Mental health of undocumented migrants and migrants undergoing regularization in Switzerland: a cross-sectional study

International migration steadily increases in the context of economic, political and environmental instability. In 2019, it concerned 272 million people, which represented 3.5% of the World’s population [1]. Undocumented migrants live in a country of destination without valid residency permit. Pathways to this situation include overstaying an entry visa, entering a country without valid travel documentation, losing valid residency permit or being born of undocumented parents [1]. Most are international migrant workers and failed asylum seekers account for a lesser stock. The population of such migrant is not precisely known but estimates pointed to 6 million people in Europe [2]. While a body of laws and conventions define the rights of regular migrants, refugees and asylum seekers, undocumented migrants remain mostly unprotected. Their limited access to civil and social rights, essential services and resources exposes them to diverse post-migration difficulties [1, 3]. They are frequently employed in informal, low-skill, precarious and hazardous jobs and are susceptible to work-related abuse and exploitation [4]. Access to medical services varies between countries and is frequently limited to emergency situations [5]. Overall, these factors tend to negatively impact on health and wellbeing of undocumented migrants [5‐7].

In Europe, there is only limited evidence about undocumented migrants’ mental health and its determinants [5]. Most studies have reported data from small samples of participants, frequently retrospectively, and often collected in healthcare setting failing to reflect the situation in the community [6]. Indeed, several factors limit research in this hard-to-reach population such as gaining trust and participation, adequately sampling and being able to comprehensively assess mental health taking account the unique social and living conditions undocumented migrants face [5, 8, 9]. While they appear to suffer less severe and frequent mental health conditions than asylum seekers and refugees, their mental health status is not as good as in the general population [10, 11]. Anxiety and depression have been reported as the most prevalent mental health problems faced by undocumented migrants in Europe while post-traumatic stress disorder (PTSD) affects more frequently migrants with a former asylum seeker or refugee background [6, 10, 12, 13]. Studies conducted among asylum seekers and refugees have highlighted how post-migration mental health stressors evolved with the duration of residency in the country of destination. Indeed, while socioeconomic factors predominated in the early settlement period, loneliness and problems with adjustment to life in the country of destination were most prominent factors later on [14]. The few studies conducted among undocumented migrants in Europe have only reported about a limited range of such factors. In Spain, migrant reported heavy workload, insufficient income and the lack of formal working contract due to their undocumented position as major preoccupations for their health [15, 16]. In Italy and Sweden, male gender, older age, precarious socioeconomic conditions, including housing insecurity, feeling physically insecure and the presence of medical comorbidities along with difficulties accessing to healthcare put migrants at higher risks of suffering a mental health condition [12, 17].^14-15A qualitative study conducted in Norway showed that while higher educational attainment was associated with less psychological distress, migrants having more people financially at charge and those exposed to abuse and discrimination showed worse mental health status [18]. To date, no study has reported about differences in mental health status and related factors among undocumented migrants at different stage of their integration process in Europe. While better integration into the host society through the reception of a residency permit has been associated with better mental health status in refugees in Western countries and in youth in the United States, no study has so far explored this topic in undocumented adults Europe [19, 20]. The burden of mental health conditions and the factors associated may differ at different stage of the integration process and thus require distinct social and health policies. The study hypothesis is that undocumented migrants at a more advanced stage of integration as attested by the eligibility to receive a residency permit may have lower prevalence of mental health conditions. So far, there is a dearth of evidence about the impact of programs aiming to promote mental health in undocumented and recently documented migrants. This paper aims to contribute to bridge these gaps and to allow policy-makers and public health planners to better tackle this major health problem. .

The Parchemins Study aims to prospectively monitor the health impact of a legal status regularization policy for undocumented migrants in Geneva, Switzerland [21]. The objective of this paper is to report about undocumented migrants’ mental health and its determinants during the first study wave.

This study showed that a majority (57%) of long-established economic migrants, undocumented or in the process of obtaining a residence permit, presented symptoms of at least one mental health condition, most frequently anxiety and depression. While undocumented migrants displayed overall higher prevalence of symptoms of mental health conditions compared to migrants in the process of regularization, the absence of residency permit per se was not a significant predictor of altered mental health when adjusting for measures of integration, social support and economic resources at the onset of the new policy implementations. Indeed, younger age, exposure to abuse and discrimination, strong feeling of social isolation, lack of financial reserve and multimorbidity were all associated with altered mental health.

Undocumented migrants in Europe, including youth, rate their quality of life and their health lower than legal residents [9, 17, 34, 35]. Mental health, while often overlooked in studies, seem to play a key role in such self-evaluation [7]. We found that 57.2% of the study participants presented symptoms of at least one mental health condition, while 45.4% screened positive for symptoms of depression and 36% of anxiety. Comparison with previous studies conducted in Europe is hazardous considering their scarcity and differences in migrants’ profiles and research methodology. Only few studies have included participants recruited in the community rather than in health services. Herren et al. found similar prevalence in a small sample of undocumented migrants in Zurich, Switzerland [11]. Schoever et al. showed that female migrants in the Netherland were unlikely to seek healthcare for mental health problems despite high proportion of positive screening for anxiety (78%), depression (64%) and sleeping disorder (71%) [9]. Andersson et al. found prevalence of similar extent in Sweden among undocumented migrants with a frequent asylum background and living in very unstable conditions [12]. Studies conducted in healthcare setting frequently found even higher prevalence [18, 36]. Of concern, we found a significant discrepancy between the proportions of participants presenting altered mental health and of those who had been diagnosed which such conditions prior to the survey. Moreover, 17.5% reported suffering from multiple chronic conditions despite their young age, which confirms previous findings [37]. Our results support that mental health is likely to represent a substantial and often unrecognized share of the burden of ill health affecting this group of population, which needs to be tackled by multi-pronged interventions.

The description of the study population highlights the daily challenges migrants were facing in the context of the new regularization policy. Most participants had been living and working in Geneva for many years but were still presenting insecurity in diverse life domains. Indeed, a large proportion lived in overcrowded housing, showed financial insecurity and lacked access to the healthcare system. Those in the regularization process or recently regularized tended to fare slightly better, reflecting the selection process leading to eligibility to apply for a residency permit. Overall, exposure to abuse, and to discrimination to a lesser extent, social isolation and the inability to pay a CHF 1500.- bill at short notice were all predictors of altered mental health. This confirms previous studies showing the negative impact of cumulative social, professional and economic stress on mental health in undocumented migrants while effective social support and engagement in community activities appeared to be protective [8, 12, 18, 34, 36]. Some authors have suggested that precarious undeclared employment conditions played a central role in the chain of events leading to altered health in this group [4, 15, 16]. Castaneda framed the negative effects of these social and legal factors as the “illegal syndrome” in the context of their frequent co-occurrence with mental conditions such as anxiety and depression [38]. Our results tended to confirm these findings considering the high proportion of participants facing cumulated stress. Of interest, migrants in the process of or recently regularized did not present overall higher odds of better mental health. This is possibly due to the still too short duration of exposure to the potential advantages of the residence status for protective effects on life insecurities to unfold. In other settings, integration policies have shown a positive effect on migrants’ health and wellbeing over the medium to longer term [39]. The next Parchemins study data collection waves will allow for better understanding of the mid-term impact of obtaining a residence permit and thus of the access to social protection on mental health. Of note, while suffering multiple chronic health conditions was strongly associated with altered mental health, better access to the healthcare system through having a health insurance showed no association with the mental health status. This may indicate that gaining easier access to the healthcare system through the regularization may not be sufficient to offset the health disadvantages and that interventions on non-health factors may prime.

Several limitations must be taken into account when interpreting the results of this study. First, our study participants are not fully comparable with other groups of undocumented migrants such as those recently arrived in Europe who had not enough time to set up a relatively stable situation. Indeed, a significant proportion of undocumented migrants is highly mobile and face great difficulty in accessing to even basic employment and housing [40]. In that sense, future studies targeting recently settled undocumented immigrants may be necessary to complement the understanding of mental health issues in this group. Second, undocumented migrants are not a homogenous population across Europe and national immigration policies define who becomes undocumented and how. For instance, undocumented groups in Geneva only include few rejected asylum seekers unlike in other cities. Therefore, our results may not be fully comparable with the situation found in other European cities. Developing a comparative study in different cities and regions may prove useful to better apprehend the global burende of mental health. On the other hand, the diversity of our sample gives strength to our results. Third, we used a non-probabilistic sampling which affects the representativeness of our study population. Yet, we set up various strategies to reach a sample as diverse as possible. Fourth, we may have overestimated prevalence of mental health conditions by using cut-off scores of 5 with the GAD-7 and PHQ-7 scales. In clinical setting, cut-off of 10 may be used to diagnose general anxiety or major depression. Yet, we based our analysis plan on similar cut-offs previously used by other researchers in the general population or in primary care setting [25, 41, 42]. Finally, measuring mental health at a different time points is likely to incur fluctuating results considering the impact of macro political, social and economic environment. For instance, the 2020 Covid-19 crisis is likely to negatively impact migrants’ mental health because of its societal consequences. In that sense, regular monitoring of mental health in this population is necessary to identify emerging needs and the role of contextual factors such as the COVID-19 pandemic. In that sense, prospective studies using mixed-methods such as Parchemins may bring valuable insight.

This is one of the largest study ever conducted in Europe among this group of migrants. It highlights the need to implement social and health policies and programs fostering better mental health in this highly vulnerable group of population by acting on different determinants of their living conditions and general health. On the short term, regularization per se is not sufficient to improve mental health in absence of improvement in other domains of life. Embedded into regularization programs, complementary policies should aim to tackle unfair working conditions and salaries by better employers’ information and closer surveillance of the informal job sectors, to ensure access to adequate housing, to strengthen social integration by reducing the fear to participate in public activities and to provide protection against abuse and discrimination. Moreover, ensuring timely and effective access to health interventions to prevent the early occurrence of chronic conditions is a priority. Providing more and better social and economic securities through legal status regularization may represent a key step towards better health and wellbeing. More research is needed to assess the long-term impact of legal status regularization on mental health.