Prevalence of Depression in migrant workers of Gulf Cooperation Council (GCC): A Systematic Review

Abdulkarim Alanazi *^1, Dr. Buhaiseh AlOwaishiz ².

1. Department of Medicine, Alfaisal University, Master student, Saudi Arabia – Riyadh.

2. Consultant Clinical Psychologist, King Fahad Medical City

Corresponding Author: Abdulkarim Alanazi, Department of Medicine, Alfaisal University, Master student, Saudi Arabia – Riyadh.

Copy Right: © 2022 Abdulkarim Alanazi, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: June 08, 2022

Published Date: July 01, 2022

Abstract

Background: Migrant’s workers experience a wide range of social, cultural, economic, and psychological changes due to their move. People's mental health may be harmed when moving to a new nation and adjusting to the culture. Foreign workers in the Gulf Cooperation Council who have no access to mental health and well-being services face a host of issues, including psychological issues, work-related issues, and decreased productivity. As a result, multiple studies have found that immigrants are more likely to suffer from depressed and anxiety disorders. In the GCC countries, however, different and contradicting depression prevalence statistics have been recorded.

Objective: The present systematic review to evaluate the overall prevalence of depression in migrant workers of Gulf Cooperation Council (GCC).

Patients and methods: A systematic review of Saudi, Gulf Cooperation Council (GCC) search was conducted in 2022 for English articles on the prevalence of Depression in Migrant workers, published in the Scientific Information Database (SID), PubMed, Scopus, and Web of Science.

Results: The pooled depression prevalence among the migrant workers in the GCC was 21%. The review findings identified some risk factors contributing to the high depression prevalence among migrant workers. Some of the contributing factors identified by various studies include workload, stressful working environment, outstanding loans, substance use, and language barriers.

Conclusion: the high depression prevalence among migrant workers is considered to be driven by the contributing factors, which requires interventions that focus on social and economic support for this population. The implication of the review findings shows the need to conduct further research to determine the trends of depressive health outcomes.

Keywords: depression, depressive disorder, migrant workers, migration, Saudi, Saudi Arabia, and Gulf Cooperation Council (GCC).

Introduction

Migrants have experienced a variety of social, cultural, economic and psychological impacts as a result of their movement. Human migration is defined as the movement of people from one place to another with the intention of settling in a new location, either permanently or temporarily (a geographic area). Internal migration (migration within one country) is the most common type of human migration worldwide (Report, 2020). Migration is often associated with an increase in human capital at the individual and family level, as well as improved access to migration networks, enabling second transfers. Both employment and out-of-work migration are affected by age (Coxhead, Cuong, N, & Linh, H, 2015). Individuals, families, and large groups of people may migrate. Conquest, conquest, colonization and migration/migration are the four main types of migration (Caves, 2004). The largest group of migrant workers in the GCC countries are Indian nationals, followed by Pakistanis, and a similar number of foreigners from Bangladesh, the Philippines and Sri Lanka (Kapiszewski, 2006). Saudi Arabia and UAE have the world's third and fifth highest populations of migrants, respectively, according to the United Nations. (Migration, 2017).

Qatar, Saudi Arabia (KSA), the United Arab Emirates (UAE), Oman, Kuwait, and Bahrain are among the Gulf Cooperation Council (GCC) countries. These countries are all in the Middle East and are classified as high-income countries in the region. They share a lot of social, religious, and cultural characteristics. Furthermore, GCC countries face many of the same health challenges and opportunities. (Karam & Itani, l, 2015). Inadequate budgeting for mental health in general may obstruct the promotion of mental health services and satisfying community needs. (Okasha, Karam, E, & Okasha, T, 2012)

Long before the Gulf Cooperation Council (GCC), the problem of migrant labour had become a source of conflict in the Arab world.  Due to the oil boom that occurred in the 1960s, there was an increase in migration from the 1970s to the 1980s (ECDHR, 2022). Since that time, foreign workers in the Gulf Cooperation Council who have no access to mental health and well-being services face a host of issues, including psychological issues, work-related issues, decreased productivity, and uneven social dynamics, as a result. Construction, sanitation, transportation, hospitality, and health care are some industries where migrant labor plays an important role. Despite their low wages, low-skilled employees contribute significantly to their host countries' economic growth and progress.

In 2016, the first study in KSA that was puplished of its measured the same purpuse,  the results showed a 20% depression prevalence among migrant workers. Duration of stay and living condition, the two a priori hypotheses, did not prove to be significant correlates of depression. (Nadiam, et al., 2016) The depression prevalence in the present study was within the range (13–25%) of estimates previously published among similar populations in the other gulf countries such as in Bahrain that reported (13%) of migrant workers had depression (Al-Maskari et al., 2011; Sarwani et al., 2013). Samiliraty, in 2021, The overall prevalence of depression among migrant workers in Qater was 38.99%. (Hasan, et al., 2021). In 2019, there was research published which was measured the prevalence of depression with migrant workers in GCC, most of the respondents were working in the United Arab Emirates (35.6%), followed by Oman (5.6%) and Kuwait (4.4%). (Uvais, Nalakath, M, Hafi, B, & Salman, C, 2019)

Despite this, when compared to psychological complications, little attention has been paid to the study of depression in migrant workers in Gulf Cooperation Council (GCC). Considering the lack of systematic studies focused on this issue in Gulf Cooperation Council (GCC), and the reality that any effort to prevent and treat Depression in immigrants in GCC, the present study aims to accurately estimate the prevalence of Depression in Gulf Cooperation Council (GCC).

Mental health services for foreign workers in the Gulf Cooperation Council:

Despite the prevalent belief that health care providers are better equipped and more sympathetic to patients with mental diseases, there is a paucity of knowledge regarding mental health illness in the available literature today. Because of their education and training, health care professionals (HCP) are expected to cope with mental illness's physical and emotional effects. (Kronfol & Al-Ghafry, 2014). There is a rapidly expanding population in GCC countries (Khoja, et al., 2017).     

Residents of the GCC countries can get mental health services for no cost. However, expatriates must pay a small fee (Zahid & Alsuwaidan, 2014). There are unique challenges in providing mental health services to migrants because of their unique presentation of some psychiatric disorders and because the migrants themselves describe a mismatch between various diagnostic criteria and phenomenology of the disorder as they describe it in their own cultural context. Depression in migrants has been associated with somatoform, anxiety, and dissociative symptoms, to name just a few.

Migrants' mixed ancestry creates a unique set of problems. GCC countries' mental health services are understaffed and under-resourced, resulting in a high incidence of psychiatric morbidity among these migrant workers. Migrants who suffer mental illness, especially if many of them remain undiagnosed or insufficiently treated, are more likely to return home early and face the same economic challenges that sparked their departure in the first place. If competent interpreters and cross-cultural psychiatrists, psychologists, and social workers are readily available, mental health diagnoses will be more accurate. There is also a need for appropriate rehabilitative services.

From 0.3 (UAE) to 8.2 (Bahrain), the number of psychiatrists per 100,000 people varies, as does the number of beds per 100,000 people (Kuwait). Psychologists and social workers are also in limited supply in the mental health field. Oman has the lowest number of social workers per capita in the world at 0.07. (Saudi Arabia) (Zahid & Alsuwaidan, 2014). Outpatient clinics are available in certain general hospitals, but institutions with inpatient mental health treatments are rare.

There has been a recent shift toward decentralization of services, with gradual growth in primary health care clinics. The GCC countries' distinct population demographics provide significant obstacles to the host countries' already limited resources for providing mental health treatments.

Evaluate the overall prevalence of mental health disorders in foreign workers in the Gulf Cooperation Council:

As part of the WHO's Eastern Mediterranean Region (EMR) countries, the Gulf Cooperation Council (GCC) nations are included (Alzahrani, 2020). As per WHO, two-thirds of adults with mental or neurological problems do not seek treatment. Some of these common illnesses can become long-term and devastating (Shaheen, 2020).

Three thousand nine hundred sixty-two items were found through electronic database searching. Using Google Scholar, 160 additional articles were found. A total of 20 papers were included in this systematic review after removing duplicate publications, screening the title and abstract, and screening the full text of each study. Seven studies looked at the prevalence of depression and anxiety, ranging from 10.7% to 85.7% and the latter from 6.9% to 58.47%. When depression and anxiety were combined, the percentages were 38.99% (95 percent confidence interval [CI] = 0.27, 0.51) and 27.31 percent (CI] = 0.06, 0.58).

Method

Criteria for including studies in the review:

Type of disorder:

For the purpose of this review, depression by according to American Psychiatric Publishing (DSM-5) (2013), Sadness, feeling empty, unpleasant mood, changes in eating or weight, sleep and psychomotor activity, followed by somatic and cognitive changes, are all common depression symptoms. affecting the person's ability to work, long-term pacing issues, or probable cause Frustration, discontent with the future, a lack of interest in people or all activities, and difficulty making decisions. Reduced energy, feelings of worthlessness or guilt, difficulties thinking, concentrating, and making decisions, and persistent thoughts of death or suicidal ideation, plans, or attempts are all symptoms of depression among immigrants.

Types of Participants:

Each research that fulfills inclusion standards for inclusion had an adult participant sample (20 years old and over). Participants would have to suffer from depression disorder. The definition of a depression by the World Health Organization (WHO) is: “It is characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities. It can also disturb sleep and appetite. Tiredness and poor concentration are common. Depression is a leading cause of disability around the world and contributes greatly to the global burden of disease. The effects of depression can be long-lasting or recurrent and can dramatically affect a person’s ability to function and live a rewarding life.” (Thomas, Stephen, & Colin, 2000).

Types of measures:

Studies were qualified for inclusion if they:

a) Used standardized physical and psychological examinations, which involves many variables, including the medical history of the diagnosis, the symptoms of depression, treatment plan, and compilation of information from the profession or family about immigrants.  In order to classify the severity of depression, psychological assessment, blood pressure, and hypertension.

b) Assessments of depressive disorder interventions were used in order to recognize and evaluate depression symptoms. The rating scales included by the researchers could be used to diagnose depressive disorders in immigrants. These were among them:  Depression Anxiety and Stress Scale (DASS) questionnaire, Center for Epidemiological Studies on Depression Scale (CES-D), The International Classification of Diseases (10th revision; ICD-10) Symptom Checklist, The Brief COPE (9th-item) Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Questionnaire (GAD-7), General Health Questionnaire (GHQ-28), The Social Functioning Questionnaire (SFQ), and The Dundee Relocation Inventory (DRI).

Types of studies:

This is a systematic review of Saudi, Gulf Cooperation Council (GCC), and international studies focused on the prevalence of Depression in Migrant workers, published in the Saudi and international journals from 2000 until 2022.In conducting this systematic review, we followed the Preferred Reporting Items for Systematic Reviews (PRISMA) standards. In this study, articles published in the Saudi and international databases, including Scientific Information Database (SID), MagIran, PubMed, Scopus, and Web of Science, were searched using the following keywords: depression, depressive disorder, migrant workers, migration, Saudi, and Gulf Cooperation Council (GCC).

Inclusion and exclusion criteria:

All the articles included are published in English and investigate the prevalence of depression in migrant workers. The articles selected had to comprise more than 90 migrant participants as the participants of the studies. These studies must have been published in peer-reviewed journals with abstracts presented in English. Some of the excluded articles were cohort studies, case series, commentaries, interventional newspaper studies, case reports, magazine and articles, conference papers, and case-control studies. Also, studies that had been printed in other languages apart from English and did not provide adequate applicable data regarding the prevalence among the migrants were excluded from the study. The studies that had participants either younger than 15 years old or older than 60 years old were excluded for effective comparability across diagnostic measurements.

Study Selection and Data Extraction:

All the articles were published in English, investigating the prevalence of depression in immigrants were chosen. Non-related and repeated studies were excluded. This information will be extracted from each study and will be presented in a suitable form:

• Full citation: name of the first author, year of publication, place of publication, country, language of the study.
• Participant characteristics: diagnostic criteria of depression.
• Prevalence of overall depression, and proportion of participants with depression by gender.
• Study Characteristics: total sample size, sample size by gender, settings.
• Assessments used: psychological tests, depression measures.
• Findings: Prevalence of depression in immigrants.

Result

A total of nine articles examining the prevalence of depression in migrant workers in the Gulf Cooperation Council (GCC) were analyzed based on the PRISMA statement (Figure 1) (Moher, Liberati, A, Tetzlaff, J, Altman, D, & PRISMA, 2009)

Studies Findings:

A total of nine articles were selected and evaluated to explore the presence of depression among migrant workers in the Gulf Cooperation Council (GCC). According to Al-Maskari et al. (2011), the prevalence of depression among the male migrant workers in the United Arab Emirates was 25.1% with 60 participants out of 239 who completed the Depression Anxiety and Stress Scale (DASS-42). Depression was found to have a direct correlation with physical illness, with 97 participants out of 301 showing signs of depression. Zahid et al. (2003) reported that schizophrenia was among the most common disorders among patients in Kuwait.

Stress-related disorders are considered the most common among housemaids. The housemaids, who are among the migrant workers, showed a higher hospital admission rate that accounted for 1.86 times more than the female patients in Kuwait. Depression defined a higher percentage of mental disorders in Kuwait.

The study conducted by Sawraini et al. (2013) determined that depression rates among migrant workers are contributed by several factors, including outstanding loans and tobacco use. The prevalence of depression for workers with outstanding loans was 13%, which accounted for the 50 participants out of the 384 who participated in the study. Another fifty participants, representing 13% of the expatriates, were found to be depressed. According to Nadim et al. (2016), the prevalence of depression among migrant workers was 20%. However, the depression prevalence did not vary with the living condition or duration of stay but was affected by stress, age, and self-reported health. Depression prevalence is significantly higher in males and females in the population in the Kingdom of Saudi Arabia.          

According to Uvais et al.'s (2019) study, a total of 94 participants played a part. The findings showed a depression prevalence level of 41% in the Middle East. Saudi Arabia had a depression prevalence of 28.9%, while the UAE had a prevalence of 35.6%. The depression prevalence for females was 14.9% and 85.1% for males. The study also showed a higher depression prevalence. According to Hamid’s (2021) study, migrant workers were associated with higher depressive symptoms. A total of 1444 Sudanese took part in the study, with unemployed and female migrants showing higher physiological distress, including depression. Generally, the prevalence of depression among migrant workers in the Gulf Cooperation Council (GCC) is higher and it is contributed by various factors, including substance use, financial issues, and workload.

Discussion

This systematic review included a total of nine studies, both peer-reviewed and cross-sectional studies. The review significantly achieved the intended aim of determining the prevalence of depression among the migrant workers of the Gulf Cooperation Council (GCC). There are some risk factors identified to be contributing to the high depression prevalence for migrant workers in the GCC. The present systematic review pooled the depression prevalence to be 21%. When comparing the rates of hospital admissions due to psychological issues, migrant workers are considered to have a higher prevalence of depression than residents. Workers are considered to have been migrating to countries in the Middle East in search of employment opportunities. One study identified a higher depression prevalence among housemaids that is considered to be caused by the working environment associated with heavy workload and language barriers (Zahid et al., 2003).

Psychological factors are considered to be among the most significant risk factors associated with depression among the migrant workers of the GCC. Migrant workers with elevated levels of emotional intelligence and higher resilience are considered to be at a lower risk of developing psychological issues such as depression. Emotional intelligence and resilience are protective factors significant in the betterment of the mental health, with their impacts contributing more to the adoption and regulation of emotions in stressful circumstances (Kotsou et al., 2019). Personality traits, including social inhibition and negative affectivity for migrant workers, are related to depression. Most of the depressed workers seemed to lack these traits. The inventions that can help in reducing the high depression prevalence should mainly focus on developing resilience and emotional control to promote the good mental health of migrant workers.          

Another risk factor that seemed to have influenced the high depression prevalence among the migrant workers in GCC were outstanding loans and tobacco use. Financial challenges are considered to be among the leading causes of depression among individuals. The majority of people who are having difficulty paying have mental health issues. The depressive issues associated with outstanding loans include the fears of possession being taken by the financial institutions. Tobacco use is among the factors causing high depression prevalence for GCC’s migrant workers. Typically, the mental health of an individual is affected when using substances such as tobacco. Tobacco use is considered common in the Middle East (King et al., 2019). The use of tobacco among migrant workers can be caused by heavy workload and a stressful working environment. The interventions aimed at reducing the high depression prevalence should focus on developing an effective working environment and providing financial support to migrant workers.

Strengths and limitations

There are several strengths of this systematic review, including the comprehensive search strategy utilized in finding the relevant studies. The review was performed systematically based on PRISMA criteria that ensured the reviewed studies were of the highest quality as possible. The theoretical knowledge regarding the prevalence of depression and some risk factors were identified in the review, defining its strength. However, there is a limitation regarding the criteria of study selection. Only English studies were considered to be eligible, which ruled out some of the studies that may have contained insightful information about depression prevalence but were published in other languages.

Conclusion

The review focused on determining the prevalence of depression among the migrant workers of the GCC. The studies included showed a significant depression prevalence among migrant workers. A total of nine studies were selected for the review, which was performed systematically using PRISMA criteria. However, there are some contributing factors that are considered to be behind the increasing depression rates among migrant workers. These factors include language barriers, outstanding loans, and tobacco use. The increasing depression prevalence showed the need to implement strategies that address mental health issues. The interventions can include the reduction of the issues of healthcare access and social integration. The implications of the review can be recommended for further and future research by conducting more longitudinal and cohort studies focusing on the trends of depressive health outcomes related to diverse factors including biological, social, demographics, environmental, and occupational.

Acknowledgments

I would like to express my special thanks of gratitude to my supervisor Dr. Buhaisah AlOwaishiz who exerted great efforts in supporting and inspiring me throughout all stages of my research. I appreciate you sharing your knowledge and providing me with feedback and motivation during this research.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorder, fifth edition. Washington, DC.

2. AlShehabi, O. (2015). Histories of Migration to the Gulf. Transit states: Labour, migration and citizenship in the Gulf, 3-38.

3. Alzahrani, O. (2020). Depressive disorders in the Arabian Gulf Cooperation Council countries: a literature review. The Journal of International Medical Research.

4. Carlson, D. S., Grzywacz, J. G., Ferguson, M., Hunter, E. M., Clinch, C. R., & Arcury, T. A. (2011). Health and turnover of working mothers after childbirth via the work–family interface: An analysis across time. Journal of Applied Psychology, 96(5), 1045–1054. https://doi.org/10.1037/a0023964

5. Caves, R. (2004). Encyclopedia of the City. Routledge. ISBN: 9780415252256.

6. Cholewinski, R., De Guchteneire, P., Guchteneire, P. F., & Pecoud, A. (Eds.). (2009). Migration and Human Rights: The United Nations Convention on Migrant Workers' Rights. Cambridge University Press.

7. Coxhead, I., Cuong, N., Linh, H. (2015). Migration in Vietnam: New Evidence from Recent Surveys. SSRN Elctronic Journal. DOI: 10.2139/ssrn.2752834.

8. ECDHR. (2022). GCC Countries and Migrant Workers: Background Facts. https://www.ecdhr.org/?p=902

9. Hasan, S., Yee, A., Rinaldi, A., Azham, A., Hairi, F., Nordin, A. (2021). Prevalence of common mental health issues among migrant workers: A systematic review and meta- analysis. Plos one. DOI: 10.1371/journal.pone.0260221.

10. Hamid, A. A. (2021). Psychological Distress and Homesickness Among Sudanese Migrants in the United Arab Emirates. Frontiers in Psychology, 12, 710115-710115.

11. Karam, E., Itani, L. (2015). Mental health research in the Arab world: an update. Br J Psych Int. 2015;12:S-25.

12. Khaled, S. M., & Gray, R. (2019). Depression in migrant workers and nationals of Qatar: An exploratory cross-cultural study. International Journal of Social Psychiatry, 65(5), 354-367.

13. Khoja, T., Rawaf, S., Qidwai, W., Rawaf, D., Nanji, K., & Hamad, A. (2017). Health Care in Gulf Cooperation Council Countries: A Review of Challenges and Opportunities. Cureus.

14. King, J. L., Reboussin, B. A., Spangler, J., Ross, J. C., & Sutfin, E. L. (2018). Tobacco product use and mental health status among young adults. Addictive behaviors, 77, 67-72.

15. Kotsou, I., Mikolajczak, M., Heeren, A., Grégoire, J., & Leys, C. (2019). Improving emotional intelligence: A systematic review of existing work and future challenges. Emotion Review, 11(2), 151-165.

16. Kronfol, Z., Saleh, M., & Al-Ghafry, M. (2014). Mental health issues among migrant workers in Gulf Cooperation Council countries: literature review and case illustrations. Asian Journal of Psychiatry, 10, 109-113.

17. Labour Migration. (2017). Labour Migration. International Labour Conference. https://www.ilo.org/africa/areas-of-work/labour-migration/policy-frameworks/WCMS_671736/lang--en/index.htm

18. Mohammed, R., & Kosalram, K. (2022). Psychosocial Workplace Factors and Health Problems among Indian Migrants in Gulf Cooperation Council Countries. Indian Journal of Public Health Research & Development, 13(1).

19. Mohan, H., & Lone, Z. A. (2021). Loneliness and Mental Health Amongst Indians Working in Abu Dhabi, UAE., H., & Ahmed Lone, (2021), 559-572.

20. Nadiam, W., Alotaibi, A., Al-Mohaimeed, A., Ewid, M., Sarhandi, M., Saquib, J., Alhumdi, K., Alharbi, A., Taskin, A., Migdad, M., Alshammari, J., Alharbi, s., Saquib, N. (2016). Depression among migrant workers in Al-Qassim, Saudi Arabia. Elsevier. www.elsevier.com/locate/jad

21. Okasha, A., Karam, E,. Okasha, T. (2012). Mental health services in the Arab world. World Psychiatry. 2012;11:52-54.

22. Sarwani, S., Abdulla, K., Mandeel, M. (2013). Prevalence of Stress, Anxiety and Depression among Expatriate Workers. Bahrain Medical Bulletin. DOI: 10.12816/0000751.

23. Shaheen, R. (2020, July 22). Top 5 most common mental health disorders in the UAE. Retrieved from bepsycologycenter: https://bepsychologycenter.com/blog/5-most-common-mental-disorders-in-uae/

24. Thomas, T., Stephen, B., & Colin, M. (2000). The global burden of cerebrovascular disease. Global Burden Dis, 21(06), 06.

25. Unlu, B., Wit, M., Fassaert, T., Cuijpers, P. (2014). The relationship between acculturation strategies and depressive and anxiety disorders in Turkish migrants in the Netherlands. BMC Psychiatry. DOI: 10.1186/s12888-014-0252-5.

26. Uvais, N., Nalakath, M., Bishural, N., Salman, C. (2019). Depression, Anxiety, and Coping During the COVID-19 Pendemic Among Indian Expats in the Middle East: A Survey Study. Psychiatrist. https://www.psychiatrist.com/pcc/covid-19/psychological-stress-and-coping-during-covid-19/

27. World Migration Report. (2020). International Organization for Migration, 2019. https://worldmigrationreport.iom.int/

28. Zhng, J., Li, S., Hashimoto, K. (2014). R(-)-ketamine shows greater potence and longer lasting antidepressant effects than S(+)- ketamine. Elsevier. DOI: 10.1016/j.pbb.2013.11.033.