First-episode psychosis and migration in Italy (PEP-Ita migration): a study in the Italian mental health services

Several studies report a higher incidence of psychotic disorders in immigrant populations when compared to native populations [1‐4]. Epidemiological studies about the incidence of severe mental disorders in migrants, as well as the identification of specific vulnerabilities and stressors associated with migration, have significantly contributed to the development of models explaining the etiopathogenesis of psychosis in this population. According to the sociodevelopmental model of Morgan et al. [3], the exposure to negative life events can impact on brain development (in particular on the dopaminergic system), as well as on personal sensitivity to stress, inducing a state of persistent vulnerability to psychosis (consisting of social bias, psychotic-like experiences and affective disorders). These factors are thought to weigh on from the perinatal period and through different life stages [5, 6]. During childhood, incidents such as head injuries, infectious processes, separation from parents, lack of social relationships, psychological, physical or sexual abuse and bullying are likely to be associated with the development of psychosis [7‐9]. During adolescence, cannabis abuse is considered an ‘at risk’ behavior, along with other subjective experiences, such as discrimination and bullying at school, which appear to increase the individual risk of developing psychotic disorders [10, 11]. In adulthood, relevant factors that seem to be associated with the onset of psychosis are social exclusion, racial discrimination, discrepancy between expectations and achievements, lack of confidants/emotional relationships, and loneliness [12, 13].

Risk factors for the development of psychosis are not only at an individual level, but also in the social area [14]. It has been shown that the risk of developing psychosis is higher in urban areas [15‐17], but the meaning of this association remains unclear; it is assumed that one reason could be social isolation which occurs in large urban areas [18, 19]. In addition, other factors, such as exposure to pollutants, lifestyle, capacity/ability to relate to environment, and restricted working environments, may represent other risk factors. Indeed, the quality and the resources of the social structure in which a person lives (the so-called “social capital”) may also significantly affect their risk of developing psychosis [20]. Some studies have shed light on how urban areas which are characterized by the presence of strong socio-economic disparities show a higher incidence of psychosis [21].

The migratory process is a life experience that puts the individual at an increased risk of dealing with the events and factors listed above [22]. In fact, the events experienced by migrants with psychotic onset may be considered a negative life event itself. A better understanding of this process may constitute the key to explain the higher risk of psychosis in these patients.

The high incidence of psychosis in migrants has been described by Morgan [23] as ‘a tragedy of public health’. Moreover, it has been reported that access to mental health care for migrants can be particularly difficult, notwithstanding the high psychiatric morbidity that exists in this population [24‐26].

Only few studies have investigated the risk factors for the onset of psychotic disorders in migrants in Italy [4, 27]. Here health care is provided to the population by the Italian National Health Service, which is built like the British National Health Service. All the population has unlimited health care coverage, which is provided by “Local Health Units”, each responsible for a geographically defined catchment area. Access to health services is generally free of charge. Accordingly with the 1978 reform, psychiatric care is delivered by general hospital psychiatric wards for acute admissions, and community mental health centres (CMHC) providing psychiatric care to geographically defined areas. Non-resident people such as temporary migrants can access to care as much as resident population for urgent and/or necessary cases. CMHCs (an average of 1.81 services per 150,000 population) deliver individual consultations and domiciliary care activities, keep contacts with other health and social agencies and provide emergency interventions. They have a multidisciplinary staff, including psychiatrists, psychologists, social workers, nurses, and educators. Migrants are cared by the same CMHCs of the general population, and cultural-competent activities are provided on demand (e.g. interpreters, cultural mediators, social/legal support, etc.) [28, 29]. So structured, such an organization would facilitate access to care for migrants presenting first-episode psychosis in Italy; yet, previous studies demonstrated that migrants with mental disorders might follow different and more complex pathways to care [26].

Migration to Italy is a relatively recent phenomenon, mainly developed in the last 20 years and still increasing (+8.2% in 2013) [30]. At the beginning of 2013, migrants represented 7.4% of the resident population. Migrants come to Italy from any continent, more frequently from European countries (both EU, 27.4% and non-EU, 23.4%); 22.1% from Africa, followed by Asian (18.8%) and American (8.3%) migrants. The most represented countries of origin are Romania (21.2%), Albania (10.6%), Morocco (9.9%), China (4.6%), Ukraine (4.4%), Philippines (2.9%), Moldova (2.9%), India (2.6%), Poland (2.4%) and Tunisia (2.3%) [31]. Most migrants in Italy live in the Northern regions (61.8%) and emigrated to find a job, though the reason for migration has suddenly changed in the recent years: in 2012, family reasons (81.322 migrants) became more frequent than work reasons (52.328 migrants), probably because of the progressive decrease of job offer in Italy and the stagnation in labour market [30]. Also, migrants who come to Italy are frequently asylum-seekers: in 2012 about 60.000 people have reached our coasts from Tunisia and Lybia.

Based on these premises, this research project was promoted in order to understand risk factors for psychosis in migrants, which could be targeted by specific psychosocial interventions.

The study will be carried out by 11 study centres across Italy and will be coordinated by the Bologna Transcultural Psychiatric Team (BoTPT) [27, 32‐34]. The BoTPT is a team of the University of Bologna, which works closely with the Bologna Department of Mental Health and Pathological Addictions in its provision of cultural-competent treatment care of mental disorders. It also performs consultation and liaison interventions for other urban services that deal with social and health problems of migrants and their families, such as local social services and voluntary organizations. The BoTPT also collaborates with other psychiatric services and University departments in Italy on the topic of migration and mental health. These collaborations are performed in order to understand the occurrence of different disorders in relation to specific cultural contexts, the different migratory movements in different areas, as well as the specific models of care. An initial investigation involving four Italian centres revealed important differences in pathways to care and the socio-demographic characteristics of migrants attending psychiatric services [26].

More recently, Bologna has become part of the EU-GEI European project (European Community’s Seventh Framework Program, grant agreement No. HEALTH-F2-2009-241909, Project EU-GEI: European Network of National Schizophrenia Networks Studying Gene-Environment Interaction) coordinated by the University of Maastricht. Bologna’s participation in EU-GEI and the Work Package 2 (coordinated by Craig Morgan and Robin Murray from the Institute of Psychiatry – King’s College, London) allowed the use of EU-GEI’s methods both in Bologna and in the independent network of Italian mental health centres which are taking part to the Italian study on first-episode psychosis and migration (PEP-Ita migration study).

The Italian study on first-episode psychosis and migration (PEP-Ita) brings together spontaneous and independent research experiences in various Italian mental health centres (psychiatric wards, psychiatric consultation-liaison services and/or CMHCs) with the purpose to study the incidence of psychosis in migrants in Italy. The general aim (“core”) of the study is to explore the socio-demographic and clinical characteristics, and the pathways to care of a population of first-episode psychosis (FEP) migrants in Italy. The study has the following secondary aims: 1) to understand risk and protective factors for the development of psychotic disorders in migrants; 2) to evaluate the link between psychopathology of psychotic disorders in migrants and socio-demographic characteristics, migration history, life experiences; 3) to assess the clinical and social outcome of FEP in migrants.