Contact with psychiatric care prior to suicide: are there differences between migrants and the majority population in Sweden? A cohort study of 12 474 persons who died by suicide between 2006 and 2016.

AIMS: The aim of this study was to determine possible differences in psychiatric care contact and the type of contact in the year prior to suicide by migrant status and region of origin compared to Swedish persons. METHODS: A population-based open cohort design, using linked national registers, to study all individuals aged 20-64 years who died by suicide between 1 January 2006 and 31 December 2016 in Sweden (N = 12 474). The primary exposure was migrant status compared to the Swedish majority population in the following categories: non-refugee migrants, refugee migrants and children of migrants. The secondary exposure was region of origin in seven regions: Sweden, other Nordic countries, Europe, Sub-Saharan Africa, the Middle East and North Africa, Asia, the Americas and Oceania. The four outcomes were psychiatric in- and outpatient care, prescribed and purchased psychotropic medication and a variable composing the other variables, all measured the year before death. Logistic regression models adjusted for age, sex, income and marital status estimated the likelihood of psychiatric care utilisation by type of care within the year prior to death by migrant status and region of origin (individually and combined). RESULTS: Out of all who had died by suicide, 81% had had psychiatric care of any type in the year before death by suicide. Among refugees the prevalence of psychiatric care before death by suicide was 88%. Compared with the Swedish reference group, non-refugees and persons from Asia and Sub-Saharan Africa had a lower likelihood of utilising psychiatric care prior to suicide driven by a lower use of prescribed psychotropic medication. Persons from the Middle East and North Africa had a higher likelihood, driven by higher use of psychiatric outpatient care and prescribed psychotropic medication. Non-refugees' likelihood of utilising care before death by suicide was lower within the first 5 years of living in Sweden. CONCLUSION: A large share of those who die by suicide use psychiatric care the year before they die. Non-refugee migrants and persons from Asia and Sub-Saharan Africa have a lower likelihood of utilising psychiatric care prior to suicide compared to Swedish, whereas persons from the Middle East and North Africa have a higher likelihood. Health care and policy makers should consider both migrant status, region of origin and time in the new country for further suicide prevention efforts.

Cross-cultural training in mental health care--challenges and experiences from Sweden and Germany.

Globalization and cultural diversity challenge mental health care in Europe. Sensitivity to culture in mental health care benefits effective delivery of care to the individual patient and can be a contribution to the larger project of building a tolerant multicultural society. Pivotal for improving cultural sensitivity in mental health care is knowledge in cross-cultural psychiatry, psychology, nursing and related fields among professionals and accordingly training of students and mental health professionals. This paper will give an overview, and a critical examination, of current conceptualisation of cross-cultural mental health training. From German and Swedish experiences the need for crosscultural training and clinical research on evaluation will be presented.

Turkish migrant women encountering health care in Stockholm: a qualitative study of somatization and illness meaning.

This paper presents the results from a qualitative study conducted with the aim of exploring structures of illness meaning among somatizing Turkish-born migrant women (age 31-48) living in a poor and low status suburb of Stockholm in contact with local health care services. Two to three interviews regarding experiences and understanding of illness were conducted as well as one year, validating follow-up interviews. Interviews were analysed with a grounded theory approach. Results are presented as the participants' agenda of understanding. Distress was communicated by concrete expressions about the body, emotions, social and life situation. Pain was prominent and often lateralised to one side of the body. The use of traditional expressions of distress ranged from open use to avoidance. Attribution was characterised by verbalising links of coherence between health and aspects of life. Psychiatric attribution was rarely accepted or valued as a tool for recovery, or as helpful in linking bodily symptoms to emotional distress. Three main sources for healing were used: medical care in Sweden and in Turkey and traditional treatment. Own capacity to influence recovery was mostly regarded as low. Relations to family and the clinician were regarded as important to recovery. The encounter with local health care had brought the participants in contact with a psychological agenda of understanding their illness and new ways of dealing with illness and healing. Some expressed a feeling of being misunderstood whereas some related positive experiences of re-evaluation. They were all actively trying, but experiencing varying degrees of difficulty, to grasp the meaning of the caregiver. The results of the study point to the mutual need of exploring meaning in the clinical encounter to help patients make sense out of different perspectives of illness and healing. The need for enhanced knowledge about this process in a migration context will be discussed.

[Mental illness among immigrants and refugees. Are needs and available care adequate?]. / Psykisk ohälsa bland invandrare och flyktingar. Ser behoven och vården ut som vi tror?

A considerable proportion of the Swedish population are of immigrant or refugee origin. This puts new demands on psychiatric care. In Stockholm county, immigrants of non-Scandinavian origin are characterised by lower psychiatric care utilisation rates than are the remainder of the county population. Population studies of multi-ethnic suburban areas in west Stockholm have shown the non-Scandinavian subgroup of the population to be characterised by somewhat lower utilisation of acute and short-term psychiatric care, as compared with native Swedes, but a clearly higher utilisation of primary psychiatric care facilities. Available evidence suggests the existence of several subgroups with high frequencies of mental ill-health in these areas. If sectorized psychiatry is to meet the demands of the population as a whole, economic prioritization is needed, as well as improved knowledge and methodology regarding cross-cultural psychiatry.