Social Psychiatry
12, 25-35
Social Psychiatry
(1977)
9 by Springer-Verlag 1977
Mental Illness in Immigrants to England and Wales" An Analysis of Mental Hospital Admissions, 1971 R. Cochrane Department
of Psychology,
University
of Birmingham
S u m m a r y . A study has been m a d e of all admissions to mental hospitals in England and Wales in 1971 by place of birth. After age/sex standardization of rates and reallocating those patients for w h o m place of birth w a s not recorded to appropriate categories, several surprising findings emerged. C o m p a r e d to the native born, those born in Ireland and Scotland had very high rates of mental hospital admission. Poles also had high rates but W e s t Indians and those born in the U. S. A. had rates comparable to the native born. Rates of mental hospital admission for i m m i grants from India, Pakistan, G e r m a n y and Italy w e r e rnueh lower than native born rates. All immigrant groups studied had higher rates of admission for schizophrenia than natives but m u c h of this discrepancy can be explained by the age structures of the populations being compared. The Irish and Scots had extremely high rates of alcohol and drug related disorders and personality and behaviour disorders but W e s t Indians w e r e underrepresented in these diagnostic categories. Various explanations for these and other results are considered and it is concluded that the m o s t tenable hypothesis is one of differential selection for migration - where migration is relatively easy the less stable m e m b e r s of a population self select for migration but where migration is relatively difficult only the m o s t stable individuals can achieve migration.
There is now an extensive literature on psychological disturbance among immigrants. In reviewing some of this literature, Malzberg (1969) found that, almost without exception, the foreign-born had higher rates of admission to mental hospital than the native born population of the host countries. Similarly, the definitive review by Sanua (1969) found evidence from many countries (U. S. A. , Canada, Australia, Norway, Finland, Iceland, Israel, China, Switzerland, Poland, Peru and Britain) that mental illness rates as measured by mental hospital admissions were higher for immigrants than non-immigrants and that this was particularly true of admissions for schizophrenia. However, both Malzberg and Sanua comment that the majority of studies which provide this evidence have employed relatively crude comparisons between immigrants and others. They have, for example, generally ignored such
factors as the age, sex and social class structure of the populations involved, even though these variables are known to be related to the incidence of mental illness. In Malzberg's own work on mental hospital admission figures in the U. S. A. , he found that controlling for age, sex and urban-rural distributions completely eliminated the differences in rates between immigrants and natives usually found in crude comparisons. Even though Britain has recently experienced relatively large in-migrations from several parts of the world there has been a noticeable dearth of studies on the psychological well-being or otherwise of these groups. There have been some attempts by G. P. 's and others (e. g. Pinsent, 1963; Kiev, 1965; Tewfik and Okasha, 1965) to compare the symptoms found in the mental illness of West Indians and natives in small localized groups, but these have not
26 permitted an acceptable calculation of rates for a k n o w n population. T h e r e have only been three m o r e systematic studies of mental hospital admissions w h e r e rates have been calculable for k n o w n populations but each of these has suffered f r o m defects of scale or methodology. H e m s i (1967) c o m p a r e d first admission rates of W e s t Indians and natives aged between 15 and 45 in two L o n d o n B o r o u g h s and found t h e m to be m u c h higher a m o n g the immigrants. H o w e v e r , the rates w e r e calculated on the basis of only 40 W e s t Indian patients and no sex standardization of the i m m i g r a n t and host figures w a s attempted. T h e s a m e criticisms apply to H a s h m i ' s (1968) study in B i r m i n g h a m which w a s also based on the 1961 census. Although he found that all i m m i g r a n t s and specifically Irish and Pakistani i m m i g r a n t s had higher rates of referral to psychiatric clinics than did the British-born, s o m e of the n u m b e r s involved are very small. F o r e x a m p l e only 16 Pakistani patients w e r e found. A n y calculation of rates per 1,000 population based on such small n u m b e r s is obviously unreliable. T h e addition or loss of just a handful of patients will greatly influence the rates. Although rates w e r e calculated to a k n o w n base population, no standardization of any sort of the various populations c o m p a r e d w a s undertaken. Bagley (1972) also failed to adjust figures for differences in population structure w h e n c o m p a r i n g the rates of mental illness in ethnic minorities in C a m b e r w e l l although he did attempt to m a t c h patient groups to each other on such factors as age, sex and social class w h e n c o m p a r i n g the distribution of diagnoses a m o n g ethnic minorities. This study w a s also adversely affected by small n u m b e r s in s o m e groups and by the fact that data on those patients born in India and Pakistan w e r e c o m bined. T h e importance of standardizing mental hospital admission figures w h e n c o m p a r i n g different groups cannot be overstated. It is well known, for example, that w o m e n have far higher rates of admissions than m e n - 432 per i00,000 and 317 per i00,000 respectively in England and W a l e s in 1971 (Department of Health and Social Security, 1973). It is also the case that s o m e i m m i g r a n t populations differ f r o m the host population in their sex c o m p o s i tion - for e x a m p l e 7 2 . 4 % of all Pakistani's living in this country in 1971 w e r e m a l e c o m pared with 4 8 . 4 % of m a l e s in the native born population. Obviously a c o m p a r i s o n of the crude rate of Pakistanis and natives will be confounded by sex differences in rates. T h e
Social
Psychiatry,
Vol.
12, No.
1 (1977)
s a m e case can be m a d e for age standardizing. A g e specific rates of admission to mental hospital vary to an even greater extent than do sex specific rates and again m a n y i m m i g r a n t populations differ f r o m the native population in age structure. A g e - s e x standardization is a comparatively simple process if reliable figures on the age-sex composition of the base population are available. If this is the case, it is simply a matter of adjusting rates for s u b - s a m p l e s of the total population to m a k e t h e m c o m p a r a b l e with one another in t e r m s of a c o m m o n base structure - that of the entire population.
Method Four sources of data were used in this study: the 1971 Census, Country of Birth tables (Office of Population Censuses and Survey, 1974), the report of in-patient statistics from the 1971 Mental Health Enquiry (Department of Health and Social Security, 1973), information on admissions by country of birth supplied by the D. H. S.S. and the results of an analysis of all admissions to a mental hospital serving an area of high immigrant concentration in Birmingham. All immigrant groups whose total number living in England and Wales exceeded i00,000 in 1971 were included in the study. For the purpose of this study "Country of Birth" is the independent variable rather than "ethnic origin" so inevitably a proportion of immigrants will in fact be of British stock but born overseas. Some figures on this variable and other possibly important demographic characteristics were abstracted and recalculated from 1971 census reports and are included as Table i. Children born in this country to immigrant parents are therefore included in the England and Wales group but there were only a small number of these aged over 15 years in 1971 and as this study is confined to patients (and populations) aged 15 years and over there will be relatively few second generation immigrants included in this study. Perhaps one or two other definitions are in order. Because of the way in which data were obtained, "Irish Republic" includes those who gave their birthplace as "Ireland" together with those who specified the Republic. The West Indies consists of Barbados, Guyana, Jamaica and Trinidad and Tobago, it excludes those who gave their country of birth as just "West Indies". This exclusion was necessary to match D. H. S.S. data with Census data.
R.
Cochrane:
Mental
Illness
in Immigrants
to England
In this study first admissions and re-admissions are considered together because of the difficulty of deciding on the reliability of the definition of first admissions for those born overseas - it is not always clear whether this refers to first admissions in Britain or first admissions in any part of the world. From figures supplied byD.H.S.S., crude, age adjusted and age-sex adjusted rates of all admissions aged over 15 years to mental hospitals in England and Wales in 1971 by Country of Birth were calculated. These data are included as Table 2. A major obstacle to the calculation of correct rates of admissions by country of birth is the large proportion of all patients for whom this information is missing. In 1971 this amounted to fully 30% of all patients. Obviously, this could have a significant impact on the relative rates of various groups if they were allocated on the basis of their actual (but unknown) country of birth. The absence of this information is one reason why the D. H. S.S. do not routinely publish these figures (D.H.S.S., 1975). It also posed a problem in Bagley's study where information on country of birth was not available in 16 % of cases. He considered that most of these were likely to be Irish or English as these are the patients who "did not present any feature which would had made this variable seem of significance to the examining physician" (Bagley, 1972, p 25). Although Bagley excluded these cases from his study he considers that this probably lead to an under representation of English and Irish patients. Hemsi also noted that while place of birth or origin was usually present for West Indian patients, native patients did not 'usually have their birthplaces stated in hospital records' (Hernsi, 1967, p. 96). From a study of the ii00 or so patients admitted to one hospital in Birmingham in 1971 it was found that 17 % did not have information on place of birth recorded. A search of the notes of these patients for clues as to place of birth revealed that, as far as it was possible to decide, all of them were, in fact, from Britain or Ireland. The only possible exceptions were one or two elderly patients with English names, long established residences in Britain and British nationality who could conceivably have been West Indian but for whom there was no evidence either way. As very elderly West Indian born immigrants are relatively rare and there seem to be good reasons for agreeing with the comments of Bagley and Hemsi concerning the salience of place of birth appearing greater for cloured or foreign
and Wales
27
sounding individuals than for natives, it was decided to reallocate the patients for whom place of birth was unknown to the English, Scottish and Irish groups in proportion to their numbers among patients for whom birth place was recorded. These "amended age-sex adjusted" rates are given in the final column of Table 2. Finally sex-specific rates per i00,000 population were calculated for each diagnostic category by country of birth. Because of the small numbers involved in some cells of this crosstabulation it was not possible to age standardize the data. The diagnostic categories contained in Table 3 require some explanation. They are the categories used by the D. H. S. S. based on the 8th Revision to the International Classification of Diseases. The biggest anomaly in this classification system concerns diagnoses relating to depression. If the diagnosis is recorded as "involutional
melancholia" or "manic-depressive psychosis" then these patients are recorded under the "Affective Psychoses" heading. If, however, the diagnosis is "depressive neurosis" the patient is classified as "Neurotic". If, as is probably m o s t c o m m o n , the diagnosis is simply "Depression" the patient is put in the "Other Conditions" category. To c o n t e m p o r a r y psychological thought this division of depression is unfounded and it certainly m a k e s the interpretation of figures on mental hospital admissions for depression very difficult. Those patients for w h o m place of birth w a s not available w e r e again reallocated to the England and Wales, Scotland, Northern Ireland and Irish Republic categories in proportion to the n u m b e r s of patients k n o w n to c o m e f r o m these areas within each diagnostic category.
Results The figures in Table 1 reveal that not only do the various immigrant groups included in this study differ markedly in important ways from the native born group, but they also differ from each other. It is first worth noting that none of the groups except the Scots and Irish accounted for more than 1% of the total population of England and Wales in 1971, so all may be considered tiny minorities. Although there is a general tendency for males to be over represented among immigrants this is only markedly so for Pakistanis and Poles, nevertheless all figures presented in this report have been sex standardized. The proportion of immigrants who may be con-
28
Social
Table
i. Demographic
characteristics
of population
resident
Psychiatry,
in England
Vol.
12, No.
and Wales,
1971
1 (1977
Country
of Birth
Total
% of Total
% Male
% Both Parents British born
% Over 45 yrs.
% Entering before 1960
England
and Wales
44562475
91.41
48.4
93.8
37.8
i00
775495
1.59
50.9
93.8
37.6
i00
215800
0.44
50.4
93.8
44.3
100
Irish Republic
675870
i. 38
47.9
3.0
44.4
70.2
West
235895
0.48
49.9
1.6
18.0
31.8
India
312840
0.64
54.1
12.2
27.6
30.9
Pakistan
136150
0.27
72.4
3.8
13.4
17.2
Germany
148250
0.30
37.0
28.9
30.8
61.3
Italy
103465
0.21
47.8
i. 0
26.8
52.7
Poland
104450
0.21
66.1
0.3
80.0
89.3
U.S.A.
100460
0.20
53.8
20.8
22.8
28.1
Scotland Northern
Ireland
Indies
Table 2. Crude, age/sex adjusted, and amended* age/sex per i00,000 population over 15 years (England and Wales,
M
F
Total
Age/Sex Rates M F
Total
Amended Adjusted M F
England &Wales
286
385
338
306
380
345
434
551
494
Scotland
490
474
482
492
489
481
712
679
895
N. I r e l a n d
913
766
840
982
763
867
1391
1102
1242
Irish Republic
764
842
804
723
780
753
1065
1153
1110
West Indies
485
725
605
449
621
539
449
621
539
India
386
456
418
368
436
403
368
436
403
Pakistan
353
486
388
294
374
336
294
374
336
Germany
371
504
462
356
513
439
356
513
439
Italy
235
441
343
272
400
340
272
400
340
Poland
510
882
636
610
790
704
610
790
704
U.S.A.
329
616
461
359
576
473
359
576
473
Country
of Birth
Crude
Rates
adjusted rates of mental hospital 1971) by country of birth Adjusted
~
admisslon
, Age/Sex Rates Total
A m e n d e d by reallocation of patients for w h o m country of birth was not given to England and Wales, Scotland, Northern Ireland and Irish Republic groups.
R.
Cochrane:
Mental
Illness
in Immigrants
to England
sidered to be of British ancestry is much more variable between the country of origin groups, ranging from a maximum of almost 29 % for those from Germany (presumably servicemen's offspring) to 0.3% for the Poles. The age distribution of the groups is also quite varied with the Poles again at one extreme with 80 % being over 45 years of age in 1971, and the Pakistanis as the other with only just over 13 % over this age. These two groups also lie at opposite positions in length of residence in England and Wales. Most Poles arrived in Britain before 1960 (in fact the great majority of Polish men arrieved during or immediately after World War II) but only 17 % of Pakistanis arrived in Britain before 1960. The most important data in this paper are contained in Table 2 which provides the basis for a comparison of rates of mental hospital admissions for the native and immigrant populations. As expected age/sex standardization made very little difference to the England and Wales group's rates because they contribute most to the definition of the age/sex structure of the total population upon which the standardization was based. It has, however, seriously affected some other rates of the minority groups whose age/sex structure deviated from the total. It increased some rates (e.g. for Poland) and decreased most others. A comparison of the unamended age/sex adjusted rates shows that all immigrant groups had higher rates than the native (England and Wales born) group except for the Italians and Pakistanis who had rates almost identical to those of the natives. Amending the rates by reallocating those whose birth place was not recorded, considerably alters the picture. The native rate is exceeded by that of the Scottish, both Irish groups, the Poles and the West Indians. The Indians, Pakistanis, Germans and Italians have considerably lower rates than do the native born. The usually observed excess of female over male admission rates is reversed for the Scottish and Northern Irish group and considerably reduced in the Irish Republic group. For all three of these groups the males have an even greater excess over their English counterparts than do the females. Turning to diagnostic differences the most conspicuous findings for both males and females is the large over representation of those diagnosed as schizophrenics among most immigrant groups, especially the West Indians; the striking excess of alcohol related diagnoses among the Scottish, Irish and to alesser extent the U.S.A. born group. The Pakistani
and Wales
29
males are grossly under represented in all categories of diagnosis except schizophrenia where their rate is much higher than that of the host population. Those whose country of birth was not stated are broadly similar in diagnostic groupings to the British born groups and have apportioned to these groups in Table 3. The Scottish and Irish groups (both male and female) have particularly large excesses compared to the native group in the categories of drug dependence and personality disorder as well as alcoholism. The West Indian males on the other hand have particularly low rates in these three categories. Italian males have lower rates in every single diagnostic category than their English counterparts, including schizophrenia. Male and female Poles have very elevated rates for schizophrenia and somewhat high rates for affective psychoses.
Discussion The major findings of this study are that total mental hospital admission rates for immigrants for Britain are very varied and for the "New Commonwealth" or ~'coloured" groups they are the same as, or lower than, British rates; internal migrants from another part of Britain to England and Wales have very high total rates of mental hospital admission, in general immigrants have higher rates than do natives for admission to mental hospitals for schizophrenia and related disorders; the Scots and Irish have exceptionally high rates of admission for disorders relating to alcohol and drugs as well as personality and behaviour disorders. Before these findings can be taken as an indication that the pattern of mental illness is distributed in this way, and possible explanations sought, some problems of interpretation must be considered. The major difficulty is assessing the validity of using mental hospital admissions as an index of mental illness. The problems with this index are as follows : i. There are undoubtedly many cases of mental illness that are not admitted as inpatients at mental hospitals. Some of these are treated as outpatients, some byG. P. rs and some do not come into contact with any psychiatric agency. This is only a problem for this study if there is reason to believe that different groups have different patterns of usage of mental hospital at the same symptom levels. In other words, if it is accepted that mental hospital admissions generally underrepresent "true" rates of mental illness (Srole et al. 1962;
30
Social
Table 3. Rates* of mental Wales, 1971) by diagnosis
hospital admission per and country of birth
i00,000
Psychiatry,
population
over
Vol. 15 years
12, No. (England
1 (1977) and
A. m a l e s
Country of Birth
Schizophrenia, Schizoaffective, Paranoia
Affective Disorders
Senile & PreSenile Psychoses
Alcoholism, AIcohol Psychoses
Neuroses
87
45
19
28
48
6
43
140
Scotland
90
42
18
218
56
i0
i00
178
N.
Ireland
96
78
22
349
121
15
201
341
Irish Republic
83
69
27
265
88
20
139
265
290
30
1
14
19
3
27
i00
India
141
31
4
34
33
7
36
I01
Pakistan
158
22
1
i0
36
2
18
105
Germany
99
35
3
23
41
9
58
102
Italy
71
35
11
4
22
0
30
62
Poland
189
63
17
33
42
1
27
137
U.S.A.
76
32
0
49
30
7
54
79
87
92
37
8
88
3
41
202
97
99
37
46
iii
4
67
227
Ireland
160
147
38
69
172
21
iii
373
Irish Republic
254
174
40
54
165
9
114
395
West
323
91
3
7
67
3
46
186
India
140
57
8
9
64
3
29
147
Pakistan
103
38
0
14
103
0
55
175
Germany
130
59
12
3
98
5
48
142
Italy
127
61
i0
2
67
4
33
136
Poland
301
119
26
9
139
6
40
241
U.S.A.
133
122
12
38
78
12
98
124
England
West
B.
& Wales
Indies
Personality & Behaviour Disorders
Others +
females
England
& Wales
Scotland N.
Drug Dependence
Indies
* England & Wales, Scotland, N. Ireland and Irish Republic whom country of birth was not available. (See Text).
rates
include
+ "Other" includes other psychotic disorders, depression not specified other psychiatric conditions, epilepsy, undiagnosed cases, and admissions chiatric disorders.
reallocated
patients
for
as neurotic or psychotic, for other than psy-
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Mental
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to England
Phillips, 1966;) the question becomes; do mental hospital admissions differentially underrepresent for different immigrant groups? There is very little evidence on this point. Cochrane and Stopes-Roe (1976) ina community survey of psychological symptoms among Asian immigrants to Britain obtained results remarkably consistent with those reported here; namely that Indians had about as many symptoms as native controls, whereas Pakistanis reported significantly fewer than average. Community studies on behaviour problems in children of different ethnic origins (Rutter, 1974; Kallarackal and Herbert, 1976) have shown that West Indian children have more problems of adjustment than their English counterparts whereas Indian children have less; a finding that is also consistent with those presented here for adults. Apart from these studies it is only possible to speculate on the possibility of usage differentials of mental health services. While it is possible that language and cultural difficulties prevent some groups making full use of facilities, it is equally plausible to suggest that possible scarcity of alternative sources of help produced by separation from family, friends and neighbours may make use of mental hospitals more likely for immigrants than for natives at the same level of symptomatology. These are hypotheses that remain to be tested. 2. In this study figures for all admissions to mental hospitals rather than first admissions were used. Thus, it is not only new cases that are being considered and indeed the same individual patient may be represented more than once in one year's figures. If it were the case that different immigrant groups were more or less likely to return to hospital frequently, this would mean that the figures could represent different patterns of admissions as well as, or instead of, different numbers of people being admitted. One factor that is known to be related to frequency of readmission is diagnosis. Over all diagnoses there are approximately two readmissions for every first admission, but for schizophrenia there are four times as many readmissions as first admissions; thus groups such as immigrants, with a high proportion of schizophrenia in relation to other diagnoses will tend to have their overall rates increased because of the large numbers of readmissions. However, except for schizophrenia, only a small proportion of all readmissions will be within the same year so the effect on total rates is unlikely to be large. In any case the net effect will be to make the number of immigrant patients appear higher
and Wales
31
than it actually is compared to the number of native patients. 3. As has been dealt with at some length, the age/sex structures of the populations from which the patients come are likely to have a considerable effect on rates of hospitalization. The figures for total rates have been age/sex standardized to take these variations into account, but the sex specific rates by diagnosis are not age standardized. Thus the higher rate of senile and pre-senile psychoses in the native group is directly attributable to the presence of many more elderly people in the population than is the case for immigrants. The major discrepancies in the rates of admission for schizophrenia and for alcoholism are not entirely explicable in this way however. The age group which produces the highest rates of admission for schizophrenia and related disorders is the 25-45 group. While it is true that some immigrant groups (particularly West Indians, Indians and Pakistanis) are more concentrated in this age band than the native born population this is also true of the Italians who have the lowest rates for schizophrenia and the reverse is true of the Poles (i.e. there is a smaller proportion of the total populations in the 25-45 age band than for native born) who have the second highest rate of admissions for schizophrenia. Therefore the apparently higher rates of admission for schizophrenia of West Indians, Indian and Pakistanis may be accounted for at least in part, by the age structure of the populations but this cannot be true of the high rate of the Poles neither can it explain the low rate of the Italians. In considering alcoholism and alcohol psychoses, it is quite clear that there are no population structural variables capable of explaining the e n o r m o u s l y high rates achieved by the Scottish and Irish groups which in turn account for a large portion of their excessive overall rate of mental hospitalization. Turning to other factors which influence the interpretation of these data there are again several unresolved issues. W e might consider, for example, whether mental illness should be considered in isolation or should be considered in the context of other f o r m s of deviant behaviour. Is it possible that i m m i g r a n t groups that are higher or lower than the native born on rates of mental illness might balance this with differentially high or low rates for other forrnes of deviance? Unfortunately, few reliable indicators are available. T h e r e is evidence that young W e s t Indian m a l e s are m o r e likely to be u n e m p l o y e d than natives ( C o m m u n i t y Relations C o m m i s s i o n ~ 1974) but the opposite
32
Social
Table 4. Estimated suicides in England and Wales by country of birth for males and females aged 20 years and over, 1970-72 (adapted from Adelstein and Mardon, 1976) Country
of Birth
Standardised
Mortality
Ratio
Males
Females
All countries
i00
i00
Scotland
138
145
Ireland (all parts)
154
149
85
60
India & Pakistan
i00
122
Germany
177
239
Poland
221
207
98
198
West
Indies
U. S.A. Estimated undetermined
suicides include official suicides, deaths and accidental poisoning.
is true of Indians and Pakistanis (Cochrane and Stopes-Roe, 1976). Lambert (1970) looked at crime figures for areas of high immigrant concentration in Birmingham and, although he found elevated crime rates in these areas, this could not be attributed to the immigrants. Overall, his findings correspond closely to those reported here - namely that Irish immigrants were probably overrepresented in crime figures in proportion to their numbers in the population, Asian immigrants were underrepresented and West Indians were somewhere between. Recently, the Office of Population Censuses and Surveys has made available statistics on rates of suicides and probable suicides by country of birth (Adelstein and Mardon, 1976; and Office of Population Census and Surveys, 1976). These are expressed as standardized mortality ratios comparing death rates of immigrant groups to a base of i00 for the total population. The statistics in Table 4 are in a different form from those presented elsewhere in this paper (all parts of Ireland are combined, as are Indian and Pakistan, and no figures are available for the native born as a separate group, but it is estimated that the SMR for both male and female natives is somewhat below i00) but the overall trend is quite clear. All immigrants, except West Indians, have elevated rates of suicide. The
Psychiatry,
Vol.
12, No.
1 (1977)
very high rate of the Poles can, in part, be explained by the relatively aged nature of the Polish population and the fact that suicide rates are higher in older age groups. Possibly the low rate of West Indians is explicable in terms of their young average age but structural explanations cannot account for the high rates among the other immigrant groups included in Table 4. The overall pattern of deviant behaviour among immigrants to Britain is, therefore, somewhat confused, but there is no evidence to suggest that other forms of deviant behaviour compensate for differences in rates of mental illness between immigrant groups themselves or between immigrants and natives. Because of the way in which figures are collected by both the Office of the Census and D. H. S. S. it is only possible to classify immigrants by country of birth and not by ethnic origin. Table 1 contains estimates of the proportion of immigrants from various countries who are of British ethnic origin. It is certain that some patients recorded as being born in foreign and commonwealth countries will, in fact, be British by descent. It is not likely that variations in rates between immigrant groups can be explained in this way, however. Two groups of immigrants with very low proportions of individuals of British parentage (Poland and Italy) have respectively very high and low rates of mental illness. Similarly, the natives and the Scots with identical proportions of British born parents have very different rates. As the data in this paper are ecological it is impossible to establish absolutely that the variation in rates is not accounted for by immigrants of British origin, but this is extremely unlikely. There are three main hypotheses that have been put forward to explain relationships that have been found between migration and mental illness (Murphy, 1973). They are: that immigrants may be drawn from populations with rates different from those of the host population they join, that the process of migration itself affects the mental health of migrants, and that there is a selection for migration on the basis of factors related to mental illness. It is not possible to test these hypotheses directly in this study, but there are some leads to indirect tests of the first two of these hypotheses. The first hypotheses clearly requires evidence on rates of mental illness in the home populations from which immigrants are drawn. Even if such evidence were available it would be virtually meaningless to compare figures
R.
Cochrane:
Mental
Illness
in Immigrants
to England
because of the vast difference in facilities available in different countries. The only exception to this is, perhaps, Scotland where the Health Service is not very different from that in England and Wales. Unpublished figures supplied by the Scottish Health Services Common Services Agency (1976) yield crude sex-specific rates of admfssion to mental hospitals in Scotland of 426 per I00,000 for men and 484 per I00,000 for women of all ages. The age standardized rates for those aged 15 and over are 580 and 634 for men and women respectively. These figures are for all admissions and not just for the native born, but this group will form the vast majority of all admissions in Scotland. The figures for women in Scotland are considerably higher than for native born women in England and Wales but roughly comparable to those for Scottish born women living in England. The figures for men in Scotland are also higher than for natives in England but considerably lower than for Scottish men living in England where rates exceed even those of female Scottish migrants. The fact that these Scottish figures show rates intermediate between those of English natives and Scottish migrants means that there is some evidence of higher rates in the population from which Scottish migrants are drawn than the rates for the host populations they join. However, the discrepancy between native English and Scottish rates is not sufficient to explain the very high rates of mental hospital admission of Scotts living in England and Wales, particularly the males. It is, therefore, necessary to consider the other explanations of elevated mental hospital admission rates found in this particular group of migrants to England and Wales. The second hypothesis, that the process of migration affects the mental health of migrants, is only plausible in a rather tenuous f o r m on the basis of the data presented here. Strictly, of course, it is necessary to have information on the mental health of immigrants before and after their migration. In the absence of premigration data, w e are forced to rely on post migrati9n rates of mental illness. It appears that groups with a priori the m o s t difficult adjustments to m a k e in terms of language and culture (the Asians) do not show a high incidence of mental illness, whereas those with far fewer adjustments to m a k e (the Irish and Scottish groups) show extremely high post migration rates. Immigrants with intermediate adjustments to m a k e (e. g. W e s t Indians) have intermediate rates. A possible mediating variable that m a y account for this negative relationship between magnitude of adjustment
and Wales
33
and mental illness, might be the degree of improvement in life situation experienced preto-post migration. India and Pakistan are among the world's poorer countries, so we might expect immigrants from these areas to have experienced, on average, an improvement in living standards upon taking up residence in England. There would be relatively little change in living standards pre-to-post-migralion from Scotland or Ireland to England. However, m a n y anomalies in the data remain unexplained by this interpretation. The low rates of mental illness a m o n g immigrants from the U.S.A. and G e r m a n y would not be predicted neither would the marginally higher rates a m o n g W e s t Indians. The third hypothesis, in a revised form, is potentially the m o s t interesting and in s o m e w a y s the m o s t plausible. It would take the form of differential selection for migration depending upon the difficulties involved in achieving relocation. W h e r e poverty, lack of contact with western culture, poor c o m m u n i c a tion and distance present great obstacles to migration, and where failure to achieve acceptable living standards in the country of origin cannot be attributed to personal failure, it m a y be that only the most stable m e m b e r s of the population can o v e r c o m e these obstacles and b e c o m e immigrants. This would account for the low rates of mental illness a m o n g Asians. Where, however, migration is relatively easy and the country of origin is not very different from the host country, it m a y be those w h o have failed to adjust or be successful in their h o m e environment w h o self select to migrate. T h e y would then bring their psychological problems with them. This might account for the high rate of mental illness in the Scottish migrants especially as there is evidence that the rates of mental illness in Scotland are not very different from that of natives in England and Wales. The s a m e could equally be true of the Irish groups. The observation that for the Scottish and Irish groups the excess of mental hospital admissions is largely explained by the very high rates of alcohol, drug and behaviour problems manifested by these groups is also quite compatible with this explanation. Migration w a s m a d e relatively easy for m a n y W e s t Indians in the 1960's by the recruiting compaigns of London Transport and others w h o facilitated their re-location to England so this group had fewer obstacles to e v e r c o m e and therefore, if this hypothesis is correct, would not be overrepresented by healthy m e m b e r s of the population as are the Asians. Again the data throw up considerable anomalies for example,
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Social Psychiatry,
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why should the Poles have very high rates and the Italians very low rates? Analysis of the particular circumstances that surrounded the migrations of these groups would be necessary to assess the validity of the explanation.
Hospital, Birmingham; I would also like to thank Dr. A. Adelstein, Dr. C. Mardon and Mr. D.J. Till of the Medical Statistics Unit, Office of Population Censuses and Surveys, for allowing the data in Table 4 to be reproduced.
Conclusions
References
i. Previous studies of mental hospitalization rates of immigrants to Britain have failed to take into account the difference in age/sex structure of the populations involved or to deal adequately with the large number of patients for whom place of birth is not known. Incorporating these variables considerably alters rates and the data presented here is at variance with previous studies. 2. Migrants from within the British Isles to England have higher rates of mental illness as measured by mental hospital admissions than do the native born. Immigrants from overseashave varied rates, many of which are lower than those of the native born. 3. Rates of mental hospital admission for schizophrenia are higher for the foreign born than the native born, but some of this excess may be accounted for by the age structure of the populations. 4. Rates of admission for alcoholism, drug dependence and personality and behaviour disorders are extremely high for those born in Scotland and Ireland, but low for those born in Asia or the West Indies. 5. There is no evidence that other forms of deviance compensate for variations in rates of mental illness among immigrant groups. 6. There is evidence that Scottish migrants to England have higher rates of mental illness than Scots who remain in Scotland. 7. A plausible, although unsubstantiated, explanation of the observed differences is that of differential self-selection for migration depending upon economic conditions in the country of origin and relative difficulty of migration.
Adelstein, A., Mardon, C.:Suicides 1961-74. Population Trends. 2, 13 (1976) Bagley, C. : A comparative study of mental illness among immigrant groups in Britain. Ethnics, i, 23 (1972) Cochrane, R., Stopes-Roe, M.: Psychological disturbance in Asian immigrants to Britain: a pilot study. In preparation (1976) Community Relations Commission: Unemployment and Homelessness: A report. London: H. M. S.O. 1974. Department of Health and Social Security: Statistical Report Series Number 6: Inpatient statistics for England and Wales, 1971: London: H.M.S.O. 1973 Department of Health and Social Security: Personal communications (1975)o Hashrni, F. : Community psychiatric problems among Birmingham immigrants. J. soc. Psychiat. 2, 196 (1968) Hemsi, L.K. : Psychiatric morbidity of West Indian immigrants. Social Psychiatry 2, 95 (1967) Kallarackal, A. M., Herber, M. : The happiness of Indian immigrant children. New Society 26th February, 422 (1976) Kiev, A.: Psychiatric morbidity of West Indian immigrants in an urban group practice. Br. J. Psyehiat. iii, 51 (1965) Lambert, J.R.: Crime, Police and Race Relations. London: OUP 1970. Malzberg, B. : Are immigrants psychologically disturbed? In S.C. Flog. andR. E.Edgerton (Ed.) Changing Perspectives in Mental Illness. New York: Holt, Rinehart and Winston 1969 Office of Population Censuses and Surveys: Census of Great Britain, 1971: Country of Birth Tables. London. H. M. S.O. 1974. Office of Population Censuses and Surveys: Personal communication (i 976) Murphy, H.H.M. : Migration and the major mental disorders: a reappraisal. In C. Zwingmann, and M. Pfister-Ammende: Uprooting and After: New York: Springer 1973 Phillips, D. C. : The true prevalence of mental illness in a New England State. Community Mental Health Journal 2, 35 (1966)
Acknowledgements. The author wishes to acknowledge the assistance, in preparing this paper, given by: Mrs. Mary Stopes-Roe, University of Birmingham; Mr. N. Bottomley, Information Services Division, Scottish Health Service Common Services Agency; Miss M.A. Elliott and Mr. R.J. Eason, Department of Health and Social Security; Dr. F. Hashmi and the Medical Records Office Staff, All Saints
R. Coehrane:
Mental
Illness in Immigrants
to England
Pinsent, R. F. : Morbidity in an immigrant population. Lancet 1963 I, 437 Rutter, M., Yule, W., Berger, M., Yule, B., Morton, J., Bagley, C. : Children of West Indian immigrants - 1 Rates of behavioural deviance and of psychiatric disorder. J. Child. Psychol. Psychiat. 15, 241 (1874) Sanua, V. C. : Immigration, migration and mental illness: a review of the literature with special emphasis on schizophrenia. In E. B. Brody (Ed.). Behaviour in New Environments. California: Sage Publications, 1969 Scottish Health Services Common Services Agency: Personal communications. (1976) Srole, L., Langner, T.S., Michael, S.T., Opler, M.K. : Mental Health in the
and Wales
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Metropolis. The Mid-Town Study. Glencoe: The Free Press. 1962 Tewfik, G.I., Okasha, A.: Psychosis and immigration, Postgrad. reed. J. 41, 603
(1965)
Accepted
June
ii, 1976
Dr. R. Cochrane Department of Psychology University of Birmingham P.O. Box 363 ]Birmingham BI5 2T, T England
