First-episode Psychosis and Migration in Italy: Results from a Study in the Italian Mental Health Services (Pep-Ita Study)

Background: Migrants present high rates of psychosis. A better understanding of this phenomenon is needed. Methods: We conducted a multicentre First-Episode Psychosis (FEP) prospective study over two years (January 2012–December 2013) to evaluate first-generation migrants presenting with FEP at the participating Community Mental Health Centers (CMHCs). Results: 109 FEP migrants were identified. Almost half of them were highly educated, employed and in a stable affective relationship. The average age was 32.8 (± 9.8) years, and the average length of stay in Italy was 8.6 (± 8.8) years. About 2/3 of patients were referred to CMHCs following Emergency Department access or psychiatric admission. Conclusions: Our finding of a “high functioning portrait” of FEP migrants allow us to hypothesize that a high burden of negative psychosocial factors is likely to be needed for the FEP onset. Furtherly, mental health services should implement more appropriate resources and organizational methods to respond to migrants’ health needs.


Introduction
Nowadays, the mental health of migrants is a major individual and public health issue in the EU. Unlike other European countries such as England and France, where migration has been a structural component of society for centuries, Italy is only recently facing a rapid transformation of identity, changing from a country of emigration to a country of immigration. From the beginning of 2012 to the end of 2013, the number of migrants in Italy increased from 4.052.081 to 4.922.085 (+ 21.5%).
Epidemiological evidence showed an increased incidence of psychotic disorders among several migrant populations compared to natives [1][2][3][4][5][6]. To explain the high rates of psychosis in migrants, Morgan et al. in 2010 [5] proposed a socio-developmental pathway to psychosis, highlighting the putative causal role of adverse social conditions and experiences. Throughout the whole migration process (from the decision to migrate to the adjustment to the new society), migrants may be exposed to several social disadvantages, including, among others, unemployment, poor living conditions, social isolation, and discrimination. To our knowledge few studies have investigated the risk factors for the onset of psychotic disorders in firstgeneration migrants in Italy [6][7][8].
Despite the high rate of psychotic disorders in migrants, access to mental health care for migrants can be particularly difficult [9][10][11]. In Italy, health care coverage is unlimited and free of charge for the whole population. Psychiatric care is delivered by general hospital psychiatric wards for acute admissions, and Community Mental Health Centres (CMHCs) providing psychiatric care to geographically defined areas. Non-resident people, such as migrants, can access care as much as the resident population for urgent and/or necessary cases, and are referred to the same CMHCs as the general population [12,13]. The Italian National Health Service (NHS) organization would facilitate access to care for migrants presenting FEP in Italy. The health services organization showed important differences among Italian regions [14]. Previous studies showed that migrants with mental disorders might follow different Pathways to Care (PtC) in Italy [10,11].

Objectives
The present study aims to: 1. describe the socio-demographic and clinical features of migrants with FEP consecutively recruited in 9 Community Mental Health Centers (CMHCs) in Italy; 2. explore the clinical characteristics and PtC of migrant patients at the onset of psychosis and evaluate possible differences between centres.
This study is part of the Italian multicentre research project PEP-Ita (First Episode Psychosis -Italy), a prospective study conducted over a two-year period (1st January 2012-31th December 2013) to evaluate first generation migrants with psychotic onset presenting for the first time to the 9 participating CMHCs [15].

Study Design
The aims and methods of the PEP-Ita project have already been described in a previous work [16]. The design of the PEP-Ita study was drawn in accordance with the EUGEI project (gene x environment interaction European study) (No. HEALTH-F2-2009-241909) [17].
The centres participating in the study collected relevant data on all new cases of migrants seeking treatment for FEP for the first time during the recruitment period (1 st January 2012-31 th December 2013).
Inclusion criteria were:

Setting and Study Population
The study catchment areas were defined in terms of the Census Area covered by participating CMHCs. Based on data from the Italian National Institute of Statistics (ISTAT) [20], the whole catchment area was of 2.135.145 inhabitants and 6.5% of migrants. Considering a conservative estimate of yearly incidence cases of 40/100.000 among migrants [6], we expected to recruit 111 FEP migrants cases by year 2. We conducted a leakage study to identify any subject that may have been missed during the critical data collection period. To do so, we reviewed all new mental health service registration forms and interrogated the computerized information systems. The 9 participating centres, located in different regions of the national territory, were: Andria, Bari, Bologna, Cagliari, Chivasso, Foggia, Modena, Novara and Pavia (see Fig. 1 and Table 1).
The research was coordinated by the Bologna Transcultural Psychosomatic Team (BoTPT) of the University of Bologna [21]. The BoTPT, in collaboration with the Department of Mental Health of the Bologna Local Health Authority, facilitates psychosocial interventions for migrant populations and examines the key issues concerning the mental health of migrants.

Assessment
For each patient we collected the following information: (1) socio-demographic data (gender, age, date of birth, country of origin, ethnicity, length of stay in Italy, marital status, level of education, employment status, housing status); (2) medical and psychiatric history of patients and their families; (3) clinical data (psychiatric diagnoses, medical comorbidities, age at onset and at first contact with CMHC, duration of untreated psychosis (DUP), previous psychiatric admissions); (4) PtC: referral by general practitioners, by ER or general hospitals, by psychiatric ward, by other psychiatric services, by the police or by judicial authorities, informal referral (by relatives OR self-referral).
Those characteristics were derived from clinical and electronic charts in the CMHCs involved.

Statistical Analysis
Data were analyzed using SPSS for Windows Version 14.0. Methods for inter-group comparison (p = 0.05) included χ 2 test for category-dependent variables (the Bonferroni correction was applied where required), independent t-test analysis (one-way analysis of variance) and analysis of covariance for continuous dependent variables.
The study protocol has been approved by ethics committee of the coordinating Centre (Bologna, protocol n. 113/2006/U) and has been submitted to each local ethics committee. The study was conducted in accordance with the Declaration of Helsinki.

Socio-demographic Characteristics
109 FEP migrants were identified during the study period. Table 2 shows socio-demographic features of included migrant patients. 36% of the sample was from Eastern Europe, 27% from Asia, 16% from Sub-Saharan Africa, 15% from Maghreb, 6% from Central and South America and only 1% from Western Countries. The average age at the time of evaluation was 32.8 (± 9.8) years, while the average age at onset was 31.8 (± 9.9) years. The average length of stay in Italy was 8.6 (± 8.8) years. Almost half of the sample was single, while the other half was currently or had been in a stable affective relationship (married, cohabitant, in a stable relationship, divorced or widower). More than half had a high school diploma or higher degree. About 40% were employed, while one third of patients were unemployed and another 22% were economically inactive (9, 8% housewives, 12, 11% retired, 1, 0.9% invalids). One third of patients lived with their acquired family (partner/spouse and/or children), while 27% lived with their family of origin (mother, father, siblings, etc.) and 21% lived alone. Table 3 shows socio-demographic characteristics of patients by study centres. More than half of the sample (62%) lived in Northern Italy (Bologna, Modena, Novara, Pavia, Chivasso), while 39% lived in Southern Italy or on the islands (Bari, Foggia, Andria, Cagliari). Among study centres we found significant differences in relation to regions of origin of the patients (p = 0.002). The most represented region of origin was Asia in Bologna (36%) as well as in Bari (53%), while in Pavia, Andria and Foggia most of migrants came from Eastern Europe (60%, 50% and 44% respectively), in Modena from Sub-Saharan Africa (33%) and in Novara from Maghreb (36%). Marital status showed a trend of statistical differences, with more single people in Bologna (45%), Bari (65%), Modena (58%) and   Pavia (60%) and more married people in Andria (62%). A trend for a significantly higher number of migrants with a high school diploma has been found in Bologna, Andria, Chivasso and Novara. In Bologna and Modena most patients lived with their family of origin (41% and 43% respectively); in Andria (50%) and Novara (50%) with acquired family; alone in Bari (35%) and Foggia (40%).

Clinical Characteristics
Almost 2/3 of patients were referred by hospitals (psychiatric wards, Emergency Rooms, other hospital wards), 12% from other psychiatric services (private specialists or private clinics), 11% made an informal access (auto-referral or being referred by relatives), 8% were referred by general practitioners and 5% by police or judicial authorities. The average duration of untreated psychosis (DUP) was 9.3 weeks (± 21.6). The most frequent diagnosis was non-affective psychosis (42%), with schizophrenia representing 9% of the total sample, followed by psychosis NOS (33%) and affective psychoses (21%); the remaining 5% had other diagnoses (brief psychotic disorder, substance-induced psychotic disorders). One patient in six (35% of patients for whom the information was available) presented medical comorbidities: 8% of patients were suffering from internal diseases (anaemia, gastroesophageal reflux disease, high blood pressure), 3% from metabolic diseases (diabetes, hypercholesterolemia), 2% from traumatic diseases (bone fractures, other injuries) and 3% from other diseases (autoimmune, neoplastic diseases). 21 (19.3%) of the patients use substances with cannabis being by far the most used (by 20 out of the 21 substance users) ( Table 4). Clinical information was available for 8 centres. We found significant differences between centres in relation to PtC. As shown in Table 5, psychiatric wards were the main source of referral in Bologna (41%), Foggia (69%) and Pavia (60%), while in Bari, Modena and Novara patients were predominantly sent to CMHCs by the ER or other hospital wards (77%, 42% and 57% respectively). Informal referral was found almost exclusively in Bologna (18%) and Modena (21%). The most frequent diagnosis was non-affective psychosis in Bologna (50%), Modena (54%) and Pavia (80%), while it was affective psychosis (47%) in Bari and psychosis NOS (63%) in Foggia. Only 4 centres evaluated DUP: the average DUP in Novara was 1.8 weeks (± 0.8), while in Bologna it was 10.3 weeks (± 6.9) and in Modena 14 weeks (± 39.2).

Socio-demographic Characteristics
East European migrants are the most numerous group of origin in our sample as well as in the general migrant population of Italy: migrants come to Italy mainly 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 [22]. The distribution of the migrants' groups of origin in the samples collected by the 9 centres varies accordingly with the differences found in the general population of those centres. Despite different distributions, FEP migrants recruited by the PEP-Ita study have very similar socio-demographic characteristics in the 9 involved centres. One interesting result of our study is the "high functioning portrait" of the migrants with FEP in Italy: they are generally highly educated, in their thirties, and are quite frequently employed and in a current or past stable affective relationship. Thus, migrants with FEP in Italy seem to have a higher personal and social functioning compared to Italian born natives with FEP, who are very frequently single, less educated, unemployed, and living with parental families [6,7]. This result pushed us to generate the hypothesis that there is a higher burden of social-environmental risk factors at the psychosis onset in migrants compared to natives. Further study with a direct control group of natives and healthy people is needed to test this hypothesis.
As expected, FEP migrants compared with migrants in the general population are more often male (55% of our sample, 47% of migrants' general population) and unemployed (34% vs 14.1%). Male gender and unemployment are 2 well known socio-demographic characteristic frequently found in FEP patients. We did not find other relevant differences between migrants in our sample and those in the general population. In particular our finding about education shows around half of the sample has high school or more, which is consistent with the level of education found in migrants in the general population (40.5% high school license; 9% university degree) [22].
Interestingly, the mean age of FEP migrants in our sample is similar to those of migrants in the general population (31.8 vs 31.1) and similar to the mean age found by previous studies on Italian natives with FEP [6] and by studies conducted in other countries [23,24].

Clinical Characteristics and PtC
Around 2/3 of FEP migrants were referred to CMHCs after emergency access to a general hospital or after psychiatric admission and only around 20% had a GP referral or direct access to mental health services. This result is consistent with a large body of evidence which indicates that migrants in western countries have different access to and low utilization of community mental health centers (CMHCs) despite the high prevalence of mental disorders [25][26][27][28].
The mean DUP of 9 weeks found in our sample is relatively short in comparison with other studies [29]. This result, along with the emergency-pattern of psychiatric services' use and the high personal and social functioning found in our FEP migrants, could indicate an acute onset of psychosis in this population. However, data on DUP were missing for 4 centres, as its assessment was part of the optional levels of the PEP-Ita study. Non-affective psychoses represented the largest diagnostic group in our sample, in accordance with previous evidence [6,7]. The second most frequent diagnostic group was NOS-psychosis; in our opinion this second diagnostic cluster could reflect the discordant clinical presentation of these patients, characterized by psychotic clinical symptomatology and high personal and social functioning. Notably, none of the migrants included in our sample received a diagnosis of substance related psychosis. Moreover, a large proportion of FEP migrants presented to CMHCs with medical comorbidities.
Finally, our findings show a significant amount of heterogeneity across the nation regarding FEP migrants' PtC. This is consistent with our previous study [10], where differences in the PtC between the various centres were not explained by the socio-demographic factors taken into account. One possible explanation for inter-centre variations in migrant PtC might be connected to the degree of awareness of "mental health" services and social services on the part of immigrants in each region, as well as to the degree of cultural competence in different CMHCs.

Conclusions
Migration is a rapid and growing phenomenon in western countries and the association between psychotic disorders and migration history is a public health concern. In Italy, Mental Health Services are working to identify appropriate resources and organizational methods to respond to the mental health needs of migrants. The emergency-pattern of the CMHCs utilization, together with a mean duration of stay in Italy of around 9 years, the mean age at first CMHCs contact of around 31 years (very similar to the mean age of migrants in general population) and the high personal and social functioning found in migrants with FEP by our study allow us to hypothesize that they are a highly resistant population. It is probable that the onset of psychosis in migrants occurs only when the burden of negative psychosocial factors (such us racism, social isolation, discrepancy between expectations and achievement) overcomes a high threshold. In our study, FEP migrants frequently access the CMHCs with a medical comorbidity: this indicates the need to develop a more appropriate policy of health care delivery for the migrants population in Italy. Further studies with both native and healthy migrants control groups are needed to better understand psychotic disorders in migrants.