 than 2^nd generation migrants (13.4 %) with at least one migrated parent or a parent abroad. Migrants came from over 100 countries. Migrants with Polish and Turkish origins were the largest groups from single countries among 1^st generation migrants, of whom the great majority had immigrated between 1970 and 1999. We found considerable demographic and social differences between 1^st, 2^nd generation migrants and native Germans. First generation migrants were the youngest group, had the highest rate of partnerships and earned least; second generation migrants had the highest socioeconomic status and income. Findings regarding health behavior were mixed: 1^st generation migrants reported the highest and native Germans the lowest rate of smoking; the opposite was the case for alcohol intake.

Given the considerable social group differences, we compared mental health indicators between groups adjusting for age, sex and socioeconomic status. Consistent with previous literature [9, 11] 1^st generation migrants reported considerably more depression, generalized anxiety, panic attacks in the past 4 weeks, and suicidal ideation compared to native Germans. 2^nd generation migrants did not differ from native Germans regarding mental health. We are not aware of literature on Type D; which was also increased among 1^st generation migrants.

Among the first generation migrants, a Turkish origin was found as a risk factor for depression and panic compared to native Germans. The heightened distress of Turkish migrants was not reflected in their comparatively low intake of antidepressants of anxiolytics, which are usually first line treatments of anxiety and depression in Germany. Compared to Polish migrants only showed an increased type D behavior and more suicidal ideation, but no other indicators of heightened distress.

These findings corresponded to Morawa and Erim [9] and Igel et al. [13] who also found that Turkish migrants reported more depression and lower quality of life compared to Polish migrants (contradictory findings by Mewes et al. [10]). They were robust after adjusting for sex, age, SES and years in Germany. Group differences in our sample were quite large (e.g., OR 3.02; 95 % CI 1.80-5.04 for suicidal ideation of Turkish vs. native Germans; OR 1.80; 95 % CI 1.26-2.58 for Polish migrants). Our findings support the high mental distress and suicidality reported in Turkish women and extends these to Turkish men who have not been included in the previous studies [8]. It is also worth noting that Polish migrants reported more Type D behavior, which is seen as a significant risk factor for impaired physical and mental health for patients with cardiovascular disease [31].

Interestingly, 2^nd generation migrants did not differ from native Germans and even exceeded their mean socioecomomic status, while the mental health of 1^st generation migrants was compromised compared to native Germans and 2^nd generation migrants. This finding is highly relevant, given the fact that the average time lived in Germany was about 30 years. Contradicting the phase model of Butler et al. [1], mental health problems in 1^st generation migrants did not dissipate with time; thus, other factors (e.g., experiences of discrimination, language problems) may be responsible [13].

Differences between migrants of Turkish and Polish vs. other countries of origin are consistent with the distinction between “visible” and “invisible minorities” [32‐34] as elaborated in a North American context [16‐18]. It was shown to make a difference whether the migrant is visibly different in the sense that his phenotype marks him as being different from the majority society of the country he has migrated to. In Canada, for instance, Indian, African and Caribbean migrants are said to be part of visible minority communities. Others who are not visibly different from the majority population have the privilege of “passing”; they are marked as migrants only by differences in dress, language, accent, or behavior. It has been argued that for visible minority groups, it is much harder to assimilate since, regardless of the extent to which they have adopted the cultural traits of their host societies, they often continue to be stigmatized as “foreign.” Moreover, they may have internalized the idea that their phenotype marks them as inferior to the dominant culture. Conversely, invisible minorities may be accepted into the host society much more readily, as could be the case for migrants of Polish origin. Another related issue is the concept of a “racialization of religion” [19]: In this process, a given cultural and religious difference results in the respective group being perceived as phenotypically different; cultural difference gives rise to a perception of the individual as physically different, regardless of their dress, customs, etc. This may have significant result for the individual’s self-esteem and the sense that they are being discriminated against by the majority population. Turkish migrants are frequently visibly different from the German majority society, whereas Polish migrants may have the privilege of “passing”. Regardless of the extent to which they have adopted the cultural traits of the German societies, Turkish migrants may thus continue to be stigmatized as “foreign.” Thus, Polish immigrants, being mostly of Catholic denomination, may more easily assimilate to German majority culture; Turkish immigrants, who often have Muslim religion and cultural traditions, may be stigmatized and may find it harder to adopt German cultural traditions. Worse mental health among Turkish 1^st generation migrants compared to Polish and other origins is also consistent with previous findings attributing worse mental health of Turkish migrants to differences in correspondence between cultural, religious aspects and physical appearance and resulting experiences of discrimination which then contribute to decreased health [14]. While we cannot preclude language problems as a potential reason, an alternative explanation for the considerable proportion of older, low status Turkish 1^st generation migrants refusing to answer the mental health questions could be a culturally bound reluctance to admit mental health problems. Similar reasons could account for the comparatively low rate of antidepressant treatment among Turkish migrants. These findings underscore the need for providing suitable and culturally sensitive psychosocial services to migrants [35].

The findings of the present study indicate that 1^st generation migrants, particularly of Turkish origin, reported more distress than native Germans, whereas the mental health of 2^nd generation migrants did not differ from native Germans. Identifying subpopulations among migrants with higher levels of distress and associated risk factors is essential for providing suitable and culturally sensitive psychosocial services to migrants.