Undocumented Immigrants in Psychiatric Wards

Since the 1990s, more undocumented than documented immigrants have been arriving in the United States, with an additional 300,000–500,000 undocumented persons arriving each year (1, 2). While it is well known that Latino immigrants are relatively healthy upon arrival, they are paradoxically more likely to have poor health and low socioeconomic status after arrival. This can be attributed to language and cultural barriers, poverty, separation from family, stressors in the homeland prior to migration, discrimination and exploitation endured, lack of insurance, and decreased education (2, 3).

There are surprisingly little data on undocumented immigrants and the many health issues they face, despite their large and increasing presence. In particular, there are virtually no studies on the intersection of undocumented immigrants in the United States with the psychiatric world. Additionally, there are very little data about immigrant access to health services (1). While the health care system is meant to provide services regardless of criminal history and documentation status, in a study by Cavazos-Rehg et al. (2) involving 143 Latino immigrants in St. Louis, 39% feared seeking social services out of concern for deportation. In 2013, a research group led by Lovato demonstrated that one in eight undocumented Latino immigrants presenting to the emergency department fear discovery and deportation (4). Similarly, Bustamante et al. (5) showed that compared with documented immigrants from Mexico, undocumented immigrants from Mexico were 27% less likely to visit a doctor and 35% less likely to have a usual source of care.

In the face of an increasing undocumented population, it is critical for the hospital system to learn how to care for them. Unfortunately, on top of the difficulties undocumented immigrants face accessing the health care system, little legal oversight exists regarding hospital management of them. In sight of this, we present our care for an undocumented Honduran man with psychosis and provide a concise review of the available literature for managing undocumented psychiatric patients.

Case

“Mr. A” is a 23-year-old monolingual, undocumented Honduran man who was brought by emergency medical services to NewYork-Presbyterian Hospital after he was found trying to break into a car without a shirt in the middle of winter. He was severely agitated, requiring restraints and intramuscular haloperidol, lorazepam, and diphenhydramine, after which he slept through the night. Psychiatry was consulted, and he was seen with a Spanish interpreter. The patient was a poor historian, often contradicting himself, making nonsensical statements, or simply not responding to questions.

On later evaluation, the patient was able to report his name and birthdate. He mentioned that he came to New York from Honduras with his brother 3 years ago. The night he came into the emergency department, he was “running as fast as possible to get world peace” by working with “everyone.” He believed that he talked with God and also the devil, who told him to kill people, which he could not do because he was “here for peace.” He was admitted to the inpatient psychiatric unit, where he received haloperidol (10 mg q.h.s.), valproic acid (500 mg q.a.m. and 1,000 mg q.h.s.), and a tapering clonazepam regimen, with improvement in his mood and psychotic symptoms, which allowed us to fill the gaps of his story.

The patient revealed that he had been in a depressive state for the 3 months preceding presentation and had many prior episodes consistent with major depression. His first episode was at age 12, leading to chronic marijuana use “to feel happier.” One month prior to the depressive episode, his brother had been deported back to Honduras. The day of the incident, the patient went to the train station to find work elsewhere when he received a text and video from God on his phone instructing him to help the poor. The events following were unclear, but the patient believed it was God’s order that he should break into the car. The day of the incident, he had five beers and a joint.

Disposition was complicated given the patient’s lack of documentation. Because of the recent deportation of his brother, his desire to return, and his need for long-term outpatient psychiatric follow-up, we worked to help him return to Honduras. We attempted to secure identification by trying to contact the Honduran consulate, with multiple calls, a faxed letter, and a hand-delivered letter to the consulate. It took 10 days to receive an e-mail, and another 8 days before we secured a phone call. The consulate agreed to help the patient generate his ID and passport. Six weeks into the patient’s admission, and after a hospital expenditure of $281,000, he was reunited with his family back in Honduras.

Discussion

Our case of a Honduran man with psychosis highlights several important issues regarding undocumented immigrants struggling with psychiatric problems. Most of these patients need extensive care that hospitals lack the funds to provide. Repatriation back to the patient’s home country with the assistance of consulate services is an option, though speed of response and coordination varies by the size of the consulate (6). In a similar case report by Vesga-López et al. (6) in 2009 about a Mexican patient, success was much quicker, attributed partly to the larger presence and increased staffing of the Mexican consulate (7). Severity plays an important role in determining disposition, with facilitated repatriation providing greater assurance of continued high-level care with more severely ill patients. For patients with milder symptoms, discharge to sliding-scale/free/low-income clinics may be more viable. Our patient fell in the middle of this spectrum, and his strong personal preference convinced the team to pursue repatriation.

The rise of undocumented immigrants has led to increasing health care costs, causing hospitals to strategize cost-containment measures (8). Overall, the United States health care system spends roughly $2 billion a year caring for undocumented immigrants. Three laws guide the care of severely ill or injured patients who come through the emergency department, independent of legal status. The Emergency Medical Treatment and Active Labor Act states that emergency rooms must stabilize all patients in emergency situations. Second, Medicaid is legislated to reimburse emergency department costs. Finally, the Medicare Conditions of Participation ensures that hospitals cannot discharge patients without an appropriate plan. Not only is the compensation grossly inadequate for hospitals caring for undocumented patients, no laws are set up to ensure even some level of compensation following discharge. With the confluence of reduced compensation and lack of governance, hospitals have been repatriating patients without legal oversight. This strategy will continue with the increasing number of undocumented patients. There is no current figure for the prevalence of repatriation, but it is a growing phenomenon. While repatriation is done to reduce overall costs, it is important to note that this process is quite expensive. Hospitals commonly spend $25,000 or more to send patients back via medically equipped planes (8).

Needless to say, laws governing repatriation are needed; without them, patients may be vulnerable to abuse and unethical conduct. Although not the case for our patient, hospitals may discharge patients without consent. While hospitals may not have the explicit right to repatriate patients, it is unclear what else hospitals should do. As such, hospitals navigate through legal and ethical gray areas that need clarification (8). As proposed by Cavazos-Rehg et al. (2), the government must either allow undocumented immigrants to become eligible for Medicaid or set up legal boundaries for repatriation.

Given the growing population and the rising cost of caring for undocumented immigrants, studies are crucial for hospitals to provide optimal care. What is clear is that given the vulnerable nature of this population, more needs to be done to meet their mental health needs.

Key Points/Clinical Pearls