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Montefiore in the News

February 18, 2020

By Jonathan Ross, MD MS and Sara Guevara, MD

The last several years have seen an unprecedented number of news stories about changes in immigration policy, dramatic rises in deportations, and the negative effects that these events have had on immigrant communities in the U.S. 

Most recently, on January 27th, the U.S. Supreme Court allowed the administration’s new ‘public charge’ rule to take effect, effectively making it much harder for immigrants who are likely to use public benefits to get a Green Card. The current political climate has led to high levels of uncertainty and anxiety in many immigrant communities. 

As health care providers at Montefiore Health System in the Bronx, NY, we have seen firsthand how the national conversation on immigration affects the health – in particular the mental health – of our patients. Many report high amounts of stress related to fear of deportation, family separation, and concerns related to accessing health or social services. Other patients have simply stopped coming to medical appointments or using services they are eligible for, such as health insurance.

We have heard many heart-wrenching stories from our patients about the immigration-related fears and concerns they have. However, the truth is that we have a limited understanding of exactly how immigration status and the related stress impacts mental health. Some studies have shown that immigrants have less anxiety or depression compared to persons born in the U.S., while others have shown the opposite. And few of these studies have looked at how immigration status itself affects mental health outcomes.

To try to better understand the relationship between immigration status and mental health, we conducted a study of anxiety and depression in one of the largest research cohorts of immigrants in the U.S., the Hispanic Community Health Study / Study of Latinos. We found that persons born outside of the U.S. had similar rates of anxiety or depression compared to those born in the U.S., and that this relationship did not change based on whether immigrants were undocumented, had legal residency, or were naturalized citizens. Worryingly, however, we found that persons with undocumented immigration status were much less likely to report being treated for depression than any other group. Our results may reflect the fact that undocumented immigrants are less likely to have insurance, may face additional barriers to receiving health care and may be afraid of coming to medical appointments. But in a time where immigrant communities are being criminalized and attacks on low-income families and communities of color are increasing, these findings are highly concerning and should be a call to action.

What can be done to try to address this well-founded immigration-related anxiety and stress? First, we need to continue to better understand the situation by studying it. In a research study we are conducting of patients receiving care at Montefiore, participants have reported multiple concerns relating to immigration and its impact on their health. One participant described the paralyzing anxiety and fear he was experiencing related to immigration issues. Others described personal traumatic experiences with immigration authorities, situations where family members have avoided medical care due to immigration status, and the fear of their personal information potentially being shared with immigration officials. Several participants felt that they did not know how to access legal services. These preliminary findings highlight the importance of providing trauma-informed care and creating safe spaces for patients as essential steps in addressing mental health disparities experienced by immigrants.

Beyond research, there are direct actions that we, together with our colleagues, have taken to address the immigration-related stress and anxiety our patients experience. We have organized and led trainings of health care providers so that they understand the changing laws and policies when it comes to immigration.  

Training clinicians and administrators on how to ensure the physical and psychological safety of immigrant patients — especially if interacting with legal authorities — can ensure that medical staff are empowered to protect their patients’ rights regardless of race, ethnicity, nationality or immigration status. Importantly, increasing awareness among providers of how the ‘public charge’ rule. works will help them better address the stress and worry that patients may be feeling and ensure they can access the healthcare and services they need. It is crucial to get this information directly to immigrant communities as well, and so our colleagues have conducted sessions for patients and community members to increase awareness of the legal rights and resources available to them. 

We want patients who may be worried about the current immigration climate to feel welcome and comfortable receiving medical care, including mental health care. There are a few key messages that we believe Montefiore and all healthcare systems could send to help reduce the stress, anxiety and worry that our patients and their communities may be experiencing. Our patients and community members should feel confident that we will not make medical decisions based on immigration status and will keep all of their personal information – including immigration status – confidential.  They should be able to clearly understand which public benefits might be counted against them under the new ‘public charge’ rule. And finally, patients should feel secure that the providers they are seeing can help them access important health, legal and social resources in a way that will not endanger them. By having clear policies in place with respect to these issues and committing to training staff accordingly, Montefiore and other health systems can provide reassurance to immigrant patients and communities and allow them to feel safe accessing care. 

The current political climate toward immigrants, and the stress and worry that it causes, has serious health consequences for our patients. By taking steps to understand these consequences and action to reduce them, we can help our patients to feel safe, get the care they need and live healthy and fulfilling lives.

Contributors:

Jonathan Ross, MD MS, is an Assistant Professor in the Department of Medicine with a clinical and research focus on HIV and immigration.

Sara J Guevara MD, is a third year Family Medicine Resident with a focus on immigration status as a social determinant of health 

Ross, J., Hua, S., Perreira, K. M., Hanna, D. B., et al. (2019). Association between immigration status and anxiety, depression, and use of anxiolytic and antidepressant medications in the Hispanic Community Health Study/Study of Latinos. Ann Epidemiol, 37, 17-23.e3.