Incorporating Evidence of Migrant Women with Schizophrenia into a Women’s Clinic

Abstract

Many gender differences in mental and physical health, along with accompanying social needs have been reported by those suffering with schizophrenia. The goal of this review is to explore the literature on migrant and culturally diverse women suffering with schizophrenia to develop and implement effective strategies in specialized clinics. In general, we found higher rates of mental health symptoms among migrant and refugee women when compared to men. Several factors contribute to this vulnerability, suggesting that women may experience more pre- and post-migration-related trauma. In clinical populations, migrant status, region of origin, age at the time of migration, migration with family or alone, and migration to join family determine the risk of schizophrenia and the clinical course of the illness. Refugee migrant women have a higher risk of schizophrenia than non-refugee migrants and native-born populations. Migration is associated with poor access to mental health services; low social support, lack of awareness of services, and language barriers may mediate this association. These findings call for specific assessments on migrant women, interventions (e.g., focus groups), and improvement in current programs. In our clinics, we have recently incorporated assessment and intervention strategies that may be effective in our programming.

1. Introduction

Women with schizophrenia have specific clinical and social needs that differ from those of men [1]. In view of these gender differences in mental, physical health, and social risk factors, a new specialized unit for women with schizophrenia and related disorders has been developed as a pilot project in the context of community mental health services [2] which cover the clinical care of nearly a population of 220,000 inhabitants in a well-defined area of the north of Barcelona, in Terrassa and Sant Cugat (Spain). Forty per cent of the population who attend both mental health units suffer from a severe mental illness. Schizophrenia is the most common diagnosis; 58% of the population suffering with schizophrenia are women. Programs and planned services currently offered by the specialized unit have been previously described [2].

Inspired by the recent literature demonstrating the mental health, physical health and social needs in schizophrenia, this unit was inaugurated in January 2023 to address these care needs specific to women [3]. Five working groups, called “observatories”, were designed to study the effectiveness of treatment for five specific areas of concern. These observatories were developed to study the following: (1) somatic morbi-mortality (2) hyperprolactinemia, (3) substance use disorders, (4) social exclusion and discrimination, and (5) prescription and drug safety. These observatories consist of monthly staff meetings dedicated to the following processes for these five clinical or social phenomena: review all cases, monitor patient health, and share clinical decisions.

For the observatory studying somatic morbi-mortality, all deaths from women who suffered with schizophrenia were analyzed, and all causes of somatic morbidity were reviewed and discussed with the intention of actively intervening in these risk factors [4]. The literature emphasizes that high mortality rates are found in people with schizophrenia that can be attributed to respiratory illness, cardiovascular risk factors and cancer [5]. The clinical staff monitored the medical comorbidities of women with schizophrenia and proposed a close collaboration with other medical services to improve the physical health of these women. Analyses of case reports were proposed at the monthly meetings to illustrate the main medical comorbidities of our cohort of women.

The observatory studying hyperprolactinemia consisted of monthly meetings where prolactin levels of women with schizophrenia were monitored, with input and collaboration of primary care physicians and neuroendocrinologists. This working group is relevant because antipsychotic-induced hyperprolactinemia has been associated with short-term and long-term consequences, osteoporosis being one of them [6]. Prolactin tests, physical examinations, and clinical histories were monitored and reviewed by the clinical staff. Women with moderate or severe hyperprolactinemia also received close follow-up. Neuroendocrinologists were actively involved in the clinical management of these women.

The occurrence and consequences of substance use disorders were the main target of the third observatory, which mainly focused on the prevention, monitoring and treatment of alcohol use disorders, benzodiazepine dependence, and opioid prescription [7]. Clinical staff monitored the occurrence of substance use, and the effectiveness of the proposed interventions. If necessary, addiction specialists were also involved in the clinical care of these women. Frequently, these women had received special attention from addiction psychologists. Men and women with schizophrenia metabolize drugs differently, which impacts on the safety and tolerability of antipsychotic medications. The observatory of prescription and drug safety mainly focused on the sex/gender differences on antipsychotic efficacy, pharmacokinetics, and pharmacodynamic effects, with special emphasis on the prescription of clozapine [8]. One of the main objectives of the observatory of prescription and drug safety was to monitor the differences in treatment response and adverse events between pre- and postmenopausal women with schizophrenia, because there is evidence that after menopause there is an estrogen-dependent loss of efficacy of antipsychotic medications and an increase in antipsychotic-related adverse events.

The observatory of social exclusion and discrimination is one of the five pillars of the unit, with the aim of proposing some prevention and intervention strategies for socially excluded women. These new clinics for women with schizophrenia have nearly 10% of migrant women from four different regions and cultures [3]. These women have specific health and social needs. Latin American, African, European, and Asian women are routinely attended. Community services are offered to migrant women with schizophrenia with the main aim of improving social support and personal and social functioning. Migration to a new country can be traumatic and may affect men and women differently [9]. This recognition is crucial when caring for women who suffer from a severe mental illness. A recent systematic review explored gender differences in the association of psychosis with (among other risk factors) migration [10]. There are many variables in this association such as the reasons for migration, the nature of the migration, the quality of the welcome into the host country, and the match of ethnicity between the migrants and the residents of the welcoming country. Selten et al. compared the risk of a first admission to a Dutch hospital for Surinamese-born immigrants versus that of Dutch-born citizens [11]. The risk was higher for the immigrants.

Migrant women with schizophrenia have clinical and social needs that differ from those of men, particularly because migrant women are more likely to have experienced traumatic events that occur during pregnancy and the postpartum period [3]. Social support affects men and women differently. Pre-migration-related trauma and other social determinants of physical health and mental health affect access to mental health services [10], particularly for women with schizophrenia.

Depending on biology but also on cultural tradition and expectation, men and women have somewhat different ways of expressing psychological/psychiatric distress, whether migrants or not [12]. In recognition of this difference, our group aims to develop a specialized approach to assist socially excluded women that focuses on the needs of migrant women from different cultures. Social and clinical needs are strongly influenced by the culture of the migrant women. It is therefore important to take these differences into consideration when planning healthcare services.

Aims

In order to design and implement effective treatment strategies for migrant and culturally diverse women with schizophrenia in the Mutua Terrassa-Functional Unit for Women with Schizophrenia, the first aim of this paper is to review the literature on the hazards of migration experienced by women in general, with particular attention to those women who then develop a serious mental illness such as schizophrenia. The second aim is to explore the literature on the impact of culture on the clinical course and prognosis of women with schizophrenia, with a view to developing a specific, culturally sensitive approach for these women.

2. Results

2.1. The Impact of Migration on Women’s Mental Health

The search yielded 827 articles with the results of empirical studies published up to February 2024. From the total retrieved records, 52 articles met the inclusion criteria as they were focused on migrant, refugee, and asylum-seeking women. A general review of the findings identified four main themes.

2.1.1. Migrant Women Report Higher Risk of Mental Health Disorders

Most studies consistently report higher rates of mental health symptoms among migrants and refugee women when compared to men [13,14,15,16,17,18,19,20,21], with few studies reporting higher mental health disorders in men [22,23]. Some studies also suggested gender-related and cultural barriers for migrant women reducing their access to mental health services [24,25,26,27].

The most prevalent mental health disorders include the following: depression [13,18,28,29,30,31,32,33,34,35], anxiety [13,18,28,30,31,32,33,34,36], post-traumatic stress disorder (PSTD) [13,32,33,34,37,38,39,40], somatization and suicidal risk [38,41], and schizophrenia [17]. Various factors contribute to this vulnerability suggesting that women may have experienced more pre- and post-migration-related trauma [13,16,18,19,30,34,42,43,44] due to challenging living conditions in camps [13,20,42], increased burdens in domestic and parenting responsibilities [14,20], vulnerability to abuse and sexual violence [42], as well as discrimination [45,46,47], stigma [48,49,50], and limited prospects for resettlement [43].

2.1.2. Differential Risk Factors for Women’s Mental Health During the Migration Process

The migration process entails distinct risks to women’s mental health including those that occur pre-migration, during the migration transit, and post-migration in their host countries.

Multiple studies indicate that pre-migration-related factors can be harmful to mental health [21], with enduring effects post-migration [21,28,31,33,37]. The findings highlight that women and girls are most exposed to higher gender-based violence and sexual violence pre-migration than men [17,29,33,35,37,40]. Pre-migration-related trauma is one of the primary reasons to migrate among women. Several studies have reported the following trauma experienced by these women: domestic violence [28,29,33,37], near death experiences [28], childhood sexual abuse [28], extortion and kidnapping by cartels/gangs [42], persecution, human and sex trafficking [35,38], religious persecution [39], and natural disasters and war [33].

Among the main migration-related factors related to mental health, studies indicate that women are more likely to experience the following: loss or forced separation from family members or friends [13,39,42,44], adverse or stressful conditions and instability of housing/shelter [13,29], gender-based violence [13,29,42], sexual violence [42], uncertainty regarding legal status, lack of legal support and hazardous conditions during the transit [29,34,42], mistreatment by migratory authorities [14,29,42], and limited healthcare access, near-death experiences and food and water shortages [13].

Upon arrival at their final destination and settling, women have reported high acculturation stress [14,30] as they adjust to their new lives. Specific post-migration-related factors that affect their psychosocial wellbeing include the following: a lack of or reduced access to health services [19,21,28,36] and mental health services often resulting in delayed early attention to disorders [17,19,36] due to their migrant status, financial difficulties (e.g., inaccessibility to food programs, affordable housing) [21,36,37,44,45,46,51], a lack of work opportunities and frequent unemployment [14,16,37,38,39,43,45], and social isolation and a lack of social support [14,30,31,37,38,39,44]. Other significant factors can include the following: experiences of discrimination and stigma among the new communities [30,31,36,41,42,51,52], low proficiency in the language of the host country hindering access to services [21,37,44], presence of police harassment [33] and fear of repatriation [39].

2.1.3. Immigrant Women’s Health Needs in Host Countries

Specific interventions in the countries receiving immigrant women can mitigate risk factors and promote their mental health. Among the most important factors is providing accessible medical care and community-based psychosocial services to restore their physical and psychological wellbeing [13,35,36], both within the camp or temporal settings [29] and beyond the resettlement to mitigate acculturative stress [31,34]. Mental health support should prioritize trauma-informed care [44] to ensure these services are accessible in low-resource settings, multicultural populations [35,36] and to address language barriers [13,36,37]. Trauma-informed care recognizes the clinical symptoms as the result of adaptations to traumatic events. This model of care validates resilience and promotes a culture of empowerment and safety and incorporates shared decision-making in health care interventions. The practice of trauma-informed care takes into account the impact of trauma on the understanding of the biological, psychological, and social development [44].

Cultural training is an imperative among mental health professionals to understand the cultural and religious background of migrants [29,45], and to avoid risk of under-diagnosis due to cultural differences in the perception and presentation of symptomatology [13,52] and improve acceptance, utilization and impact of mental health services [53]. Social workers and nurses can be a strategic group that should be trained for an early assessment of intimate-partner or family violence [43,54], as well as in gender-based violence in general, which may persist after the migration process [28,37]. An effective network of referral to mental health workers and community agencies, as well as home visits and the promotion of community activities between the immigrant communities with social and religious groups can reduce isolation, enhance social support, and minimize mental health symptomatology [37,41,46]. On a larger scale, social campaigns aimed at fostering positive attitudes towards refugees and migrants can help to reduce xenophobic attacks and discrimination against these groups [19,36].

2.1.4. Motherhood and Migration

Motherhood presents unique challenges for migrant and immigrant women [31], where migratory mourning can compromise their mental health and that of their children [55]. These mothers usually face poverty, limited social support, worries about the ability to care for their children, and the future of their children, with a higher risk for psychological distress [20,29,44]. Reasons to migrate, such as child and forced marriage and giving birth at young ages in women from Afghanistan, were associated with mental health burden [29]. In refugee mothers, having children predicted higher trauma, anxiety, and somatic symptoms [34], including suicidal risk and a greater sense of hopelessness with regards to their future than with other migrant women [43]. Immigrant women assessed during the perinatal period reported higher mental health difficulties [56,57,58,59,60] affected by low social support [61], with a risk of trauma transmission to their children [56].

Additionally, unsafe conditions in overcrowded shelters during migration expose women and children to risks and increased fears about their own safety and that of their children [62,63], including discriminatory treatment and denial of services due to pregnancy or childcare responsibilities [42]. The separation of a mother and her offspring is also frequent during the migration process; those women who give birth to a child in a new country and are separated from their other children during migration report higher symptomatology of postpartum depression, anxiety, and clinical depression related to trauma compared to other migrant mothers [46]. Also, immigrant women who become mothers after surviving sex trafficking will require comprehensive perinatal mental health support and support with parenting, including family reunification [39]. Affordable services for housing and childcare play a strategic role to improve the mental health in immigrant mothers [36,45].

2.2. The Impact of Migration on Women with Schizophrenia

A total of 729 records were initially screened. A total of 23 studies met the criteria and were included in this review. The results are presented addressing the evidence related to (1) risk factors, (2) clinical symptoms, (3) prevention, (4) intervention, and (5) rehabilitation.

2.2.1. Risks Factors for Schizophrenia

Migration has been described extensively as a risk factor for the onset of schizophrenia [64]. Women with schizophrenia have specific health needs compared to men. The risk of schizophrenia appears to differ between refugee migrants forced out of their country of origin and non-refugee migrants who have chosen to migrate to a new country. A study from the linked Swedish national register data explored whether refugees were at an elevated risk of schizophrenia and non-affective psychotic disorders when compared with non-refugee migrants from similar regions and with Swedish natives [64]. A total of 1,347,790 people were recruited from (1) the Swedish born population (n = 1,191,004 people), (2) refugees (n = 24,123), and (3) non-refugee migrants (n = 132,663). In this study, migration came from a variety of world regions. Refugees showed an increased risk of psychosis compared to the Swedish-born population and compared to non-refugee migrants. The increased risk in refugees versus non-refugee migrants was higher in men than in women. However, the risk of victimization was higher in women, an important endorsement for individualized care.

A retrospective single-center study investigated the rates of compulsory admission in migrant populations compared with the native-born population hospitalized for an acute mental disorder [65]. Sociodemographic and clinical variables, such as age, nationality, employment status, housing situation, diagnosis, psychiatric care, and medical care, were compared between migrants and the native-born population, including voluntary or compulsory admission. The total sample comprised 185 migrant patients (women: 98; 52.97%) and 933 native-born patients (women: 466; 49.95%). The rate of compulsory admission was significantly higher in the migrant group. A diagnosis of schizophrenia in men was associated with higher rates of compulsory admission. The authors suggested the need to include the presence of cultural mediators as a preventive strategy in emergency settings to increase voluntary admission rates.

A recent register-based, population-wide, nested case-control study from Sweden consisted of 5539 participants with schizophrenia (SCZ) and 20,577 with bipolar disorder (BD), all born between 1973 and 1998 [66]. Five healthy controls, matched for age and sex, were identified from the register for each patient participant. For each participant, their region of origin, their migrant status (first or second generation), and their age at migration were registered. Second generation migrants were categorized by both maternal and paternal migrant status [66]. In this sample, first-generation migrants comprised 20% of SCZ cases, and only 7% of BD cases. Second-generation migrants were more comparable to the two diagnoses (21% SCZ, 18% BD). Most SCZ migrant cases were male (68%), while most BD cases were female (66%). Whereas first-generation migrant patients presented with an increased risk of schizophrenia relative to their matched controls, migration was negatively associated with a risk for bipolar disorder. Age at the time of migration was an important variable differentiating between the two disorders. With respect to gender, first-generation female migrants had a significantly lower risk than males for both SCZ and BD. For both disorders, there were statistically significant sex differences for childhood migrants from Africa and Asia, with males at a greater risk than females. For second generation migrants, two migrant parents conferred significant risk of schizophrenia to their children, especially if they themselves had migrated in childhood [66].

Social isolation, age, and gender have been associated with the risk of schizophrenia. Mitter and co-workers [67] investigated whether the increased incidence of schizophrenia-like psychosis might be higher in older migrants compared to British-born populations in the United Kingdom (UK). A total of 86 individuals from the Mile End and Maudsley centers were included in two retrospective case series. Associations between age, sex, migrant status, and markers of social isolation with the late onset of schizophrenia-like psychosis were analyzed. The rate of first contact was higher in migrants compared to the UK-born population, and a lower age at the onset of schizophrenia spectrum disorders was found in migrants. A higher mean age of onset was found in British-born women. However, the authors concluded that age and gender were not sufficient to explain differences between migrant and British-born patients.

While transnational migration has been widely reported as a risk factor for schizophrenia, rural-to-urban migration has received less attention. A recent study investigated acute patients with schizophrenia who needed psychiatric hospitalization in a province of China [17]. Former migrant workers hospitalized with schizophrenia were compared with a subpopulation of former migrant workers from the general adult population in terms of symptom severity and age at onset. The percentage of migrant workers in hospital with schizophrenia was higher than would be expected, especially so for migrant women.

The perceived role of the family network during the migration process has been found to be sex-specific. Dykxhoorn et al. investigated whether the presence of immediate family or family networks was associated with a risk of non-affective psychosis in the context of immigration [68]. A cohort of 838,717 migrants to Sweden with a diagnosis of non-affective psychosis were included. Family network was defined as the presence of adult first-degree relatives immigrating with the individual, or relatives living in Sweden at the time of immigration of the cohort participant. An increased risk of psychosis was observed in men who migrated with immediate family compared to men who migrated without family. Females who migrated without family were found to present an increased psychosis risk compared to women who migrated with family.

2.2.2. Clinical Symptoms in Migrant Women with Schizophrenia

Clinical symptoms for women with schizophrenia vary by culture and migration status. Lempesi et al. compared clinical symptoms and social functioning in schizophrenia between immigrant and native-born patients suffering from schizophrenia in Greece [69]. Of the patients included in the study, 65 were immigrant and 58 were native-born Greek. Psychopathological symptoms were assessed by using the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS). For the assessment of social functioning, the Global Assessment of Functioning scale (GAF) was used. The Greek sample had a longer illness duration and were older than the migrant group. Immigrant patients suffered from less severe psychotic symptoms and were less impaired in global functioning than the native-born group. The authors concluded that, perhaps, the most severe immigrant patients had returned to their country because of a lack of financial and social support.

Swami et al. [70] investigated the cross-cultural aspects of schizophrenia in a multi-ethnic sample from Malaysia. The sample consisted of 561 individuals, and included Malay, Chinese, and Kadazan-Dusun participants. Subsamples: 124 women and 98 men comprised the Malay group; 70 women and 96 men the Chinese group; and 120 women and 53 men the Kadazan-Dusun group. A questionnaire was used, consisting of 72 statements about schizophrenia to be endorsed on a seven-point rating scale. Factor analyses, including all the 72 items of the questionnaire, revealed four factors. Factor 1, containing items related to stress (social life, interpersonal relationships, childhood development), explained 11.79% of the variance. Factor 2 explained 8.94% of the variance and included items related to the treatment of schizophrenia, including stress reduction. Factor 3 accounted for 7.42% of the variance and was related to behavioral symptoms and clinical outcomes. Factor 4 explained 6.96% of the variance and addressed the functioning of psychiatric hospitals. The study found that all three ethnic groups agreed that schizophrenia could be caused by faulty interpersonal relationships, social life or childhood development. Malays and women in general agreed most strongly with the statement that schizophrenia could be treated by a change of how societal responsibilities were distributed. Exploring explanatory beliefs about illness with individual patients appears capable of improving therapeutic relationships and leading to superior outcomes of treatment.

The relationship between marital status, culture and clinical outcomes has been of interest in recent years. As part of the follow-up data from the ISoS, the WHO-Collaborative International Study of Schizophrenia, Hopper et al. [71] investigated the rate of marriage for members of three Indian cohorts and compared it to the rate in other countries. At the time of the follow-up, the rate of marriage was 73% in general (men, 71%; women, 74%). The odds of marriage at follow-up for Indian woman with a poor 2-year course were reduced but remained at 2:1. At the 10-year follow-up, it was observed that Chennai subjects showed a high marital rate (70%), a fact the authors attributed to cultural imperatives for offspring in Hindu society. Furthermore, at the onset of psychosis, men and women from the Indian group were found to be more likely to be married compared to other country groups. Indian women married at an earlier age compared to their counterparts from elsewhere; those who were unmarried when the first episode of psychosis occurred were still more likely to marry than women with schizophrenia in other parts of the world, suggesting that marriage rates were higher in Indian women compared to the other groups. However, the authors found unmarried Indian men with schizophrenia were more likely to be married at follow-up than women. These data from India are very interesting, strongly suggesting that the very low marriage rate for schizophrenia in Western countries, especially for men, is not entirely due to the nature of schizophrenia itself but more to social pressures and opportunities. For migrant women from these countries, these findings are of interest and should be taken into account because they impact on the clinical course of schizophrenia in women.

The effect of culture (American versus Turkish) on sex differences in clinical features of schizophrenia was investigated in a sample of 369 schizophrenia patients [72]. American patients (n = 275) fell into two categories, Caucasian or Black. Turkish patients (n = 94) were homogeneously Caucasian. The patients underwent an interview consisting of 31 standardized questions covering clinical history. The Brief Psychiatric Rating Scale (BPRS) and the Itil-Kestiner Psychopathological Rating Scale were used to assess psychotic symptoms. No statistically significant differences were found between the American and Turkish groups in terms of age, age at onset of symptoms or of diagnosis, age at first treatment, and age at first hospitalization. American women were more than twice as likely to be single than Turkish women. Turkish women were more likely to be married than American women. In univariate analysis, Turkish schizophrenia patients showed more severe conceptual disorganization in both sexes, than did American patients. Hallucinatory behavior was most frequently found in separated, divorced, or widowed Turkish women, and in American married men. This study investigating the impact of culture in clinical features and symptoms in American and Turkish schizophrenia patients found that, after controlling for marital status, only three symptoms differed between Americans and Turks: mutism, disorientation, and stupor.

A large body of research indicates that gender and education have a specific effect on suicidal ideation and completed suicide rates. However, very few studies have analyzed the interaction of these variables with migration in psychosis populations. The impact of acculturation and enculturation on the prevalence and severity of suicidal ideation was investigated in a sample of 45 Hispanic/Latino individuals with psychosis spectrum disorders in the United States (US) [73]. Gender and education were controlled in the analysis. Higher acculturation and lower enculturation were significantly associated with higher rates of suicidal ideation. This study concluded that Hispanic/Latino patients with psychosis disorders (including schizophrenia) should be encouraged to maintain traditional practices and values from their own cultures in men and women.

2.2.3. Prevention of Stigma and Discrimination in Migrant Women with Schizophrenia

Social risk factors, in particular stigma and discrimination, are important targets when planning clinical care for women with schizophrenia. A Canadian qualitative study investigated the experiences of ten immigrant and refugee women (five from China, five from Sudan) who suffered from severe mental illnesses, including schizophrenia [74]. They showed a high prevalence of social risk factors for mental illness, such as isolation and exclusion, loneliness, lack of family and community support, and lack of independence.

Sociocultural perspectives related to stigma have been investigated in people suffering from schizophrenia [75] in order to plan appropriate anti-discriminatory interventions. A total of 200 outpatients from six adult mental health units of the National Institute of Mental Health and Neurosciences in Bangalore, India, were included in the study. Diagnosis of schizophrenia was confirmed by using the International Classification of Disease (CD-10). Stigma and discriminatory experiences were assessed by using a semi-structured instrument. The questionnaire included four questions allowing the participants to discuss the following: (1) changes in life attributed to illness, (2) personal experiences that others may not experience, (3) coping with illness experiences, and (4) feelings of shame and perceived discrimination. Myths related to marriage, pregnancy, and the postpartum period were also explored. Of the participants in the study, 188 were men and 82 were women, 57% were married and 31% never married. The authors found that both men and women experienced stigma. Men were more likely to experience stigma in their work roles, and women experienced it in their marital life, during pregnancy, and while caring for children.

2.2.4. Intervention in Migrant Women with Schizophrenia

Trabsa et al. investigated migration-related factors in 99 non-refugee migrant patients with psychosis (including schizophrenia) [76]. Details of the migration process, socio-demographic, and clinical data were recorded. To assess stressful events over the last year, the Holmes and Rahe Social Readjustment Scale was used. The authors found that women with psychosis were more likely to be married, and divorced, than men. Homelessness was more common in men than in women (24.7% vs. 6.8%). Women were more likely than men to be employed, either part-time or full-time. A lower age at first migration and being racialized were associated with higher levels of stress among women. It was emphasized, that, although most migrant women in Spain were African, Latin American women were more likely to use mental health services than African women. Barriers to access that are relevant for intervention were identified by the authors.

O’Mahony and Donnelly [77] conducted a qualitative study on access to mental health services among immigrant women with mental disorders with the aim of planning and subsequently implementing culturally sensitive mental health care services. Migrants of both sexes receiving different levels of care were included in the study. Immigrant women reported difficulties in accessing mental health services, which they attributed to social stigma and unfamiliarity with Western biomedicine. They reported to be more familiar with spirituality-based health practices. The same research group, O’Mahony and Donnelly [78] explored help-seeking strategies for immigrant women. They found that language barriers, unawareness of services, and low socioeconomic status contributed to making mental health services difficult to access. They reported that the health care relationship between the health care providers and immigrant women had a significant influence on women receiving help.

Johnson et al. [79] prospectively explored 131 patients with schizophrenia in India with the aim of investigating the impact of local cultural explanations, attributions, and actions on the long-term patient outcomes. The Structured Clinical Interview for DSM-III R Patient Version was used to assess psychopathology and confirm diagnosis. The Schedule for Assessment of Insight Expanded (SAI-E) was used to evaluate insight. The latter is an instrument that has been widely used in Western and non-Western cultures. The Brief Psychiatric Rating Scale (BPRS) was used to assess psychotic symptoms and the Short Explanatory Model Interview (SEMI) to explore emic perspectives of illness. Emic refers to subjective or insider accounts of events. More than half the participants reported that the disease model was their best explanation for their illness, while the others preferred non-medical explanatory models. The latter group had a lower BPRS score in the 5-year follow up than those who adhered to the Western medical model. Western practitioners need to understand the value of traditional explanations for mental disorders.

A recent study investigated a sample of Japanese residents aged 18–64 years to explore cultural facilitators and barriers to service use [80]. As part of the Stigma in Global Context—Mental Health study (SGC-MHS), the authors conducted a survey on a nationally representative sample of Japanese citizens. Respondents to the survey were asked to describe an individual with symptoms meeting diagnostic criteria for schizophrenia. In a second step, the participants were asked to suggest what the individual with such symptoms should do, a question meant to elicit the contemporary Japanese perspective on how schizophrenia should be managed. Responses were analyzed to describe the types and patterns of mental health care suggested by respondents, revealing their cultural take on mental health care provision. Six cultural “toolkits” have been described as follows: (1) deflect the problem, (2) recommend lay consultation, (3) suggest general medical care for the patient, (4) suggest general medical care for patient and family, (5) specialty care, and (6) tertiary specialty care. More than 40% of the respondents suggested combined strategies comprising professional care plus other options, such as traditional medicine (traditional medicine has been integrated into modern medicine in Japan). An understanding of the cultural context in a country or region is useful when making decisions for their care.

2.2.5. Rehabilitation in Migrant Women with Schizophrenia

As social needs and illness conceptualization can vary between cultures, several studies have examined physiological and social needs to plan an integrative rehabilitation. Hosáková and Hosák [81] investigated the social needs of patients with schizophrenia in the context of rehabilitation and recovery for patients in the Czech Republic. Of the 244 participating patients suffering with schizophrenia, 115 were women. The short version of the Camberwell Assessment of Need questionnaire (CANSAS) was used to investigate the physiological and social needs of people diagnosed with schizophrenia. The CANSAS questionnaire includes 22 items dealing with housing conditions, daily activities, physical and mental health, perceived threats, substance use, relationships with family and friends, care of children, sexual health, education, transportation, and socio-economic factors (e.g., money, digital communication, and benefits). Psychiatric nurses administered the questionnaire. The study found unmet physiological and social needs in social relationships, economics, and treatment of psychotic symptoms. Sexual life was also considered a relevant unfulfilled item in men, but not in women. Social needs may well differ between the two sexes.

Recovery-oriented practices include community participation by people with severe mental illness. Kidd et al. conducted a longitudinal qualitative study of 30 participants with schizophrenia living in the inner-city neighborhoods of a Canadian city [82]. Of the total sample, eight participants were identified as White, six as East Asian, seven as South Asian, and nine as African-Caribbean. Over half were first- or second-generation immigrants. Three main themes or categories emerged from the qualitative analysis: (1) social relationships, (2) self-concept, and (3) access to community resources. Victimization was highlighted in the women’s narratives. Past traumatic experiences and travelling at night were particularly reported in women’s victimization narratives. The authors concluded that these findings have several implications for programming clinical strategies. Increasing access to resources and building interventions close to community resources may be beneficial when planning clinical mental health programs for migrant people.

In an older study targeting migrant women, Garrison [83] hypothesized that many schizophrenia patients suggested from a lack of social support and could be reintegrated into society if non-kin alternatives to family support existed. Using an anthropological community study method, Puerto Rican migrant women in New York City suffering from a mental health disturbance were grouped according to level of illness severity. The author then analyzed the social supports available according to gender. The conclusion was as follows:

• Mental health services need to be localized in neighborhoods where migrants live and staffed by health professionals who understood the culture of the neighborhood.
• Understanding comes through interviews with patients at all stages of severity and by identification of social systems existing in the community.
• Neighborhood groups and supportive networks can be organized for severely ill patients.
• Supportive psychotherapy groups can be based in homes.
• Neighbors, religious leaders, and people of good will can be enlisted to help integrate mentally ill persons into their local communities.

The study, targeting women migrants, highlighted the importance of a tight social network to help the acculturation of migrants. Although the participants in this study already suffered from mental illness, supportive networks could also, theoretically, prevent schizophrenia from emerging in analogous vulnerable groups.

A recent qualitative research study investigated the subjective perspectives of people suffering from mental illness [84]. Individual and focus group interviews were organized including participants from urban, suburban, and rural communities in Japan. Participants were asked about factors that had promoted their recovery via interviews and a self-administered World Health Organization 5 Well-being Index (WHO-5) and the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). From a total of 30 participants, 15 had a diagnosis of schizophrenia, of whom 46.7% were women. The results from the individual and focus group interviews suggested connectedness as the main recovery-promoting theme. Connectedness included peer support, support groups, relationships, support from others, and compassion for others. Recovery-promoting factors were identified as having positive childhood experiences, receiving support from others, and putting recovery-oriented principles into practice.

Recovery has been also explored in a sample of Swazi women suffering from schizophrenia. Nxumalo et al. [85] investigated the process of recovery in women suffering from schizophrenia in Swaziland, a Sub-Saharan country. Fifteen outpatients participated in an interpretative phenomenological analysis and responses to an interview about their illness were recorded. Many issues were discussed: Neglect, labelling and stigmatization of women with illnesses of the brain, healing potential of family, culture, and religious beliefs. Responses were not markedly different from those of women in other parts of the world except that the importance of culture is not usually emphasized in the Global North.

Table 1. Influence of migration on epidemiological and clinical aspects of schizophrenia.

Topics of Review	Findings	Implications
Risk factors	Increased risk of schizophrenia in refugee-migrant women [66] Migrant women higher risk of victimization [66] Age at time of migration, especially during childhood impacts on the risk of schizophrenia [17] Rural-to-urban migration influences the risk of schizophrenia [68] Family network during the migration process found to be sex specific [69]	Personalized care for refugee migrant women Younger age at migration merits a detailed psychopathological assessment in relatives. Assessment of reasons and network at the time of migration is crucial
Clinical symptoms	Psychotic symptoms and social functioning differ between migrant and non-migrant women [70] Explanatory beliefs of the illness impact on clinical outcomes [71,72] Minor variations in psychopathological symptoms can be found by culture [74] Higher acculturation and lower enculturation are associated with higher rates of suicidal ideation [73] Higher compulsory admission rates are found in migrant populations compared with native-born patients [65]	Psychopathological assessment should be culturally-specific Therapeutic relationships are influenced by explanatory beliefs about illness Encouraging traditional practices and values from own cultures may reduce suicidal ideation rates Cultural mediators should be considered in the context of emergency settings
Prevention	Social risk factors (e.g., discrimination) determine clinical course and prognosis of schizophrenia [75] Perceived discrimination higher in women during reproductive years [76]	Exclusion, loneliness and lack of social support should be assessed and potentially intervene
Intervention	Immigrant women show difficulties in the access to mental health services [77,78,79] Traditional/local cultural explanations of illness impact on outcomes [80,81]	Accessibility to mental health services should be targeted
Rehabilitation	Building interventions close to community resources [82] Covering social needs of women impact on the recovery [83] Social supports are the main target to intervene in migrant women with schizophrenia [84]	Social network helps women in acculturation processes

summarizes the impact of migration on risk factors for schizophrenia, clinical symptoms, prevention, intervention, and rehabilitation processes.

2.3. Approaches and Paradigms from the Literature Being Used in Our Unit for Socially Excluded Women with Schizophrenia

The Mutua Terrassa Functional Unit for Women with Schizophrenia is a pilot project in the context of a community mental health setting that consists mainly of five observatories or pillars, one of which is meant to address the needs of socially excluded and discriminated women. In line with the findings of this review, we imported several strategies into our treatment of migrant women who are judged to be socially excluded. These strategies include anti-stigma intervention, social support, focus groups to capture women’s needs, expectations and subjective experiences, and shared decision making.

Phenomenological research, ethnographic research and action/participative research are part of this pillar of our unit.

Table 2. Positivist, humanistic/interpretative and socio-critical paradigms applied to the clinical care of women with schizophrenia [89].

	Positivist (Empirical-Analytical) [86]	Humanistic/Interpretative [87]	Transformational/Socio-Critical [88]
Focus of interest	To explain To predict	To understand To interpret	To criticize To identify potential changes
Nature of the reality	Observable Convergent (static)	Holistic Divergent (innovative)	Holistic Constructive/transformational
Objective	Quantitative Deduction Generalization	Qualitative Inductive Person-centered	Qualitative Inductive Focused-on-the differences
Perspectives	Objective (mainly)	Subjective	Subjective Interactive

summarizes the three main research paradigms that can be applied to the development of the five clinical observatories of the unit for women with schizophrenia (positivist, humanistic and transformational, or socio-critical) [86,87,88,89].

3. Discussion

In the general population, higher rates of mental health symptoms have been reported among migrant and refugee women compared to men [13]. Several factors contribute to this vulnerability, including that women may have experienced more trauma before and after migration. Migration is reported to be a risk factor for schizophrenia in both men and women. However, the stresses and trauma of migration is a larger risk factor for schizophrenia in women. The history of pre-migration-related trauma, the migration trajectory, and the difficulties of acculturation into a new society are relevant aspects to consider when planning personalized services for women with schizophrenia [3]. Migrant status, region of origin, migration with family or alone, and the age at the time of migration are relevant factors affecting the mental health of women with schizophrenia.

In our review, we found that the age at which one migrates and the cultural disparities between one’s region of origin and the host country play an important role and differ between men and women [17]. Refugees have an increased risk for psychotic disorders than non-refugee migrants [66]. This risk is higher in men than in women; however, the risk of victimization is higher in women, a factor that suggests a need for individualized care for women with schizophrenia. A history of trauma was associated with the greater severity of hallucinations in non-migrant women with schizophrenia [90]. The authors recommended personalized treatment for women according to the personal history of childhood physical abuse. A young age at migration has also been reported to be a risk factor for schizophrenia and, at the same time, correlates with a higher risk of traumatic events. Interventions that focus on trauma in the pre-migration-related and migration-related processes are relevant [91].

Exploring explanatory beliefs about illness is important for women with schizophrenia because they should be considered in people from different cultures [92]. There is an urgent need for psychoeducation and therapeutic relationship building, particularly for women with schizophrenia who have experienced trauma. Traditional practices and cultural values should be maintained in women suffering from schizophrenia. Higher acculturation and lower enculturation have been significantly associated with higher rates of suicidal ideation.

Our review points to barriers to accessing mental health services for migrant women, with a lack of family or poor social support being one of the mediating factors. For intervention and rehabilitation purposes, social needs and the cultural conceptualization of illness should be explored in depth. Focus groups can be a useful tool to capture all the needs and expectations of migrant women [88].

3.1. Integration of Relevant Findings into Clinical Care

Relevant findings from our review should be integrated into clinical care when treating women with schizophrenia. In our unit, we are planning new assessment strategies, new programs, monitoring working groups, and specific intervention strategies for migrant women with schizophrenia as a result of the literature findings.

These specific interventions and new assessment and treatment programs should be adapted to international settings. In countries with high rates of migration, new collaboration programs with primary care services should be included, as primary care is the main route to mental health services. Close collaboration with social service providers is also needed.

Patient-centered culturally sensitive healthcare models should consider the nationalities and cultures of migrants and the cultural characteristics of host countries. In addition, gender roles and social expectations may have an impact on stress in migrant people and should therefore be integrated into personalized treatment approaches [77].

With regard to the assessment of migrant women with schizophrenia, we propose a structured questionnaire that includes at least some of the key points outlined below.

3.1.1. The Pre-Migration Process

(a) Ask about traumatic events prior to migration to help clinicians identify potential risk factors for non-response to treatment or poor prognosis of schizophrenia illness.

(b) Ask about any history of sexual violence is mandatory. Women with schizophrenia are at a higher risk of victimization than men and women in the general population.

(c) Assessing other social risk factors in migrant women is important because they affect both the mental and physical health of women with schizophrenia.

3.1.2. The Migration Process

(a) Migrating with family, migrating alone, or joining family are factors that pose different risks for men and women. These should be emphasized, and their impact on women carefully assessed.

(b) The migration process is a risk factor for violence against women. Social exclusion and discrimination increase in this life situation, especially for women with schizophrenia.

3.1.3. The Post-Migration Process

(a) Age at the time of migration is important in understanding the risk of schizophrenia in women. Relatives, including children of women with schizophrenia should be carefully assessed. They are the social network of these women and are also at a higher risk of psychosis.

(b) The concept of health and the conceptualization of mental health system in migrant women should be assessed. Experiences with the health system and women’s expectations are relevant in planning prevention and intervention strategies.

(c) The role of the family, and the role of the patient in the family system, is relevant to understanding the clinical course and evolution.

(d) The cultural background of women with schizophrenia should be asked because the understanding of the illness and the application of specific therapies should be adapted.

(e) Assessment and respect for traditional practices and values of one’s own culture should be encouraged, as higher levels of enculturation are associated with lower rates of suicidal ideation.

3.2. Integration of Relevant Findings When Programming Interventions into the Clinics

Some of the currently offered programs in our unit should be adapted to include the needs and expectations of women with schizophrenia. These have been previously described [2,3]. Family groups with special emphasis on cultural background and individualized care for migrant families with relatives with schizophrenia will be developed. Supplementary sessions are planned as part of the family groups. Home and community-based services should be adapted to the culture and needs of women [84]. Respect and shared decision practices are emphasized.

New Potential Interventions Derived from the Literature Review Will Include

(a) Implementing culturally sensitive mental health care. Training programs for professionals treating women with schizophrenia are essential to improve their knowledge of different cultures. These programs can help clinicians to ensure the cross-cultural validity of diagnostic criteria in migrant women, to ensure through assessment of refugees, and to ensure early identification of psychosis in relatives (including children) of women with schizophrenia. Training in cultural humility and cultural competence are planned.

(b) The unit will develop anti-stigma campaigns to improve access to mental health services.

(c) Improve social support systems. Social workers will develop support groups for migrant women. As a first step, a focus group to identify needs and expectations will help the professionals to set targets to improve services.

(d) Involve patients in the design of psychotherapeutic groups. Citizen science should be integrated into our programming in the clinic.

(e) Trauma-informed care practices would be recommended. As migrant women are vulnerable to gender-based violence, specific interventions in our functional unit for women with schizophrenia can open new opportunities to improve economic income, and work on the self-esteem, decision-making power and autonomy.

3.3. Limitations and Strengths

There is strong evidence that mental health is affected by migration processes. Although the association between migration and mental health is well documented, very few reviews have examined the impact of gender on this association. As a first step, we conducted a narrative review focusing on the impact of migration on mental health, particularly for women. In a second step, we examined the association between migration and mental health in women diagnosed with schizophrenia. To the best of our knowledge, this is the first review to specifically examine this association in women with schizophrenia and related disorders and to provide recommendations from the literature to the clinics.

4. Methods

4.1. Screening and Selection Process

We conducted a narrative review by searching the PubMed, Scopus and the Clinicaltrials.gov databases from its inception to February 2024 for studies in the field of migration in women, and then specifically in women with schizophrenia. Relevant papers in the field were also included if they were found in the reference lists from the papers included.

A narrative review was carried out to identify scientific evidence in empirical studies that analyzed the impact of migration on women and those suffering from schizophrenia. Narrative reviews provide a general overview of a particular research topic and are particularly useful for planning future research [93]. They also provide interpretations of the literature (migration in women) and offer a clinical critique of previous research [94]. As our main aim was to develop specific assessment and intervention recommendations for migrant women with schizophrenia who are routinely seen in our unit, we preferred to develop a narrative review, rather than a systematic review, to analyze the scientific evidence.

For the first part of the review, the following search terms were used: women AND migration AND (“mental health”). In a second step, we used the search terms: (“ethnography” OR “social needs” OR “cultural diversity” OR “culture” OR “transcultural” OR “cultural competence” OR “cultural humility” OR “migration” OR “migration trauma”) AND (women OR gender) AND schizophrenia were used to investigate the association between migration and health needs in women with schizophrenia.

The screening and selection process was carried out by A.G.R. and B.P.H.

We searched the Clinicaltrials.gov database for additional potential articles. We used the following search terms: “migration AND women”, and “migration AND schizophrenia”.

4.2. Inclusion/Exclusion Criteria

Articles were included if they were relevant, if the rationale of the study was clear and clinically important, if the study design, methodology and data analysis were appropriate, and if the study results provided additional information to the field. Inclusion and exclusion decisions were made by group consensus.

In the first part of the review on the impact of migration on women, findings were grouped into four parts: (1) Migrant women report higher risk of mental health disorders, (2) Differential risk factors for women during the migration process, (3) Health needs of women in host countries, (4) Motherhood and migration. Papers were included regardless of study design. We included randomized controlled trials, observational and retrospective studies, with cross-sectional or longitudinal design, and case series. Literature reviews and case reports were excluded from this analysis.

In the second part of the review, articles were grouped into five main research themes concerning women with schizophrenia: (1) risk factors for schizophrenia in women, (2) clinical symptoms in migrant women, (3) prevention of stigma and discrimination, (4) Intervention in migrant women, (5) rehabilitation in migrant women. Studies were included regardless of the study design. Case reports and literature reviews were also excluded.

5. Conclusions

Migrant status, region of origin, age at the time of migration, migration with family/alone and migration to join family; all of these determine the risk of schizophrenia and the clinical course of the illness. Refugee migrant women have a higher risk of schizophrenia than non-refugee migrants and the native-born population. Migration is associated with poor access to mental health services. Low social support, lack of awareness of services and poor language skills may be mediated by this association. The cultural context influences the use of mental health services. Cultural explanations and attributes influence help-seeking behavior and, thus, determine long-term clinical outcomes. The stigma of mental illness exists everywhere, but more so in some regions of the world than in others. Marital and family support and gendered social roles also vary.

All these findings call for the planning of specific assessments, interventions, and the improvement of current programs in community mental health services aimed at the care of women with schizophrenia.