Inequalities in Psychiatric Service Use and Mortality by Migrant Status Following a First Diagnosis of Psychotic Disorder: A Swedish Cohort Study of 1.3M People

Abstract

It is unclear whether inequalities in mental healthcare and mortality following the onset of psychosis exist by migrant status and region-of-origin. We investigated whether (i) mortality (including by major causes of death); (ii) admission type (in- or out-patient), and; (iii) in-patient length of stay at first diagnosis for psychotic disorder presentation, and; (iv) time-to-readmission for psychotic disorder differed for refugees, non-refugee migrants and by region-of-origin. We established a cohort of 1,335,192 people born 1984-1997 and living in Sweden from 1st January 1998, followed from their 14 th birthday or arrival to Sweden, until death, emigration, or 31 December 2016.People with ICD-10 psychotic disorder (F20-33; N=9,399) were 6.7 (95%CI: 5.9-7.6) times more likely to die than the general population, but this did not vary by migrant status (p=0.15) or region-of-origin (p=0.31). This mortality gap was most pronounced for suicide (adjusted hazard ratio [aHR]: 12.2; 95% CI: 10.4-14.4), but persisted for deaths from other external (aHR: 5.1; 95%CI: 4.0-6.4) and natural causes (aHR: 2.3; 95%CI: 1.6-3.3). Non-refugee (adjusted odds ratio [aOR]: 1.4, 95%CI: 1.2-1.6) and refugee migrants (aOR: 1.4, 95%CI: 1.1-1.8) were more likely to receive inpatient care at first diagnosis. No differences in inpatient length of stay at first diagnosis were observed. Sub-Saharan African migrants with psychotic disorder were readmitted more quickly than their Swedish-born counterparts (adjusted sub-HR: 1.2; 95%CI: 1.1-1.4). Our findings highlight the need to understand the drivers of disparities in psychosis treatment and the mortality gap experienced by all people with disorder, irrespective of migrant status or region-of-origin.

Comparison of Hospitalization for Nonaffective Psychotic Disorders Among Refugee, Migrant, and Native-Born Adults in Sweden and Denmark

“…Our findings are consistent with those of previous studies that have observed an increased risk of hospitalization among nonrefugee migrants and refugees 14 , 15 and with Swedish studies showing that the risk is even greater among those who had more recently migrated and individuals who had migrated from Africa. 12 , 14 Importantly, we extended these findings by showing this was also true of second-generation migrants.…”

“…Our findings are consistent with those of previous studies that have observed an increased risk of hospitalization among nonrefugee migrants and refugees 14 , 15 and with Swedish studies showing that the risk is even greater among those who had more recently migrated and individuals who had migrated from Africa. 12 , 14 Importantly, we extended these findings by showing this was also true of second-generation migrants. Migrant status has been associated with delays in help seeking and a longer DUP, 31 , 32 potentially due to a lack of awareness or understanding of local service provision, language barriers, and stigma.…”

“…11 Given that refugees and nonrefugee migrants appear to underutilize specialist health care for several psychiatric disorders that are prevalent during the early stages of psychosis (eg, affective, anxiety, and substance use disorders), 12,13 we might expect an excess risk of hospitalization for first-episode NAPD among migrants. Consistent with this hypothesis, 2 studies 14,15 observed that refugee and first-generation, nonrefugee migrant groups were both more likely to be hospitalized during the first psychotic episode when compared with their native-born peers. Whether these disparities extend to subsequent admissions (when individuals are within the health care system) or length of stay (which might be prolonged due to clinical and/or sociodemographic factors) is less clear.…”

Differences in clinical presentation at first hospitalization and the impact on involuntary admissions among first-generation migrant groups with non-affective psychotic disorders

“…1 After psychosis onset, migrant groups tend to face greater difficulties accessing mental health care, as evidenced by more negative and coercive pathways to care, [3][4][5] lack of timely follow-up after first diagnosis, 6,7 and longer duration of untreated psychosis. 8,9 Once treatment is initiated, migrant groups are at a greater risk of rehospitalization and involuntary admission, 5,[10][11][12] nonadherence to antipsychotic medications 13,14 and disengagement from services, 12,15 which may have consequences for long-term outcomes, particularly for people who migrate in the context of adversity. 16 The reasons underlying these observed disparities in service use and clinical outcomes for migrant groups with psychotic disorders are likely complex and remain poorly understood.…”