Curr Epidemiol Rep

DOI 10.1007/s40471-017-0111-2

SOCIAL EPIDEMIOLOGY (A AIELLO, SECTION EDITOR)

Immigration and Mental Health

Margarita Alegría 1,2 & Kiara Álvarez 1 & Karissa DiMarzio 1

# Springer International Publishing AG 2017

Abstract Summary We conclude with an emphasis on social resilience

Purpose of Review While the experience of migration and processes, with a focus on how immigrants develop social
resettlement in a new country is associated with mental health relations, social capital, and social networks. We recommend
risks, immigrants generally demonstrate better mental health future directions for research that prioritize identifying and
than expected. This review describes patterns in mental health understanding social adaptation strategies adopted by immi-
outcomes among immigrants. We discuss a conceptual model grant groups to cope with immigration stressors.
of the potential underlying mechanisms that could buffer the
stress and disadvantage experienced by this substantial and Keywords Immigration . Mental health . Psychiatric .
growing population. Culture . Social resilience . Epidemiology
Recent Findings While epidemiological studies have
established a general pattern of lower risk for mental health
disorders among first-generation (foreign-born) immigrants in Introduction
the USA, recent studies highlight how this pattern varies sub-
stantially by the intersection of race, ethnicity, national origin, The sizeable and quickly growing number of immigrants in
gender, and socioeconomic status. Contextual factors includ- the USA over the past 35 years continues to have a significant
ing the family and neighborhood context, an immigrant’s so- societal effect, with a central role in terms of productivity and
cial position, experiences of social support and social exclu- economic growth in the last two decades of the twentieth
sion, language competency and ability, and exposure to dis- century [1]. Immigration remains a significant driver of pop-
crimination and acculturative stress further influence the rela- ulation growth. Estimates in 2014 suggest that approximately
tionship between immigration and mental health. 42 million immigrants were living in the USA, representing
13% of the total population, projected to increase to 22% by
This article is part of the Topical Collection on Social Epidemiology 2060 [2]. More than a third of the US Latino population and
two-thirds of the Asian population are foreign-born [3]. Of the
* Margarita Alegría 56.6 million individuals who identified as Hispanic or Latino,
[email protected]
roughly 36 million further described themselves as Mexican
[4], while of the 20.3 million individuals who identified as
Kiara Álvarez
[email protected] Asian, 4.5 million labeled themselves as Chinese [5].
The term “immigrant” encompasses a broad range of dis-
Karissa DiMarzio
[email protected]
tinct nationalities, cultures, races, and ethnicities, and does not
describe a monolithic group. Immigrants differ in various per-
1
Disparities Research Unit, Department of Medicine, Massachusetts
sonal factors and social determinants, such as primary lan-
General Hospital and Harvard Medical School, 50 Staniford St. Suite guage, social resilience, and occupation, socioeconomic status,
830, Boston, MA 02114, USA culture, and religion. However, first-generation immigrants
2
Department of Psychiatry, Harvard Medical School, Boston, MA, generally have an initial health advantage over their US-born
USA counterparts that erodes the longer they reside in the USA. This
 Curr Epidemiol Rep

phenomenon has been labeled the acculturation hypothesis [6]. lower rates [12]. The longer immigrants live in the USA, the
The established conclusion is that as immigrants become more more their risk for psychiatric disorders approaches that of
assimilated or acculturated into US social and cultural norms, US-born [11, 15].
the more their health status resembles that of the US-born. Yet, An analysis of the Asian-American sample within the
there appear to be common risk and protective factors for men- National Epidemiological Survey of Alcohol and Related
tal health outcomes that result from the immigrant experience. Conditions (NESARC) found that foreign-born Asian-
This review aims to elucidate commonalities and differences Americans had significantly lower risk of psychiatric disorders
among immigrant groups in an effort to identify key social compared to their US-born counterparts [13]. Risk of psychiatric
determinants that can be addressed to reduce disparities in illness was lowest for immigrants who arrived in the USA after
mental health outcomes. While our focus is on immigrant age 14 compared to those who arrived prior. Across all disorder
groups in the USA, we also discuss relevant international find- classes, risk for first onset of disorder was lowest prior to migra-
ings that may shed light on these processes. tion, and after migration, risk increased until it was comparable
Research on the health and mental health of immigrant groups with the US-born. A study of the Asian-American respondents in
has established that first-generation immigrants (those born in the National Latino and Asian American Study (NLAAS) found
one country, the “home” country, that migrated to the USA, here the same pattern of lower lifetime prevalence of any disorder
denominated as the “host” country) are healthier, in terms of most among immigrants overall compared to US-born, with an anal-
physical and mental health outcomes than their US-born coun- ysis by age at immigration demonstrating that this difference in
terparts [7••]. This initial advantage is often described as the prevalence was present only among immigrants who arrived at
“immigrant paradox” due to the presumption that relatively lower the age of 12 or later [14].
socioeconomic disadvantage among immigrants should be Analysis of prevalence rates among the Latino sample of
reflected in poorer health [7••]. A second group of immigrants the NLAAS also found support for the immigrant paradox in
is categorized as the “1.5 generation” to describe a group that psychiatric illness, with foreign-born Latinos having lower
falls in the middle—those who are foreign-born but arrived in the lifetime prevalence rates of mood, anxiety, and substance
USA at a young age, such that the majority of their life has been use disorders [9]. In a separate study of the NLAAS, analysis
spent in the host country [8]. Second-generation immigrants were of risk of disorder found no difference in risk of psychiatric
born in the host country to one or two foreign-born parents. Both disorders between immigrants who arrived before the age of 7
of these two later groups typically show lower health status as and US-born Latinos [10]. However, arriving at age 7 or older
compared to the first generation, in keeping with the accultura- was linked to later onset of depressive disorders among immi-
tion hypothesis. grant men and of substance use disorders among both men and
Research conducted over the past decade has aimed to un- women. Overall, it appeared that the longer immigrants resid-
pack these findings by investigating the epidemiology of men- ed in their home country, the less cumulative risk of onset of
tal health outcomes among specific immigrant subgroups psychiatric disorders they experienced, leading to overall low-
(e.g., those defined by race/ethnicity, nationality, age at immi- er prevalence rates among the foreign-born population of
gration) and by exploring the mechanisms presumed to ac- Latinos in the USA.
count for differences among groups. We first present an over- Research has also demonstrated the importance of analyz-
view of recent key findings in the epidemiology of mental ing subgroups within each ethnic category. The analysis of the
health conditions among immigrants in general and then dis- nativity effect across a greater number of immigrant groups
cuss findings of interest for specific mental health disorders. participating in the NESARC study found lower risk for mood
We then present a conceptual framework integrating these and anxiety disorders among immigrants from Mexico,
findings into an understanding of mental health risk and resil- Eastern Europe, Africa, and the Caribbean (excluding Puerto
ience among immigrants and close with a discussion of short Rico and Cuba) who arrived in the USA at age 13 or older and
and long-term research goals for the field. no difference in risk for those who arrived before age 13 when
compared to the US-born [12]. There was no difference in
psychiatric disorders based on nativity for immigrants from
Overview of Risk and Protective Factors Western Europe or Puerto Ricans born in Puerto Rico.1
Furthermore, in another study, there was a particularly large
National studies of the two largest immigrant groups in the discrepancy in lifetime prevalence of substance use disorders
USA, Latinos and Asians, have found lower rates of psychi-
atric disorders among foreign-born respondents compared 1
Puerto Rico is part of the USA and Puerto Ricans born in Puerto Rico are US
with US-born [9–14]. The general pattern of findings is that citizens; therefore, migration from Puerto Rico to the continental USA is best
those who migrated during childhood have rates of psychiatric classified as internal migration. However, cultural and linguistic differences
between Puerto Rico and the continental USA result in a migration process that
disorders similar to US-born respondents of the same ethnic- is more similar to migration from other Latin American countries than it is to
ity, while those who migrated during adolescence or later have internal migration between US states.
Curr Epidemiol Rep

between immigrants (7%) and US-born Latinos (20.4%); women having a significantly lower risk for depressive disor-
however, when examining the effect by subgroup, lower prev- ders when compared to Chinese women. In a study of Black
alence across disorders was only observed for Mexican and Americans, the National Survey of African-American Life
Cuban immigrants [9]. There were no significant differences (NSAL), no overall difference in risk of lifetime mood disor-
between Puerto Ricans and non-Latino Whites from the USA. der is found for foreign-born respondents when compared to
In an analysis of lifetime prevalence of psychiatric disorders US-born [22]. Among Black immigrants, men who have been
by Latino subgroup, Puerto Ricans had the highest prevalence in the USA more than 11 years have a substantially lower risk
across disorders of all groups [16]. These results suggest that of a mood disorder compared to the US-born, as do those who
the protective effect of being foreign-born may vary depend- immigrated between ages 13 and 17. Comparably, women
ing on the country of origin for Latinos, and that analyzing who have been in the USA 6–10 years and who immigrated
multiple nationalities under the umbrella of one ethnic group between ages 18–34 also have this advantage [22]. These
may obscure such differences. results suggest that the impact of immigration and accultura-
Categorization on the basis of race in epidemiological stud- tion to the host society may impact mental health differently
ies also makes it challenging to identify differences in the based on gender, ethnic or racial subgroups, religious affilia-
mental health status of immigrants who are categorized as tion, time in the USA, and age of immigration.
White in national surveys. In particular, there is a dearth of
nationally representative data on the mental health status of Anxiety Disorders
Middle Eastern immigrants. A subgroup analysis of the
National Health Interview Survey (2000–2010) found that Patterns observed for anxiety disorders are similar to those seen
foreign-born Whites from the Middle East were nearly twice for depressive disorders for Latinos and Asians but somewhat
as likely to report serious psychological distress when com- different for Black immigrants. Among Latinos, being foreign-
pared to US-born Whites and more than twice as likely to born is associated with lower prevalence of any anxiety disor-
report serious psychological distress when compared to der and in particular with lower prevalence of social phobia and
foreign-born Whites from Europe [17]. post-traumatic stress disorder—but when disaggregated by
We next detail the differences observed across immigrant subgroup, again, the finding only holds for Mexican immi-
groups for some prevalent psychiatric disorders. grants [9]. Among Asians, as seen with depressive disorders,
being foreign-born is associated with lower risk of anxiety dis-
Depressive Disorders orders for Asian women but not men, while English-language
proficiency is associated with lower risk of anxiety disorders
As a whole, immigrants are less likely to suffer from a depres- for Asian men but not women. No subgroup differences are
sive disorder compared with their US-born counterparts, but found in the risk for anxiety disorders in Asians [14].
when broken down by subgroup, this finding becomes more Foreign-born Black men are at lower risk of lifetime anxiety
complex [12]. For example, literature supports that immigrant disorders than US-born men, while no difference is observed
Latinos are at a significantly lower risk of any depressive for women. Risk is lower for men who have been in the USA
disorder than US-born Latinos [9]; however, this finding only 11 to 20 years and for those who immigrated between ages 13
remains significant for Mexican immigrants when further and 34. Among women, no differences are found based on
evaluated. Despite these findings, the literature appears to be years in the USA, but those who migrated to the USA after
mixed with others reporting that Mexican immigrants are at a age 18 are at lower risk for anxiety disorders [22].
significantly higher risk than US-born Mexicans [18, 19]. In a
study comparing Arab-Americans, Chaldean-Americans (a Substance Use Disorders
Catholic Christian subgroup from Iraq), and African-
Americans in the Midwest, Arab-American participants re- According to Pena and colleagues [23], rates of problematic
ported the highest rates of depression and Chaldean- alcohol use and repeated drug use increase across generation
Americans the lowest. The highest risk among Arab- status, with second and later generations reporting higher rates
Americans was for those of Iraqi descent, who in this study than first generations. Overall, Latino immigrants are at a sig-
were also Muslim. A smaller study of Iraqi refugees in the nificantly lower risk for alcohol abuse, drug dependence, and
USA reported that more than a quarter of participants met drug abuse when compared with US-born Latinos. However,
DSM-IV criteria for depression [20, 21]. similar to depressive disorders, these findings only remain sig-
Among Asian-Americans, lower risk of any depressive nificant for Mexican immigrants and are challenged by other
disorder has been found for foreign-born women but not findings in the literature [24, 25]. In contrast, there seems to be
men. English-language proficiency is protective against de- a protective effect for nativity status in relation to substance
pressive disorders for men but not for women [14]. Only disorders among Cubans and other Latinos. A similar protec-
one significant subgroup difference was found, with Filipina tive effect is observed among Asian and Black immigrants,
 Curr Epidemiol Rep

with foreign-born men and women having a lower risk of de- different than that observed in the full sample [15]. In an inter-
veloping a lifetime substance use disorder [14, 22]. While risk national study, 27 out of the 56 immigrant groups are shown to
for Asians increases for both men and women in the second and have higher suicide attempt rates than their host country counter-
third generations, the increase in risk of a lifetime substance use parts, with only four groups having significantly lower rates [34].
disorder is much greater for women [14]. In a subgroup analy- This suggests the importance of understanding differences across
sis, no differences are found between Chinese, Filipino, immigrant groups and by age of arrival.
Vietnamese, and other Asians, with the exception of a higher
risk for substance use disorders among Filipino men. For Black
immigrants, risk increases for both men and woman and is Conceptual Model
highest for men in the second generation and women in the
third generation. Migrating to the USA between ages 18 and Several authors have attempted to explain these differences in
34 for men and between ages 13 and 34 for women is associ- risk for psychiatric illness between immigrants and native-born
ated with substantially lower risk of a substance use disorder groups. For example, some authors describe immigrants’
when compared to the US-born [22]. unique set of challenges that may alter their social, economic,
and health experience [35•, 36]. Changes in practices (i.e., use
Psychotic Disorders of their primary language, or dietary practices), values (i.e.,
values related to collectivism and familism vs. individualism),
While migration is associated with higher rates of self-reported social factors (i.e., affiliation to elders), and cultural identifica-
psychotic symptoms, immigrants from developing nations, par- tion (i.e., ethnic identity) have been identified as potential risk
ticularly those from the Caribbean where a preponderance of factors that change health behaviors [37]. Other authors suggest
the population is black, demonstrate the highest rates [26–28]. that these changes in health can be accounted for by the immi-
Similarly, in a study examining the immigrant population in grant’s migration experience, their social adjustment, and
Italy, researchers found that immigrants have higher rates of achieved socioeconomic status; social supports in the host
all psychotic disorders compared with the general population country; neighborhood characteristics; access to care; and level
[29]. Likewise, another international study found that immi- of perceived discrimination [38]. Gee and Ford [39] add to
grants were at a higher risk of schizophrenia when compared these factors the effects of structural racism against different
with native-born individuals [30]. Specifically, those who im- groups of immigrants and the potential intergenerational effects
migrate as youth are at higher risk [30, 31] than those who of racism on health. Lee and colleagues [40•] delineate long-
immigrate at older ages [31]. This is particularly true for immi- term factors from both the individual’s home country (genetics,
grants from Eastern, Caribbean, and South American countries lifestyle, culture, language) and the USA (social network, age,
[30]. Hospitalization risk due to schizophrenia is significantly gender, occupation, access to healthcare, lifestyle) that could
increased for adolescent immigrants as well as second- cumulatively affect the health of immigrants at different stages
generation immigrants with one or two immigrant parents in life. These authors underscore that health differences across
[32]. Risk is also higher among females than males [30]. immigrant groups are the product of a myriad of social and
Although there is not a singular reason to explain the higher cultural factors, such as group-specific stereotypes, the family’s
incidence of schizophrenia among immigrants, several factors involvement in health, and the congruence between health be-
have been identified as possible contributors, such as low so- haviors in the country of origin and the USA.
cioeconomic status and acculturative stress [33]. The cross-national framework conceptualized by Acevedo-
Garcia and colleagues [41] connects and integrates different
Suicidality frameworks to understand immigrant health, including the life
course approach as well as push-pull factor theories and trans-
In analyses of the Collaborative Psychiatric Epidemiology national theory, reflecting the interdisciplinary nature of
Surveys (CPES), a group of nationally representative surveys studying immigrant health. Push-pull factor theories imply
of US adults, prevalence of suicidal ideation is highest in US- that aside from forced geographic dislocation, immigrants
born respondents overall, followed by those who migrated as leave their country of origin for more favorable life circum-
children and then those who migrated at older ages. Across all stances in a new country (the host or receiving country), and
four ethnic groups (Asians, Latinos, non-Latino Blacks, and non- as such, there may be some health selection bias, in that
Latino Whites), immigrants who migrated as adolescents or healthier and more resilient individuals are more likely to im-
adults have a lower prevalence of both suicidal ideation and migrate. Ultimately, differences in the health status of immi-
attempts when compared to the US-born respondents of their grants thus depend on the context of migration that can vary
same ethnic group. Among Asian and non-Latino Black immi- between immigrant groups and within groups by age and gen-
grants, those who migrated as children have a higher lifetime der [42]. Transnational theories imply that immigrants often
prevalence than the US-born of the same ethnicity, a pattern maintain ties to family and communities in their homelands,
Curr Epidemiol Rep

which can impact health through both social remittances (ex- of the predominant immigrant groups in the USA as having a
changes of ideas and social capital) and monetary remittances collectivistic worldview in which family connectedness and
(investments in one’s prior community’s growth). obligation are highly valued. However, findings are not uni-
In order to conceptualize the complexity of the immigrant form across studies and may vary by ethnic group in terms of
experience in relation to mental health, we propose a model which psychiatric disorders are most affected. For example, in
that prioritizes social processes and how these interact with one study [45], having a high level of family cohesion de-
experiences of migration, the social-ecological context of the creased the risk of last year and lifetime depressive disorders
home and host countries, and acute and chronic stressors to among Latino immigrants, while having a low level of family
produce better or worse mental health outcomes. Social pro- cohesion increased risk of last year and lifetime anxiety dis-
cesses presumed to positively impact mental health fall under orders among Asian-American immigrants. Family cohesion
the umbrella of social resilience and include the development was protective for both groups but for different psychiatric
and maintenance of interpersonal relationships, accumulation disorders. Furthermore, the effect was in the opposite direction
of social capital, and expansion of social networks. These for substance use disorders among Latinos; low levels of fam-
processes provide avenues through which to cope with and ily cohesion were actually associated with lower levels of
repair the inherent disruptions and disconnections caused by substance use disorders among this group.
migration. Social processes presumed to negatively impact It is also possible that higher levels of connection and ob-
mental health are forms of social exclusion, such as discrim- ligation to family may create additional stressors from experi-
ination and opportunity restriction, which impede the ability ences such as caring for family members, being exposed to
of immigrants to become integrated into a new environment, their struggles, or working to align one’s own goals with that
access resources equally, and develop a sense of self as valued of the family. In a cross-national study, Borges and colleagues
in relation to the larger context. [24] found that not only was the prevalence of alcohol and
These social processes play out differently in the lives of substance abuse higher among migrants to the USA but also
individuals and furthermore interact with experiences that vary among family members of migrants who remained in Mexico
by immigrant group. The migration experience itself is charac- when compared to those from non-migrant families.
terized by at least three distinct time periods—pre-migration, Familism, the term for the value of placing family well-
during migration, and post-migration—that are very different being above individual well-being among Latinos, was found
depending on country of origin, reasons for migration, and the to be linked to lower levels of parent-adolescent conflict but
context of reception once in the USA. For example, an immigrant higher levels of internalizing behavior in a study of Latina
fleeing political violence may have experienced a great deal of adolescents [46]. This implies that familism is not uniformly
trauma prior to arriving in the USA. The experience of migration protective against psychiatric disorders.
will then vary depending on whether US entry is as an undocu-
mented immigrant or as a politically protected refugee. Context Social Position and Social Capital
of reception might include settling in an ethnic enclave near
family members and in a state with large numbers of the group, An individual’s social position or place in the social structure
or it might mean settling in a location with low levels of ethnic emerges as a key determinant of mental health. A sizeable
diversity. On the other hand, immigrants that arrive as highly amount of research relates lower social position with overall
skilled workers or for educational purposes may have vastly lower self-reported health [47, 48]. Most studies on social po-
different experiences integrating into US society. Below, we de- sition and health, however, assume the universality of main-
tail various constructs suggested by the literature and our own stream American culture, with limited integration of the per-
studies central to immigrants’ mental health. spectives of immigrant populations. Nonetheless, there is some
evidence to suggest that nativity may mediate the relationship
between social status measures and mental or physical health
Factors that May Enhance or Diminish Mental [49]. The lack of consistency among social position indicators
Health across countries suggests that culture and local worlds may play
an important role in how one attributes social status [50].
Family Context
Neighborhood Context
Across studies, family conflict has been found to be a risk
factor for a number of psychiatric disorders among immi- Neighborhoods can shape health behaviors and consequently
grants, while family cohesion has generally been found to be have significant implications on risk for psychiatric illness and
a protective factor [43, 44]. Research on immigrants empha- resource allocation that can protect against hardship. Members
sizes that family cohesion is associated with developing resil- of ethnic minority groups may have better behavioral health
ience. These findings are consistent with a conceptualization when residing in neighborhoods with a high density of
 Curr Epidemiol Rep

members of the same group [51]. This relationship has been by increased restrictions on immigration, it is also the case that
observed for adolescents [52] and for adults, particularly advances in communication technology (mobile phones, af-
among Latino populations [53]. These effects seem to mitigate fordable international calling, and social media) have made
the negative effects of concentrated disadvantage that charac- frequent international contact a possibility for the vast major-
terize racially segregated neighborhoods [54, 55]. Yet results ity of immigrants [62]. Interestingly, an analysis of the influ-
are inconsistent across studies. A study of Puerto Ricans ages ence of transnational economic ties (represented by remit-
45 to 75 years old found that living in a neighborhood with tances burden or percentage of remittances sent home relative
higher ethnic density of Puerto Ricans was protective against to household income) and transnational social ties (represent-
depression symptoms at a 2-year follow-up but only for men ed by number of annual visits to the home country) on the
[56•]. In contrast, a national study of neighborhood effects on mental health of Latino immigrants found that an increase in
mental health showed that Latinos residing in neighborhoods remittances burden was associated with decreased odds of past
with greater Latino immigrant concentration were at increased year major depressive episode, while a higher number of visits
risk for depression and anxiety disorders; Puerto Ricans had back home was associated with increased odds. The link be-
the highest risk among Latino subgroups [57]. tween visits home and depression was stronger for women
than for men [63]. Similarly, a study of transnational ties
Social Supports and Social Exclusion among Arab-Americans in Detroit found they can constitute
both a risk and a protective factor. Transnational social ties
Ruiz and colleagues [58••] describe how immigrant Latinos and positive attitudes towards connections with the Arab
living in the USA create larger social networks within families world were associated with greater odds of psychological dis-
and the community that confer respect, advice, acceptance, tress for first through third-generation Arab-Americans, while
and interpersonal relationships generally lessening the nega- involvement in cross-border community organizations was
tive influence of external stressors on health. Residing in a associated with less distress [64]. While further empirical re-
location that is a newer receiving site for the immigrant group search on transnational ties is needed, these results suggest a
may exacerbate the risk for psychiatric illness. In one study of complex relationship between connections to the country of
150 Mexican immigrants who moved to a non-traditional re- origin and psychiatric illness.
ceiving site, 68% met clinical thresholds for anxiety or depres-
sion symptoms or both [59]. Greater social support was asso- Language Use and Ability
ciated with lower depression and comorbidity. While social
support may be protective across contexts, it may also be more Limited English proficiency has been linked to poor health
difficult to obtain in a non-traditional receiving setting. In a outcomes [65, 66]. On a practical level, not speaking
mixed-methods study in Canada that sought to characterize English proficiently and needing interpretation services are
the role of organizations providing settlement services to im- two major barriers to accessing and remaining in healthcare
migrants, social support was independently associated with [67], including mental health care [68–70]. A study of French
better self-rated mental health and was also higher in smaller immigrants in Canada found specific healthcare concerns
urban centers when compared to larger urban centers. resulting from language and communication difficulties in-
Qualitative interviews indicated that more intensive social cluding fear of being misunderstood, experiencing emotional
supports were available in these smaller urban centers due to distress prior to the visit, feeling unsatisfied with the care
the presence of more personal relationships and greater ease in received, delaying seeking care, and the potential for harm
coordinating between agencies and also highlighted the im- or medical errors [71]. Thus, language barriers are not simply
portance of social support in a successful resettlement. a challenge of communicating specific information but rather
However, despite the availability of more social supports, re- impact both instrumental and emotional aspects of the patient-
siding in a smaller urban center was associated with poorer provider encounter. Indeed, inability to communicate in the
self-rated mental health in adjusted models; qualitative inter- dominant language has been posited to influence health out-
views suggested that barriers presented by low cultural and comes by producing social isolation, insecurity, lack of access
linguistic diversity in these areas (e.g., discrimination and lan- to relevant information, and difficulty establishing social rela-
guage barriers) may account for this result [60•]. tionships, which in turns impacts self-esteem and position
within family and other social systems [66].
Transnational Ties
Discrimination and Acculturative Stress
The development of transnational ties implies maintaining
social, economic, political, or cultural ties across national bor- There is some evidence that Latino and Asian immigrants may
ders on a frequent and ongoing basis [61]. While it is possible experience less exposure to discrimination than their US-born
that the maintenance of transnational ties may be threatened counterparts, possibly due to less exposure to diverse ethnic
Curr Epidemiol Rep

groups [45]. However, those who do experience discrimina- mental health problems is complex and linked to a myriad
tion, along with other stressors related to acculturation in the array of factors that can be buffered or exacerbated given the
host society, may be at greater risk for psychiatric disorders. residing context, the migratory experience, the age at migra-
Evidence suggests that lower acculturation together with ac- tion, and the social processes that evolve in the host
culturative stress can increase risk of suicidal behaviors, in- environment.
cluding thoughts and attempts [72]. A study of Korean immi-
grants in New York City found that higher exposure to dis-
crimination was associated with higher depression symptoms Conclusion and Future Directions
[73]. Among Arab-Americans, discrimination was reported
more frequently by those who were Muslim, identified as A different optic is emerging examining the role of social
non-White, and lived within ethnic enclaves; however, the resilience in the migration-environment nexus, defined “as
association between discrimination and psychological distress the degree of disruption a system experiences in response to
was stronger for their counterparts who were Christian, iden- changing circumstances.” The study of social resilience exam-
tified as White, and lived outside of ethnic enclaves [74]. ines how one develops social relations, social capital, and
A recent study [75] distinguished between legal accultura- social networks to adapt to the new environment after migra-
tive stress, related to concerns about legal status, and discrim- tion, including how immigrants access resources and assis-
ination acculturative stress, related to being discriminated tance from the wider socio-political arena. It seeks to under-
against for ethnicity/race, language, or national origin. More stand how immigrants cope with and overcome adversities,
than 45% of Asian-American immigrants reported experi- learn and adapt to new experiences, and adjust their liveli-
ences of discrimination stress, and almost 20% reported expe- hoods to subsist. Considerable research demonstrates how so-
riences of legal stress. There was a strong positive relationship cial ties and social relationships (exemplified by social sup-
between discrimination stress and lifetime incidence of major port, social networks, and relationships to institutions) influ-
d e p r e s s i v e d i s o r d e r, e v e n a f t e r c o n t r o l l i n g f o r ence health [76–79]. Yet, there is a void of information on
sociodemographic variables. Age at immigration and years social resilience and its impact on immigrant health and more
in the USA moderated this relationship, such that the discrim- importantly how adapting and adjusting to the US might lead
ination stress was more predictive of a major depressive epi- to a health disparity linked to a social or economic disadvan-
sode for immigrants who arrived after age 18 and who had tage, rather than an advantage. Our first recommendation is to
lived in the USA less than 10 years. Legal stress was also conduct studies that evaluate factors that exclude or include
associated with depression in a separate model and was more immigrants from social opportunities and social relationships
predictive for immigrants who arrived before age 18. These and investigate the benefits and costs of integrating into US
results imply that acculturation stress does not operate as one society. This might require investigating how to increase so-
single risk factor and that types of stress impact mental health cial mobility and economic opportunity without disrupting
risk differently for immigrants who arrive in the USA as chil- existing social networks with peers and family that provide
dren versus as adults. benefits to mental health and well-being. It also emphasizes
the role of undocumented versus documented status and how
Other Factors that Appear to Matter different statuses might lead to different lives and privileges or
institutional benefits. What happens when immigrants have to
There are other factors that seem to be correlated to increased become invisible or camouflage to survive? How does it in-
or decreased risk for immigrants’ mental health, as exempli- fluence mobility and integration in civic society? How does it
fied in a study of Mexican Americans [59]. Having grown up impact mental health?
in a rural area prior to migration and engaging in recreational A question of interest is whether maintaining transnational
or church activities at baseline resulted in lower depression ties in the country of origin while integrating in social spheres
symptoms at follow-up. The reasons for immigration also ap- in the host country is adaptive (i.e., might confer professional
pear to matter, since having migrated for personal or family mobility) or if it is psychologically and economically draining
problems was associated with greater depression symptoms and overburdens immigrants? Does maintaining ethnic iden-
compared to those who migrated for economic reasons. tity and affiliation with family and peers while at the same
Everyday stressors (not specifically linked to immigration) time expanding opportunity outside one’s cultural group cre-
were related with higher risk for psychiatric disorders, partic- ate tensions, and what type of tensions? How does it influence
ularly among women, while acculturation stressors were as- mental health?
sociated with depression and comorbidity. In an interaction A third area of relevance for future study is the role of
model, the association between acculturation stress and de- family and extended kin networks in shielding or aggravating
pression only held for those immigrants that had fewer years adversity in the host country. How do these networks help
in the USA. These results accentuate how immigrants’ risk for mold ethnic identity, aspiration, and expectations? Are
 Curr Epidemiol Rep

intergenerational relationships a source of conflict that in- References

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 Curr Epidemiol Rep

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Curr Epidemiol Rep

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