Suicidal behaviour and healthcare use among refugees

Background: Despite higher rates of mental disorders among refugees, there is limited evidence on their risk of suicidal behaviour (suicide attempt and suicide) and how such risk is influenced by differences in country-level structural factors (e.g., the national healthcare and social services, national unemployment rates etc.) in the host countries. Moreover, research on any differences in patterns of healthcare use and trajectories of antidepressant use before and after a suicide attempt between refugees and the host population is lacking. Therefore, this thesis aimed to investigate the risk of suicidal behaviour in resettled refugees compared with the majority host populations in Sweden and Norway. A further aim was to investigate patterns of healthcare use, before and after a suicide attempt, among refugees who resettled in Sweden compared with the Swedish-born population.

Methods: In study I, three cohorts comprising the entire population of Sweden, 16-64 years of age on 31 December 1999, 2004, and 2009 (around 5 million each, of which 3.3-5.0% refugees) were followed for four years each through register linkage. Additionally, the 2004 cohort was followed for nine years to allow stratified analyses by refugees’ country of birth. Multivariate-adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) were computed. In study IV, all cases who died by suicide when 18-64-years-old during 1998 and 2018 (17,572 and 9,443 cases in Sweden and Norway, respectively) were matched with 20 sex- and age-matched population controls. Multivariate-adjusted conditional logistic regression models yielding adjusted odds ratios (aORs) with 95% CIs were used to test the association between refugee status and suicide in study IV. The multivariate models in study I and IV were adjusted for socio-demographic, labour market marginalisation (LMM) such as unemployment, sickness absence and disability pension, and morbidity factors. Additionally, in study IV, analyses were stratified by sex and age groups, by refugees’ region/country of birth and duration of residence in the host country. In study II, all refugees and Swedish-born individuals, 20-64 years of age, treated for suicide attempt in specialised healthcare during 2004-2013 (n = 85,771, of which 4.5% refugees) were followed three years before and after (Y-3 to Y+3) the index suicide attempt (t0) regarding their specialised healthcare use. With the same inclusion criteria and study design, another cohort of individuals with suicide attempt during 2009-2015 (n = 62,442, 5.6% refugees) was followed regarding their antidepressant use in study III. Annual adjusted prevalence estimates with 95% CIs of specialised healthcare use were assessed by generalised estimating equations (GEE) in study II. Trajectories of annual defined daily doses (DDDs) of antidepressants were analysed using group-based trajectory models in study III. Associations between the identified trajectory groups and different covariates related to socio-demographics, LMM, and healthcare use were estimated by chi2-tests and multinomial logistic regression.

Results: The aHRs of suicide attempt and suicide among refugees vs the Swedish-born ranged from 0.38-1.25 and 0.16-1.20 according to country of birth, respectively, showing either non-significant or lower aHRs for refugees. Exceptions were refugees from Iran with a higher risk for suicide attempt - aHR 1.25; 95% CI 1.12-1.40, compared to individuals born in Sweden. The risk for suicide attempt among refugees diminished slightly across the different cohorts (study I). In study IV, the aORs for suicide among refugees in Sweden and Norway were 0.5 (95% CI: 0.5-0.6) and 0.3 (95% CI: 0.3-0.4), compared with the respective host population. Stratification by region/country of birth showed similar statistically significant lower odds for most refugee groups in both host countries except for refugees from Eritrea (aOR 1.0, 95% CI: 0.7-1.6) in Sweden. The risk of suicide did not vary much across refugee groups by their duration of residence, sex and age except for younger refugees aged 18-24 who did not have a statistically significant relative difference in suicide risk than their respective host country peers. Factors related to socio-demographics, LMM and healthcare use had only a marginal influence on the studied associations in both countries in study IV as well as in study I in Sweden. In study II, among individuals with a suicide attempt, refugees had somewhat lower prevalence rates of psychiatric and somatic healthcare use during the observation period than the Swedish-born. During Y+1, 25% (95% CI 23-28%) of refugees and 30% (95% CI 29-30%) of Swedish-born used inpatient psychiatric healthcare. Among refugees, a higher specialised healthcare use was observed in disability pension recipients than non-recipients. Among the four identified trajectory groups, antidepressant use was constantly low (≤15 DDDs) for 64.9% of refugees in study III. A 'low increasing' group comprised 5.9% of refugees (60-260 annual DDDs before and 510-685 DDDs after index attempt). Two other trajectory groups had constant use at medium (110-190 DDDs) and high (630-765 DDDs) levels (22.5% and 6.6% of refugees, respectively). Method of suicide attempt and any use of psychotropic drugs during the year before index attempt discriminated between refugees’ trajectory groups. The patterns and composition of the trajectory groups, and the associations of the identified trajectory groups with the different covariates, were comparable among refugees and Swedish-born, except for previous sedative/hypnotic drug use, which explained the variability among the trajectory groups more for refugees than for the Swedish-born.

Conclusions: Resettled refugees had a lower risk of suicidal behaviour relative to the host population in Sweden and Norway. These findings may suggest that resiliency and culture/religion-bound attitudes towards suicidal behaviour among refugees could be more influential for their suicide risk after resettlement than other post-migration environmental and structural factors in the host country. Specialised healthcare use before and after a suicide attempt was somewhat lower among refugees than among the Swedish-born, and differences in antidepressant treatment were marginal between refugees and the Swedish-born.

List of scientific papers

I. Amin R, Helgesson M, Runeson B, Tinghög P, Mehlum L, Qin P, Holmes EA, Mittendorfer-Rutz E. Suicide attempt and suicide in refugees in Sweden – a nationwide population-based cohort study. Psychological Medicine. 2021;51(2):254–263.
https://doi.org/10.1017/S0033291719003167

II. Amin R, Rahman S, Tinghög P, Helgesson M, Runeson B, Björkenstam E, Qin P, Mehlum L, Holmes EA, Mittendorfer-Rutz E. Healthcare use before and after suicide attempt in refugees and Swedish-born individuals. Social Psychiatry and Psychiatric Epidemiology. 2021;56:325–338.
https://doi.org/10.1007/s00127-020-01902-z

III. Amin R, Rahman S, Helgesson M, Björkenstam E, Runeson B, Tinghög P, Mehlum L, Qin P, Mittendorfer-Rutz E. Trajectories of antidepressant use before and after a suicide attempt among refugees and Swedish-born individuals: a cohort study. International Journal for Equity in Health. 2021;20(1):131.
https://doi.org/10.1186/s12939-021-01460-z

IV. Amin R, Mittendorfer-Rutz E, Mehlum L, Runeson B, Helgesson M, Tinghög P, Björkenstam E, Holmes EA, Qin P. Does country of resettlement influence the risk of suicide in refugees? A case-control study in Sweden and Norway. Epidemiology and Psychiatric Sciences. 2021;30, e62, 1–10.
https://doi.org/10.1017/S2045796021000512