Inequities in Mental Health Care Facing Racialized Immigrant Older Adults With Mental Disorders Despite Universal Coverage: A Population-Based Study in Canada

Abstract

Objectives Contemporary immigration scholarship has typically treated immigrants with diverse racial backgrounds as a monolithic population. Knowledge gaps remain in understanding how racial and nativity inequities in mental health care intersect and unfold in midlife and old age. This study aims to examine the joint impact of race, migration, and old age in shaping mental health treatment. Methods Pooled data were obtained from the Canadian Community Health Survey (2015-2018) and restricted to respondents (aged ≥ 45 years) with mood or anxiety disorders (n=9,099). We employed multivariable logistic regression to estimate associations between race-migration nexus and past-year mental health consultations (MHC). We used Classification and Regression Tree (CART) analysis to identify intersecting determinants of MHC. Results Compared to Canadian-born Whites, racialized immigrants had greater mental health needs: poor/fair SRMH (OR=2.23, 99% CI: 1.67 – 2.99), perceived life stressful (OR=1.49, 99% CI: 1.14 – 1.95), psychiatric comorbidity (OR=1.42, 99%CI: 1.06 – 1.89) and unmet needs for care (OR=2.02, 99% CI: 1.36 – 3.02); in sharp contrast, they were less likely to access mental health services across most indicators: overall past-year MHC (OR=0.54, 99% CI: 0.41 – 0.71) and consultations with family doctors (OR=0.67, 99% CI: 0.50 – 0.89), psychologists (OR=0.67, 99% CI: 0.50 – 0.89), and social workers (OR=0.67, 99% CI: 0.50 – 0.89), with the exception of psychiatrist visits (p=0.324). The CART algorithm identifies three groups at risk of MHC service underuse: racialized immigrants aged ≥ 55 years; immigrants without high school diplomas; and linguistic minorities who were home renters. Discussion To safeguard health care equity for medically underserved communities in Canada, multisectoral efforts need to guarantee culturally responsive mental health care, multilingual services, and affordable housing for racialized immigrant older adults with mental disorders.

Healthy Immigrant Effect or Under-Detection? Examining Undiagnosed and Unrecognized Late-Life Depression for Racialized Immigrants and Nonimmigrants in Canada

“…Another school of thought argues that the medical underuse of immigrants, resulting from barriers to accessing health services ( Lin, 2021 ), may be the underlying reason for this “foreign-born health advantage.” As health outcomes and health care access are inextricably intertwined ( Lin, 2022a , b ), the mixed findings on mental health disparities are believed to illuminate, among other factors, underlying health care inequities that lead to the underestimation of mental health conditions among migrant communities ( Lau et al, 2013 ). Mounting evidence from scoping and systematic reviews suggest that compared to the host populations, foreign-born residents seem to underutilize mental health services due to limited health literacy ( Thomson et al, 2015 ), linguistic obstacles ( Wang et al, 2019 ), cultural differences ( Ahmed et al, 2016 ), and discrimination in the host country ( Edge & Newbold, 2013 ).…”

“…Although a recent study found that undiagnosed depression was higher among female immigrants ( Farid et al, 2020 ), the immigrant health literature tends to homogenize the experience of racialized and White immigrants as a monolithic category ( Brown, 2018 ; Lin & Fang, 2023 ). The intersectionality lens of racialization, migration, and old age has been largely overlooked in mental health epidemiology ( Gkiouleka et al, 2018 ; Lee, 2019 ; Lin, 2023 ). Moreover, racialized immigrants were often compared with their native-born peers of the same ethnic origin (e.g., Alvarez et al, 2019 ), rather than using domestically born Whites as the reference category.…”

“…Moreover, racialized immigrants were often compared with their native-born peers of the same ethnic origin (e.g., Alvarez et al, 2019 ), rather than using domestically born Whites as the reference category. Ignoring the racial heterogeneity among immigrant populations and the failure of referencing with the dominant privileged group are both serious shortcomings ( Lin, 2022b ; Lin 2023 ), because racism, nativism, language barriers, and cross-cultural differences may cumulatively influence the health and well-being of immigrants who are aging in a foreign land ( Ferrer et al, 2017 ).…”

“…Therefore, a disaggregated investigation of how intersecting stratification axes of race/ethnicity and nativity combine to shape mental health disparities in late life is warranted to inform culturally responsive mental health services ( Lin, 2022b ). The current study aims to examine racial-nativity disparities in mental health epidemiology to capture both the issue of health care access and the actual occurrence of depression symptoms.…”

“…A meta-analysis has revealed that there was reasonable evidence of inadequate clinical identification of late-life depression in primary care ( Mitchell et al, 2010 ). Although the diagnosis of a mental health condition is mainly covered by the universal coverage of physician-provided health care in Canada ( Steele et al, 2006 ; Lin, 2023 ), previous epidemiological studies found that approximately 48% of Canadians reported undiagnosed mood disorders ( Pelletier et al, 2017 ) and around 60% of Canadians with mental health needs did not use any type of mental health care ( Vasiliadis et al, 2007 ).…”