Are the estimated needs for mental health care among adolescents from different socioeconomic backgrounds met equally in Sweden? A longitudinal survey-registry linkage study.

Evidence of inequality in the utilisation of mental health care (MHC) by adolescents in Nordic countries is mixed. This study aims to investigate if there are socioeconomic differences in the utilisation of MHC, while accounting for adolescents' mental health status. We analysed a cohort of 3517 adolescents, followed from 7 to 9th grade (ages 13-16), to examine the association between parental socioeconomic position (SEP: education and disposable income), adolescents' estimated needs, and the utilisation of MHC (defined as visits to secondary psychiatric care or receipt of psychotropic medication). Logistic and negative binomial regression models, with mental health status as moderator, were used to predict utilisation during each grade. Lower SEP predicted higher odds of utilising MHC in adolescents with no/mild symptoms (e.g., odds ratio, OR = 1.33, 95% CI 1.04-1.72, lower vs highest education), but not in those with moderate-to-severe symptoms (estimates close to one and non-significant). This pattern was largely explained by treatment of attention deficit hyperactivity disorder/autism spectrum disorders (ADHD/ASD) in boys. For girls with severe symptoms, lower SEP predicted reduced odds of utilising MHC for other mental disorders (OR = 0.48, 95% CI 0.25-0.92, lower education), and fewer outpatient visits when in contact with such care, although non-significant (incidence rate ratio, IRR = 0.51, 95% CI 0.25-1.05, lowest vs highest income). Our findings suggest a more equitable use of MHC for treating ADHD/ASD, but not other mental disorders such as depression and anxiety, particularly among girls.

Association of trauma, post-traumatic stress disorder and non-affective psychosis across the life course: a nationwide prospective cohort study.

BACKGROUND: We aimed to examine the temporal relationships between traumatic events (TE), post-traumatic stress disorder (PTSD) and non-affective psychotic disorders (NAPD). METHODS: A prospective cohort study of 1 965 214 individuals born in Sweden between 1971 and 1990 examining the independent effects of interpersonal and non-interpersonal TE on incidence of PTSD and NAPD using data from linked register data (Psychiatry-Sweden). Mediation analyses tested the hypothesis that PTSD lies on a causal pathway between interpersonal trauma and NAPD. RESULTS: Increasing doses of interpersonal and non-interpersonal TE were independently associated with increased risk of NAPD [linear-trend incidence rate ratios (IRR)adjusted = 2.17 [95% confidence interval (CI) 2.02-2.33] and IRRadjusted = 1.27 (95% CI 1.23-1.31), respectively]. These attenuated to a relatively small degree in 5-year time-lagged models. A similar pattern of results was observed for PTSD [linear-trend IRRadjusted = 3.43 (95% CI 3.21-3.66) and IRRadjusted = 1.45 (95% CI 1.39-1.50)]. PTSD was associated with increased risk of NAPD [IRRadjusted = 8.06 (95% CI 7.23-8.99)], which was substantially attenuated in 5-year time-lagged analyses [IRRadjusted = 4.62 (95% CI 3.65-5.87)]. There was little evidence that PTSD diagnosis mediated the relationship between interpersonal TE and NAPD [IRRadjusted = 0.92 (percentile CI 0.80-1.07)]. CONCLUSION: Despite the limitations to causal inference inherent in observational designs, the large effect-sizes observed between trauma, PTSD and NAPD in this study, consistent across sensitivity analyses, suggest that trauma may be a component cause of psychotic disorders. However, PTSD diagnosis might not be a good proxy for the likely complex psychological mechanisms mediating this association.

Is legal status associated with mental illness among newly arrived refugees in Sweden: an epidemiological study.

BACKGROUND: There are about 80 million forcibly displaced people globally. Migrants are at heightened risk for mental illness compared to host country populations. While previous research highlights the need to adequately assess mental illness, few have taken the diversity among newly arrived migrants into account. This study aims to estimate the prevalence and associated risk factors of mental illness among asylum seekers, quota and other refugees in Stockholm, Sweden. METHODS: Using a cross-sectional design, data was collected as part of a mental health screening initiative integrated into routine health examinations in two health care clinics in Stockholm. Screening was done with the Refugee Health Screener, RHS-13, a validated instrument for assessing mental health in refugee populations. RESULTS: A total of 1163 individuals were eligible for screening, of whom 566 participated (response rate 48.6%). Among the participants, 47.9% indicated symptoms of mental illness. Compared with asylum seekers, the risk of mental illness was lower among quota and other refugees (adjusted odds ratio 0.60, 95% confidence interval 0.37-1.00). Female sex, higher age, coming from a middle-income country and low probability of being granted asylum were significant predictors of mental illness. CONCLUSION: Refugee legal status is associated with mental illness. Asylum seekers are at greater risk of mental illness compared to quota and other refugees. Our findings call for screening for mental illness among newly arrived migrants, especially among those with pending residence permits.

Sickness absence around contact with outpatient mental health care services - differences between migrants and non-migrants: a Norwegian register study.

BACKGROUND: Mental disorders are a leading cause of sickness absence. Some groups of migrants are at higher risk of both mental disorder and sickness absence. Yet, research on sickness absence in relation to mental disorders among migrants is limited. This study investigates differences in sickness absence in the twelve-month period around contact with outpatient mental health services between non-migrants and various migrant groups with different length of stays. It also considers whether these differences are similar for men and women. METHODS: Using linked Norwegian register data, we followed 146,785 individuals, aged 18-66 years, who had attended outpatient mental health services and who had, or had recently had, a stable workforce attachment. The number of days of sickness absence was calculated for the 12-month period surrounding contact with outpatient mental health services. We applied logistic regression and zero-truncated negative binomial regression to assess differences in any sickness absence and number of days of absence between non-migrants and migrants, including refugees and non-refugees. We included interaction terms between migrant category and sex. RESULTS: Refugee men and other migrant men from countries outside the European Economic Area (EEA) had a higher probability of any sickness absence in the period surrounding contact with outpatient mental health services than their non-migrant counterparts. Women from EEA countries with stays of less than 15 years had a lower probability than non-migrant women. Additionally, refugees, both men and women, with 6-14 years in Norway had more days of absence while EEA migrants had fewer days than their non-migrant counterparts. CONCLUSIONS: Refugee men and other non-EEA migrant men appear to have higher sickness absence than non-migrant men around the time of contact with services. This finding does not apply to women. Several probable reasons for this are discussed, though further research is required to understand why. Targeted strategies to reduce sickness absence and support the return to work for refugees and other non-EEA migrant men are needed. Barriers to timely help-seeking should also be addressed.

The relationship between motherhood and use of mental health care services among married migrant and non-migrant women: a national register study.

BACKGROUND: Giving birth to one's first child is a life changing event. Beyond the post-partum period, little is known about the association between becoming a mother and mental disorder among migrant women. This study investigates outpatient mental health (OPMH) service use, a proxy for mental disorder, among married migrant and non-migrant women who become mothers and those who do not. METHODS: Using Norwegian register data, we followed 90,195 married women, aged 18-40 years, with no children at baseline between 2008-2013 to see if becoming a mother was associated with OPMH service use. Data were analysed using discrete time analyses. RESULTS: We found an interaction between motherhood and migrant category. Married non-migrant mothers, both in the perinatal period and beyond, had lower odds of OPMH use than married non-mothers. There was no association between motherhood and OPMH service use for migrants. However, there was no significant interaction between motherhood and migrant category when we excluded women who had been in Norway less than five years. Among women aged 25-40 years, a stable labour market attachment was associated with lower odds of OPMH use for non-migrants but not migrants, regardless of motherhood status. CONCLUSIONS: The perinatal period is not associated with increased odds of OPMH use and appears to be associated with lower odds for married non-migrant women. Selection effects and barriers to care may explain the lack of difference in OPMH service use that we found across motherhood status and labour market attachment for married migrant women. Married migrant women in general have a lower level of OPMH use than married non-migrants. Married migrant women with less than five years in Norway and those with no/weak labour market attachment may experience the greatest barriers to care. Further research to bridge the gap between need for, and use of, mental health care among migrant women is required.

The association between persistent low parental income during preschool age and mental disorder in adolescence and early adulthood: a Norwegian register-based study of migrants and non-migrants.

BACKGROUND: Low socioeconomic status during childhood is associated with increased risk of mental disorders later in life. Yet, there is limited research on whether this association varies by migrant background, despite an overrepresentation of migrants among the economically disadvantaged. METHODS: Using national register data on a study population of 577,072 individuals, we investigated the association between persistent low parental income during preschool, measured at age 3-5 years and mental disorder during adolescence and early adulthood, measured between ages 16-25. Outpatient mental healthcare (OPMH) service use was a proxy for mental disorder and was measured between 2006 and 2015. We applied discrete-time logistic regression analyses with interaction terms to study differences in the relationship between persistent low parental income and OPMH service use by migrant background and gender. RESULTS: Persistent low parental income during preschool age was associated with increased odds of OPMH service use in adolescence and early adulthood (aOR = 1.99, 95% CI 1.90-2.08), even after adjusting for gender, migrant background, parental education and persistent lower income at later ages (aOR = 1.33, 95% CI 1.27-1.40). Statistically significant interactions between migrant background and persistent low parental income were recalculated and presented as marginal yearly probabilities. These results showed that the association was in the opposite direction for migrants; those in the higher income group had higher probability of OPMH service use, although the differences were non-significant for some groups. The relationship did not vary by gender. CONCLUSIONS: Social inequalities in mental health, as measured by OPMH service use, may have an onset already in childhood. Interventions to reduce inequalities should therefore start early in the life course. Since the association differed for migrants, future research should aim to investigate the mechanisms behind these disparities.

Association between migration status and subsequent labour market marginalisation among individuals with posttraumatic stress disorder: a Swedish nationwide register-based cohort study.

PURPOSE: The high prevalence of posttraumatic stress disorder (PTSD) among migrants in Europe is widely reported. Our research aimed to investigate the association between migration status and subsequent labour market marginalisation (LMM) events, i.e., long-term unemployment (LTU), long-term sickness absence (LTSA), and disability pension (DP) among individuals with PTSD, and to elucidate how the sociodemographic factors and the pre-existing health conditions influence such association. METHODS: We established a cohort of 36,714 individuals born between 1960 and 1995, living in Sweden during 2004-2009, aged 19 years or above, with PTSD diagnosis during 2006-2009. Migration status, categorized as refugees, non-refugees, second-generation migrants, and Swedish-born with Swedish-born parents (reference group) was considered as exposure and LMM events as outcome. The cohort was followed from 01-Jan-2010 until LMM, death, or end of follow-up (31-Dec-2016). Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by Cox regression with a seven-year follow-up. RESULTS: Refugees (HR 2.07, 95% CI 1.86-2.30), and non-refugees (HR 1.96, 95% CI 1.85-2.07) had almost doubled relative risk of long-term unemployment, compared with the Swedish-born. The hazards of long-term sickness absence were similar across the groups. Refugees (HR 1.49, 95% CI 1.24-1.77), and non-refugees (HR 1.42, 95% CI 1.30-1.56) also had elevated relative risk of disability pension, whereas second-generation migrants had moderately increased relative risks for all three labour market marginalisation events compared with the Swedish-born. CONCLUSION: Among the individuals with PTSD, being a migrant increases the risk of LMM, refugees being the foremost among migrants. Further research may benefit from including more recent migrant population, pre-migration information and measuring PTSD clinical severity.

Mental health service use among migrant and Swedish-born children and youth: a register-based cohort study of 472,129 individuals in Stockholm.

PURPOSE: Migrant children underutilize mental health services (MHS), but differences according to age, reason for migration, type of problem, and time have not been thoroughly analyzed. We aimed to explore utilization of MHS among migrant children and youth and to study if the hypothesized lower utilization could be explained by fewer neurodevelopmental assessments. METHODS: A cohort of the population aged 0-24 years in Stockholm, comprising 472,129 individuals were followed for maximum 10 years, between January 1, 2006 and December 31, 2015. We categorized individuals as accompanied refugee migrants, unaccompanied refugee migrants and non-refugee migrants, or Swedish-born. We used survival and logistic analyses to estimate rates of utilization of MHS. RESULTS: Migrant children and youth utilized less MHS than the majority population, with hazard ratios ranging from 0.62 (95% CI: 0.57; 0.67) to 0.72 (95% CI: 0.69; 0.76). Refugee and non-refugee children utilized less mental health care than their Swedish peers, apart from the youngest refugees (0-10 years) who had similar utilization as Swedish-born. The lower rates were partly explained by all migrant youths' lower risk of being diagnosed with a neurodevelopmental condition. Time in Sweden had a major impact, such that unaccompanied refugee minors had a higher utilization in their first 2 years in Sweden (OR: 3.39, 95% CI: 2.96; 3.85). CONCLUSION: Migrant youth use less MHS compared with native-born peers, and this is partly explained by fewer neurodevelopmental diagnoses. Strengthening the awareness about unmet needs, and the referring capacity by professionals in contact with migrant children could help reduce barriers to care.

Migration and risk of intellectual disability with and without autism: A population-based cohort study.

OBJECTIVE: To investigate whether parental migration, parental region of origin, timing of child's birth in relation to maternal migration and parental reason for migration are associated with intellectual disability (ID) with and without autism. METHODS: We used a register-based cohort of all individuals aged 0-17 years in Stockholm County during 2001-2011. General estimating equation logistic model and additionally sibling comparison were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). The models were adjusted for child's sex and birth year and parental age at child's birth, and additionally for migrant-specific variables in the analyses including only children with migrant parent(s). RESULTS: Within the eligible sample of 670,098 individuals, 3781 (0.6%) had ID with autism, and 5076 (0.8%) had ID without autism. Compared with children with Swedish-born parents, children with both parents born abroad had an increased risk of ID with autism (OR = 1.6, CI 1.5-1.8) and ID without autism (OR = 1.9, CI 1.7-2.0). Among these children with both parents born abroad, it was protective of ID with autism when the child's birth occurred before and later than four years after maternal migration, which was replicated in the sibling comparison. The associations with both conditions were more pronounced with parental origin in regions comprising low- and middle-income countries and with reasons other than work or study. CONCLUSIONS: Parental migration is associated with ID regardless of co-occurrence of autism. Our results indicate an association between environmental factors during pregnancy related to migration and offspring ID with autism, although further confirmative studies are needed.

Migration or ethnic minority status and risk of autism spectrum disorders and intellectual disability: systematic review.

BACKGROUND: There is an emerging evidence that the migration and the ethnic minority status are associated with the risks of autism spectrum disorder (ASD) and intellectual disability (ID). This systematic review aimed to investigate whether associations are specific to ASD or ID; whether and which migration-related or ethnically determined factors are associated with the risk of ASD and ID; and what mechanisms may explain these risks. METHODS: A systematic literature search was conducted using Embase, Medline and PsycINFO for studies reporting on the risks of ASD and/or ID among migrants, descendants of migrants and/or ethnic minorities. Risks of any ASD, ASD + ID, ASD - ID and any ID were reviewed in relation to migration and ethnic minority status, with consideration to the study quality. In addition, possible underlying mechanisms suggested in the included studies were summarized. RESULTS: Thirty-five studies were included. The summarized evidence indicated an increased risk of ASD + ID and a decreased risk of ASD - ID in migrants, descendants of migrants and ethnic minorities. These associations appeared more pronounced among children of migrant mothers, with origin in low-income countries, and among descendants of migrants. Data on ID were scarce. Suggested mechanisms explaining the increased risks of ASD + ID included environmental factors acting in utero and genetic factors (including consanguinity), while ascertainment bias was proposed to account for the lowered risks of diagnosed ASD - ID. CONCLUSION: Migration-related factors acting in utero and/or associated with origin in low-income countries may be important in the ASD + ID aetiology, although further confirmative studies are needed.

Interventions to increase migrants' care-seeking behaviour for stigmatised conditions: a scoping review.

BACKGROUND: Despite availability of effective treatments, migrants in high-income countries seek care for conditions associated with stigma to a lower extent than the rest of the population. We conducted a scoping review to map the literature on interventions to increase migrants' care-seeking behaviour in high-income countries for stigmatised conditions. Main body of the abstract: We searched 15 electronic databases and journals, hand-searched references and citations, to identify studies on interventions to increase migrants' care-seeking in high-income countries for stigmatised conditions. We applied language restrictions for English and Swedish, and searched the full time period up to 5 July 2019. Our primary outcome of interest was care utilisation. RESULTS: 5447 records were identified in the literature searches. We identified 16 eligible studies, all from North America, that reported interventions to increase migrants' care-seeking behaviour for hepatitis B (n = 1) and mental health (n = 15). Three approaches were identified: health communication (n = 10), support groups (n = 2), and primary care-based approaches (n = 4). There was a general trend towards community-based interventions tailored to individual migrant groups. Significant gaps were identified in the literature, including studies conducted in Europe and studies including men or children. Furthermore, the choice of study designs introduced significant bias that prevented accurate conclusions on intervention effectiveness. CONCLUSION: The available evidence on interventions to increase migrants' in high-income countries care-seeking behaviour for stigmatised conditions is limited in scope and quality. Future research, using reliable study designs, is needed to fill the remaining gaps and to boost the scope and reliability of the evidence.

Mortality and major disease risk among migrants of the 1991-2001 Balkan wars to Sweden: A register-based cohort study.

BACKGROUND: In recent decades, millions of refugees and migrants have fled wars and sought asylum in Europe. The aim of this study was to quantify the risk of mortality and major diseases among migrants during the 1991-2001 Balkan wars to Sweden in comparison to other European migrants to Sweden during the same period. METHODS AND FINDINGS: We conducted a register-based cohort study of 104,770 migrants to Sweden from the former Yugoslavia during the Balkan wars and 147,430 migrants to Sweden from 24 other European countries during the same period (1991-2001). Inpatient and specialized outpatient diagnoses of cardiovascular disease (CVD), cancer, and psychiatric disorders were obtained from the Swedish National Patient Register and the Swedish Cancer Register, and mortality data from the Swedish Cause of Death Register. Adjusting for individual-level data on sociodemographic characteristics and emigration country smoking prevalence, we used Cox regressions to contrast risks of health outcomes for migrants of the Balkan wars and other European migrants. During an average of 12.26 years of follow-up, being a migrant of the Balkan wars was associated with an elevated risk of being diagnosed with CVD (HR 1.39, 95% CI 1.34-1.43, p < 0.001) and dying from CVD (HR 1.45, 95% CI 1.29-1.62, p < 0.001), as well as being diagnosed with cancer (HR 1.16, 95% CI 1.08-1.24, p < 0.001) and dying from cancer (HR 1.27, 95% CI 1.15-1.41, p < 0.001), compared to other European migrants. Being a migrant of the Balkan wars was also associated with a greater overall risk of being diagnosed with a psychiatric disorder (HR 1.19, 95% CI 1.14-1.23, p < 0.001), particularly post-traumatic stress disorder (HR 9.33, 95% CI 7.96-10.94, p < 0.001), while being associated with a reduced risk of suicide (HR 0.68, 95% CI 0.48-0.96, p = 0.030) and suicide attempt (HR 0.57, 95% CI 0.51-0.65, p < 0.001). Later time period of migration and not having any first-degree relatives in Sweden at the time of immigration were associated with greater increases in risk of CVD and psychiatric disorders. Limitations of the study included lack of individual-level information on health status and behaviors of migrants at the time of immigration. CONCLUSIONS: Our findings indicate that migrants of the Balkan wars faced considerably elevated risks of major diseases and mortality in their first decade in Sweden compared to other European migrants. War migrants without family members in Sweden or with more recent immigration may be particularly vulnerable to adverse health outcomes. Results underscore that persons displaced by war are a vulnerable group in need of long-term health surveillance for psychiatric disorders and somatic disease.

Suicide risk among refugees compared with non-refugee migrants and the Swedish-born majority population.

BACKGROUND: It has been hypothesised that refugees have an increased risk of suicide. AIMS: To investigate whether risk of suicide is higher among refugees compared with non-refugee migrants from the same areas of origin and with the Swedish-born population, and to examine whether suicide rates among migrants converge to the Swedish-born population over time. METHOD: A population-based cohort design using linked national registers to follow 1 457 898 people born between 1 January 1970 and 31 December 1984, classified by migrant status as refugees, non-refugee migrants or Swedish-born. Participants were followed from their 16th birthday or date of arrival in Sweden until death, emigration or 31 December 2015, whichever came first. Cox regression models estimated adjusted hazard ratios for suicide by migrant status, controlling for age, gender, region of origin and income. RESULTS: There were no significant differences in suicide risk between refugee and non-refugee migrants (hazard ratio 1.28, 95% CI 0.93-1.76) and both groups had a lower risk of suicide than Swedish born. During their first 5 years in Sweden no migrants died by suicide; however, after 21-31 years their suicide risk was equivalent to the Swedish-born population (hazard ratio 0.94, 95% CI 0.79-1.22). After adjustment for income this risk was significantly lower for migrants than the Swedish-born population. CONCLUSIONS: Being a refugee was not an additional risk factor for suicide. Our findings regarding temporal changes in suicide risk suggest that acculturation and socioeconomic deprivation may account for a convergence of suicide risk between migrants and the host population over time. DECLARATION OF INTEREST: None.

Differences in psychiatric care utilisation among unaccompanied refugee minors, accompanied migrant minors, and Swedish-born minors.

PURPOSE: To better understand underutilisation of psychiatric care among migrant children, we compared utilisation of psychiatric care among unaccompanied refugee minors and accompanied migrant minors, with Swedish-born minors. METHODS: Using a large longitudinal database of linked national registers, we established a retrospective cohort of 1,328,397 people born 1984-1988 comparing minors born in Sweden to 2 Swedish-born parents (95.4%) to minors who had been arriving in Sweden between 2002 and 2011 with a permanent resident permit and were either unaccompanied refugee minors (0.4%), or accompanied migrant minors (4.0%). The outcome measures were different measures of psychiatric care including in- and outpatient care, and prescribed psychotropic medication. RESULT: Compared with the Swedish-born minors the unaccompanied refugee minors had a higher likelihood of utilisation of all psychiatric care except ADHD medication. However, compared with accompanied migrant minors, the Swedish-born minors had a higher likelihood of having utilised psychiatric care. CONCLUSION: Our study shows that during the first years of living in Sweden, there seems to be fewer barriers to psychiatric care for unaccompanied refugee minors compared to the accompanied migrant minors. There are a number of possible reasons for this including stronger ties with the Swedish society.

Substance use disorders in refugee and migrant groups in Sweden: A nationwide cohort study of 1.2 million people.

BACKGROUND: Refugees are at higher risk of some psychiatric disorders, including post-traumatic stress disorder (PTSD) and psychosis, compared with other non-refugee migrants and the majority population. However, it is unclear whether this also applies to substance use disorders, which we investigated in a national register cohort study in Sweden. We also investigated whether risk varied by region of origin, age at migration, time in Sweden, and diagnosis of PTSD. METHODS AND FINDINGS: Using linked Swedish register data, we followed a cohort born between 1984 and 1997 from their 14th birthday or arrival in Sweden, if later, until an International Classification of Diseases, 10th revision (ICD-10), diagnosis of substance use disorder (codes F10.X-19.X), emigration, death, or end of follow-up (31 December 2016). Refugee and non-refugee migrants were restricted to those from regions with at least 1,000 refugees in the Swedish registers. We used Cox proportional hazards regression to estimate unadjusted and adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) in refugee and non-refugee migrants, compared with Swedish-born individuals, for all substance use disorders (F10.X-19.X), alcohol use disorders (F10.X), cannabis use disorders (F12.X), and polydrug use disorders (F19.X). In adjusted analyses, we controlled for age, sex, birth year, family income, family employment status, population density, and PTSD diagnosis. Our sample of 1,241,901 participants included 17,783 (1.4%) refugee and 104,250 (8.4%) non-refugee migrants. Refugees' regions of origin were represented in proportions ranging from 6.0% (Eastern Europe and Russia) to 41.4% (Middle East and North Africa); proportions of non-refugee migrants' regions of origin ranged from 11.8% (sub-Saharan Africa) to 33.7% (Middle East and North Africa). These groups were more economically disadvantaged at cohort entry (p < 0.001) than the Swedish-born population. Refugee (aHR: 0.52; 95% CI 0.46-0.60) and non-refugee (aHR: 0.46; 95% CI 0.43-0.49) migrants had similarly lower rates of all substance use disorders compared with Swedish-born individuals (crude incidence: 290.2 cases per 100,000 person-years; 95% CI 287.3-293.1). Rates of substance use disorders in migrants converged to the Swedish-born rate over time, indicated by both earlier age at migration and longer time in Sweden. We observed similar patterns for alcohol and polydrug use disorders, separately, although differences in cannabis use were less marked; findings did not differ substantially by migrants' region of origin. Finally, while a PTSD diagnosis was over 5 times more common in refugees than the Swedish-born population, it was more strongly associated with increased rates of substance use disorders in the Swedish-born population (aHR: 7.36; 95% CI 6.79-7.96) than non-refugee migrants (HR: 4.88; 95% CI 3.71-6.41; likelihood ratio test [LRT]: p = 0.01). The main limitations of our study were possible non-differential or differential under-ascertainment (by migrant status) of those only seen via primary care and that our findings may not generalize to undocumented migrants, who were not part of this study. CONCLUSIONS: Our findings suggest that lower rates of substance use disorders in migrants and refugees may reflect prevalent behaviors with respect to substance use in migrants' countries of origin, although this effect appeared to diminish over time in Sweden, with rates converging towards the substantial burden of substance use morbidity we observed in the Swedish-born population.

Risk of schizophrenia, schizoaffective, and bipolar disorders by migrant status, region of origin, and age-at-migration: a national cohort study of 1.8 million people.

BACKGROUND: We assessed whether the risk of various psychotic disorders and non-psychotic bipolar disorder (including mania) varied by migrant status, a region of origin, or age-at-migration, hypothesizing that risk would only be elevated for psychotic disorders. METHODS: We established a prospective cohort of 1 796 257 Swedish residents born between 1982 and 1996, followed from their 15th birthday, or immigration to Sweden after age 15, until diagnosis, emigration, death, or end of 2011. Cox proportional hazards models were used to model hazard ratios by migration-related factors, adjusted for covariates. RESULTS: All psychotic disorders were elevated among migrants and their children compared with Swedish-born individuals, including schizophrenia and schizoaffective disorder (adjusted hazard ratio [aHR]migrants: 2.20, 95% CI 1.96-2.47; aHRchildren : 2.00, 95% CI 1.79-2.25), affective psychotic disorders (aHRmigrant1.42, 95% CI 1.25-1.63; aHRchildren: 1.22 95% CI 1.07-1.40), and other non-affective psychotic disorders (aHRmigrant: 1.97, 95% CI 1.81-2.14; aHRchildren: 1.68, 95% CI 1.54-1.83). For all psychotic disorders, risks were generally highest in migrants from Africa (i.e. aHRschizophrenia: 5.24, 95% CI 4.26-6.45) and elevated at most ages-of-migration. By contrast, risk of non-psychotic bipolar disorders was lower for migrants (aHR: 0.58, 95% CI 0.52-0.64) overall, and across all ages-of-migration except infancy (aHR: 1.20; 95% CI 1.01-1.42), while risk for their children was similar to the Swedish-born population (aHR: 1.00, 95% CI 0.93-1.08). CONCLUSIONS: Increased risk of psychiatric disorders associated with migration and minority status may be specific to psychotic disorders, with exact risk dependent on the region of origin.

Outpatient mental healthcare service use among women with migrant background in Norway: a national register study.

BACKGROUND: Studies show that migrant women are at greater risk of common mental disorders than the majority population, yet underrepresented in healthcare services. This study investigates the use of outpatient mental healthcare services over a five-year period among migrant and descendant women compared to majority women in Norway. METHODS: Using linked national registry data, we selected all women resident in Norway between 2009 and 2013 (N = 1,834,822). We conducted generalised estimated equations with logistic regression to assess if the odds of using outpatient mental healthcare services differed for migrant and descendant women compared to majority women. We also conducted generalised estimated equations with negative binomial regression to calculate consultation incidence rate ratios for migrant and descendant women relative to majority women among those with a common mental disorder. RESULTS: Both migrant and descendant women had lower odds (OR = 0.47 and OR = 0.60 respectively) of using outpatient mental healthcare services than majority women. Odds of using services increased with length of residency. We also found significant variation by country of origin. Among women with common mental disorders who had used services, migrants, but not descendants, had a lower consultation rate ratio than majority women. Analyses by region of origin revealed that this did not apply to women from EU European countries, North America and Australia and New Zealand. CONCLUSION: Women with migrant background are, overall, underrepresented in OPMH services. Findings indicate that migrant women may not only experience barriers to seeking and accessing care but also in maintaining access to care. This may especially be the case for newly arrived migrant women and women from non-Western countries. Treatment may not be culturally adapted for these groups. Closer investigation of the barriers migrant women experience after using OPMH services is required.

"I had no idea there were psychiatric clinics for children": A qualitative study of how migrant parents reach Swedish mental health services for their children.

Migrant children have repeatedly been shown to underutilize psychiatric services and to face barriers to care, yet few studies have examined the experience of migrant parents who are successful in their help-seeking efforts for their children's mental health. The aim of this study was to gain a deeper understanding of facilitators and obstacles to reaching care among migrant parents in contact with child psychiatric services. We explored how migrant parents in Stockholm, Sweden, experienced the process of reaching child mental health services. Participants were recruited from out-patient mental health clinics. Ten in-depth interviews were conducted; qualitative analysis of transcripts was undertaken using thematic content analysis. Parents described a desire to reach services but difficulties doing so on their own. We identified a strong dependence on referring agents, such as schools and child health centers, for parents to gain contact. Informants expressed a high degree of trust toward these agents. Contrary to previous studies, stigma was not described as an obstacle to help-seeking but was recognized by informants as a potential barrier to care had they not emigrated. Although participants in our study had differing educational backgrounds and residency times in Sweden, a common experience of reliance on others for reaching services was evident in the data. Our findings highlight the role of referring agents as bridging contacts between different welfare services. Understanding the specific local resources and services that are available to migrant parents, and strengthening these across different sectors, could potentially help reduce barriers to care.

Prenatal maternal PTSD as a risk factor for offspring ADHD: A register-based Swedish cohort study of 553 766 children and their mothers.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is highly heritable, though environmental factors also play a role. Prenatal maternal stress is suggested to be one such factor, including exposure to highly distressing events that could lead to post-traumatic stress disorder (PTSD). The aim of this study is to investigate whether prenatal maternal PTSD is associated with offspring ADHD. METHOD: A register-based retrospective cohort study linking 553 766 children born in Sweden during 2006-2010 with their biological parents. Exposure: Prenatal PTSD. Outcome: Offspring ADHD. Logistic regression determined odds ratios (ORs) with 95% confidence intervals (CIs) for ADHD in the offspring. Adjustments were made for potential covariates, including single parenthood and possible indicators of heredity measured as parental ADHD and maternal mental disorders other than PTSD. Subpopulations, excluding children with indicators of heredity, were investigated separately. RESULTS: In the crude results, including all children, prenatal PTSD was associated with offspring ADHD (OR: 1.79, 95% CI: 1.37-2.34). In children with indicators of heredity, the likelihood was partly explained by it. Among children without indicators of heredity, PTSD was associated with offspring ADHD (OR: 2.32, 95% CI: 1.30-4.14), adjusted for confounders. CONCLUSIONS: Prenatal maternal PTSD is associated with offspring ADHD regardless of indicators of heredity, such as parental ADHD or maternal mental disorder other than PTSD. The association is partly explained by heredity and socioeconomic factors. If replicated in other populations, preferably using a sibling design, maternal PTSD could be identified as a risk factor for ADHD.

Refugee status and the incidence of affective psychotic disorders and non-psychotic bipolar disorder: A register-based cohort study of 1.3m people in Sweden.

BACKGROUND: Refugees are at increased risk of non-affective psychotic disorders, but it is unclear whether this extends to affective psychotic disorders [APD] or non-psychotic bipolar disorder [NPB]. METHODS: We conducted a nationwide cohort study in Sweden of all refugees, non-refugee migrants and the Swedish-born population, born 1 Jan 1984-31 Dec 2016. We followed participants from age 14 years until first ICD-10 diagnosis of APD or NPB. We fitted Cox proportional hazards models to estimate hazard ratios [HR] and 95 % confidence intervals [95%CI], adjusted for age, sex and family income. Models were additionally stratified by region-of-origin. RESULTS: We followed 1.3 million people for 15.1 million person-years, including 2428 new APD cases (rate: 16.0 per 100,000 person-years; 95%CI: 15.4-16.7) and 9425 NPB cases (rate: 63.8; 95%CI: 62.6-65.1). Rates of APD were higher in refugee (HRadjusted: 2.07; 95%CI: 1.55-2.78) and non-refugee migrants (HRadjusted: 1.40; 95%CI: 1.16-1.68), but lower for NPBs for refugee (HRadjusted: 0.24; 95%CI: 0.16-0.38) and non-refugee migrants (HRadjusted: 0.34; 95%CI: 0.28-0.41), compared with the Swedish-born. APD rates were elevated for both migrant groups from Asia and sub-Saharan Africa, but not other regions. Migrant groups from all regions-of-origin experienced lower rates of NPB. LIMITATIONS: Income may have been on the causal pathway making adjustment inappropriate. CONCLUSIONS: Refugees experience elevated rates of APD compared with Swedish-born and non-refugee migrants, but lower rates of NPB. This specificity of excess risk warrants clinical and public health investment in appropriate psychosis care for these vulnerable populations.