This is a verbatim copy/paste of my term paper for the Therapeutic Relationships course as a part of the Mental Health and Addictions program at Camosun College last term. The assignment was to synthesize two articles on a single topic and write a paper about it. I’m posting it because it is a topic deserving more attention. This paper was originally submitted on March 28th, 2019.
Suicidality in Ethnic Minorities and Immigrants
Identifying and treating suicidal ideation is difficult even in the most straightforward cases, where the suicidal individual presents with commonly understood symptoms of mental illness, has a psychosocial background which compliments the diagnosis, and is communicative enough to inform us of their feelings. Recent findings have pointed to a need for caregivers to understand how factors such as non-white ethnicity and migration status can cause risk factors for suicide to present differently than in people who are white, non-migrants, or both.
Suicide in Ethnic Minorities
Bhui et al. (2011) found that suicide risk indicators that caregivers use to identify suicidal ideation in White male individuals may not be able to accurately identify suicidality in non-white male ethnic minorities. This is backed up by their statistical findings, which indicated that “indicators such as suicidal ideas, depressive symptoms, emotional distress, and hopelessness were significantly more common among White British inpatients than other ethnic groups” (p. 143), whereas “male inpatients from Black African backgrounds were significantly more likely to have committed suicide that White British men” (p. 141). Assuming that an equal quality of care was given to all patients analyzed in the study, this indicates that the metrics successfully used to identify suicidality in White British male inpatients failed to identify suicidality in Black African male inpatients.
The statistics back up this claim: though 55.7% of White British inpatients in Bhui et al.’s (2011) study who completed suicide were noted to have experienced suicidal ideation, only 5.6% of Black African inpatients and 4.2% of South Asian inpatients were reported to have expressed the same characteristic before completing suicide (p. 144). A similar disparity is found with other risk factors in their study, such as emotional distress (92.6% of White British inpatients versus 23.5% of Black African inpatients, 10% of Black Caribbean inpatients, and 16.7% of South Asian inpatients), hopelessness (56% of White British inpatients versus 5.9% of Black African inpatients, 5% of Black Caribbean inpatients, and 12.5% of South Asian inpatients), and depressive illness (53.7% of White British inpatients versus 11.1% of Black African inpatients, 15% of Black Caribbean inpatients, and 29.2% of South Asian inpatients) (p. 144). These statistics point to discrepancies either in the success of caregivers attempting to identifying risk factors in non-white individuals or in the ability of these risk factors to predict suicidality in non-white inpatients.
Forte et al. (2018), in their literature overview on the topic of suicide in immigrants and ethnic minorities, validate the claim that non-white ethnic and cultural groups present symptoms of suicidality differently than White people. They found that in American Indian populations, the risk factors that preceded suicidality most often were not the classical symptoms noted above, but “thwarted belongingness and perceived burdensomeness” (O’Keefe et al., 2014, as cited in Forte et al., 2018, p. 15). In Hawaiian youth, acculturation was identified as a significantly impactful risk factor for suicidal ideation (Else et al., 2007, as cited in Forte et al., 2018, p. 15). In African Americans, religious well-being was found to be a more accurate predictor of suicidal ideation and attempt history than acculturation (Walker et al., 2005, as cited in Forte et al., 2018, p. 15). Forte et al. (2018) note that significant risk factors for both migrants and ethnic minorities were “language barriers, worrying about family back home, and separation from family” (p. 17). Additional risk factors leading to suicide for ethnic minorities were “arranged/forced marriage, lack of information on the health care system, loss of status and loss of social network, and also acculturation and thwarted ambition” (Ngwena, 2014, as cited in Forte et al., 2018, p. 16). It is important to note that none of these risk factors were assessed of inpatients by caretakers in the group analyzed in Bhui et al.’s 2011 study. Forte et al. (2018) conclude that ethnic minorities “may manifest a specific phenotype of suicidal behaviour” than non-minorities and non-immigrants (p. 17).
An additional factor to consider when assessing the factors that lead to suicidality in ethnic minorities is how the medium of treatment may affect outcomes: A study analyzing suicidal ideation in American Indian college students found that 57% of participants reported that they would not seek help from a mental health professional. However, their help-seeking likelihood was increased if they were able to access help from mental health professionals if the helper was also American Indian (Scheel et al., 2011, as cited in Forte et al., 2018, p. 16). This shows the importance of cultural competency on behalf of the helper, as the majority of students that participated in this study were unwilling to be treated by a mental health professional who wasn’t from the same cultural background as them.
As a point of interest, Bhui et al. (2011) also found that primary diagnoses between White and non-white inpatients were quite different, with schizophrenia being diagnosed much more often in non-white inpatients who ended up completing suicide than their White British counterparts (76.5% of Black African inpatients, 60% of Black Caribbean inpatients, and 50% of South Asian inpatients versus 22.1% in White British inpatients) (p. 144). Bhui et al. notes that this is supportive of previous research by Morgan and Stanton, 1997, and Hoyer et al., 2004.
Suicide in Immigrants
Though Forte et al. (2018) note that some studies report lower incidences of suicide in immigrant social groups, and others report mixed results (p. 4), the majority of studies point to higher rates of suicide attempts among immigrants than non-immigrants. Additionally, although they also note that some studies report lower rates of depression in migrant populations than in native populations (Zhong et al., 2015, as cited in Forte et al., 2018), data presented by Bhui et al. (2011) suggests that assessed rates of depression may not accurately predict rates of suicide in non-white populations. Higher rates of suicide amongst immigrants than in native populations were found to have occurred in studies conducted in Sweden (Johansson et al., 1997, as cited in Forte et al., 2018, p. 4), England (Ryan et al., 2006, and Leavey, 1999, as cited in Forte et al., 2018, p. 4), the Netherlands (Burger et al., 2009, as cited in Forte et al., 2018, p. 4), and Israel (Ayalon, 2012, as cited in Forte et al., 2018, p. 4). Even immigrants who were born outside of the country in which they live experience higher rates of suicide; a study reporting on first-generation Asian-American immigrants in the United States found that rates of suicidal ideation were markedly higher than in Americans with non-immigrant parents (Duldulao et al., 2009, as cited in Forte et al., 2018, p. 4). Bhui et al.’s (2011) study potentially supports this claim as well, as they note that the broad ethnic categories they studied potentially included immigrants – specifically, they noted that the groups they studied that completed suicide at higher rates “might contain refugees and asylum seekers who escaped persecution” (p. 145). However, it is worth noting that their data did not include that information, so this statement is speculative. Further research must be done to make distinctions past the simple label of ‘migrant’ to assess suicidality in migrants who immigrated voluntarily, such as for business, versus migrants who immigrated involuntarily, such as for fear for their lives.
Risk factors for suicide in post-migration immigrant populations are noted to be different than the classical risk factors addressed above. In Bhutanese refugees resettled to the United States between 2008 and 2011 who completed suicide, 71% were reported to experience difficulties with language barriers, leading to hopelessness, 43% experienced stress from being separated from their families, and 57% were worried about family back home (Hagaman et al., 2016, as cited in Forte et al., 2018, p. 16). Forte et al. (2018) notes that cultural stressors “play a key role as risk factors for suicidal behaviour” (p. 16). Forte et al. (2018) additionally notes that multiple studies have shown that immigrants as well as ethnic minorities receive lower-quality psychiatric care and are less likely to contact psychiatric services while in crisis, leading to “a global worsening of their mental health condition and an increased risk of suicide” (p. 17). Overall, cultural stress and social isolation appear to confer a significant risk factor contributing to suicidality in immigrants.
Underlying socioeconomic factors associated with migrant status can themselves be predictors of suicidality as well. Forte et al. (2018) notes that “factors such as socio-economic status, social exclusion, discrimination, and deprivation are more clearly related to suicidal behaviour than the status of migrant itself” (p. 17). Thus, it is important to dive deeper past the label of ‘migrant’ and address the socio-economic factors associated with the migrant experiences itself that may predict suicidality.
All data points to the idea that frontline caregivers need to continue expanding their collective and individual understandings of how suicidality presents – particularly in groups that include ethnic minorities and migrants. This is evidenced by the lack of correlation between rates of suicide in non-white & migrant people and presentation of classical risk factors such as emotional distress, hopelessness, and depressive illness. It is clear that in order to accurately predict suicidality in immigrants and ethnic minorities, increased cultural competency of caregivers is necessary in order to account for cultural differences in expression of suicidality as well as the effects of migration on mental health. Additionally, as the literature grows, it is necessary to make distinct the difference between migrants who immigrate for reasons such as business versus those who immigrate without choice, such as asylum seekers. Forte et. al (2018) notes that more research is necessary to “develop a more reliable and standardized assessment of suicidal behaviour in [ethnic minority and immigrant] populations and to identify dedicated strategies of risk prevention for each group” (p. 17).
Forte, A., Trobia, F., Gualtieri, F., Lamis, D., Cardamone, G., Giallonardo, V., . . . Pompili, M. (2018). Suicide Risk among Immigrants and Ethnic Minorities: A Literature Overview. International Journal of Environmental Research and Public Health, 8(15), 7th ser. doi:10.3390/ijerph15071438
Bhui, K. S., Dinos, S., & Mckenzie, K. (2012). Ethnicity and its influence on suicide rates and risk. Ethnicity & Health, 17(1-2), 141-148. doi:10.1080/13557858.2011.645151