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Published On May 25, 2017

POLICY

A Dream Deferred

Atheendar Venkataramani explores the detrimental effects that immigration policy can have on the mental health of undocumented immigrants.

The Deferred Action for Childhood Arrivals (DACA) program was established in 2012 and granted renewable work permits to more than 750,000 undocumented immigrants who arrived in the United States as children and teenagers. It also allowed a population that had grown up with a lifelong fear of deportation to step out from the shadows.

A team of researchers, led by Atheendar Venkataramani from the Division of General Internal Medicine at Massachusetts General Hospital, wanted to know whether it was possible to measure the mental health effects of the act. Their study, published in the April 2017 issue of The Lancet Public Health, shows that DACA significantly reduced psychological distress among those eligible for the program.

On one hand, the study shows how policy can have measurable effects on mental health. On the other, it raises new concerns about the future of those protected under DACA, the fate of which remains uncertain under the new administration.

Q: What prompted you to look at people eligible for the DACA program?

A: My recent research looks at how people’s economic expectations and aspirations influence their health behaviors and outcomes. Starting when I was a resident, I’ve heard patients tell me that they don’t feel hope for the future and don’t feel they can get out of their current station in life. Because of this, they say they are less interested in adopting healthy behaviors, such as quitting smoking. I started with that insight. I then realized that economic opportunity could have even more direct effects on mental health.

My colleagues and I decided to focus on the DACA program because we needed a natural experiment to test this theory—a policy or event that changes economic opportunity for people. DACA literally extends access to the American dream to a group of people who are high risk when it comes to health outcomes.

Q: How did you find the data for this group?

A: My colleagues and I used data from the National Health Interview Survey, which surveys tens of thousands of people every year about health behaviors, health care utilization and other matters. We focused on young, noncitizen Hispanic men and women who met the DACA eligibility criteria and those who did not.

Then we looked at how the health outcomes of these two groups changed before and after the policy was put into place in 2012. We were specifically interested in overall self-reported health and psychological distress, which is our measure of mental health.

Q: What were the results?

A: The implementation of DACA was associated with a meaningful reduction in psychological distress among the eligible group. The survey asked participants to rank how often in the previous 30 days they felt nervous, hopeless, restless or fidgety, worthless, or depressed.

From those answers, we grouped the respondents into those who were experiencing what we call “moderate distress and above” and “less than moderate distress.” And we found that after the passage of DACA, there was a 40% reduction in the number of eligible people reporting that higher level of distress.

Q: And you believe that this was a direct result of the legislation? 

A: Yes. Let’s think about what DACA is doing. It’s providing an economic pathway. There’s work by Nolan Pope, an economist at the University of Chicago, who found that the DACA program led to increases in employment and reductions in the rate of poverty. This economic benefit could certainly spill over to health. DACA also provides nonmaterial benefits, such as access to the American dream, hope, and certainty about being able to live in the United States and be near your family. All of those factors have tremendous psychological benefits.

Q: How does this research inform your clinical practice as a primary care physician?

A: The results show that policies that are more inclusive to immigrants can have positive health effects. It’s also possible—and there is growing evidence for this—that policies that exclude immigrants can have negative health effects. So I think it’s incumbent on us as physicians to understand that and to ask our patients—who may have uncertainty about their immigration status—how they are doing from a mental health standpoint.

We also need to protect the identities of undocumented immigrants and make sure there’s a safe space where they can get needed health care—something MGH is already doing. There are stories of patients who don’t even show up, out of fear of being identified as undocumented and having that information reach the authorities. Not only does that result in mental health consequences, but some of these patients have physical health problems or chronic diseases that need treatment.

Q: What might happen if the DACA program is cancelled under the current administration?

A: For starters, there would be an immediate threat to the mental health and economic status of almost a million people. And a lot of these people have children. Such an event creates tremendous stress within a family. We know from early childhood research that psychological distress within a family can severely tamper with the cognitive development of kids. It’s one of those events that would have ripple effects that most people are not thinking about. Both from a policy and a scientific perspective, it’s not hard to imagine the destruction it would wreak.

Q: What do you hope people, especially policymakers, will take away from your work?

A: Here is a generous policy aimed at a group of people who have spent considerable time in the United States and who are inspired and ready to contribute. Giving them that chance has yielded tremendous economic benefits and has been a great public health move. So I think the lesson is that economic opportunity matters in more ways than one—a lesson that we can apply broadly.