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Mellin D, Mittendorfer-Rutz E, Montgomery CJD, Cullen AE, Taipale H. Initiation of antipsychotic medication among refugees, non-refugee migrants, second-generation migrants, and Swedish-born adults with incident non-affective psychotic disorders. Soc Psychiatry Psychiatr Epidemiol 2025:10.1007/s00127-025-02887-3. [PMID: 40180627 DOI: 10.1007/s00127-025-02887-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 03/21/2025] [Indexed: 04/05/2025]
Abstract
BACKGROUND It is not known if there are differences in antipsychotic initiation between migrants and native-born individuals diagnosed with non-affective psychotic disorder. This study aimed to determine (1) potential differences in initiation rate and type of first antipsychotic medication between refugees, non-refugee migrants, second-generation migrants, and Swedish-born young adults with incident non-affective psychosis and (2) which sociodemographic and clinical factors are associated with initiation. METHODS This register-based cohort included 12,960 adults aged 18-35 years, residing in Sweden during 2007-2018, with an incident diagnosis of a non-affective psychotic disorder in inpatient or specialised outpatient care. Sociodemographic and clinical factors associated with antipsychotic initiation were determined using modified Poisson regression models yielding Relative Risk, RRs, and 95% Confidence Intervals, CI. RESULTS Initiation of antipsychotic use was slightly less common among refugees (65.6%) compared to non-refugee migrants (70.2%), second-generation migrants (71.0%), and Swedish-born individuals (71.1%). However, after adjustment for sociodemographic and clinical factors, there was no difference in initiation rates between refugees and Swedish-born individuals (adjusted RR 0.96; 95% CI 0.92-1.00). Olanzapine was most common initial antipsychotic in all groups. However, compared to the Swedish-born, refugees (1.47; 1.10-1.97), non-refugee migrants (1.70; 1.26-2.27) and second-generation migrants (1.43; 1.05-1.97) were more likely to initiate the use with long-acting injectable antipsychotics, and also with first-generation antipsychotics, particularly haloperidol. Sociodemographic factors associated with initiation were similar among refugees and Swedish-born individuals, including younger age, higher education and inpatient care. CONCLUSION Our finding that migrants were more likely to initiate long-acting antipsychotics suggests that clinical teams anticipate medication non-adherence among migrants.
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Affiliation(s)
- Daniela Mellin
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ellenor Mittendorfer-Rutz
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Christopher J de Montgomery
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health, Danish Research Centre for Migration, Ethnicity and Health (MESU), University of Copenhagen, Copenhagen, Denmark
| | - Alexis E Cullen
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Heidi Taipale
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden.
- Niuvanniemi Hospital, Kuopio, Finland.
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
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Lehti V, Salama E, Niemelä S, Tanskanen A, Gissler M, Suvisaari J, Taipale H. Use of benzodiazepine and related drugs in migrants and Finnish-born persons: a nationwide register-based study. Scand J Public Health 2023; 51:1222-1230. [PMID: 35876428 PMCID: PMC10642218 DOI: 10.1177/14034948221112470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 05/20/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022]
Abstract
AIMS Benzodiazepines and related drugs (BZDR) are often used longer than generally recommended. The aim is to study patterns of use among migrant and Finnish-born users of BZDR, and to identify factors that are associated with long-term use and BZDR polytherapy. METHODS This register-based study includes a nationwide sample of migrants (n=8729) and their Finnish-born controls (n=11 388) who had purchased BZDR in 2011-2014, but not in 2009-2010. Information on drug purchases was obtained from the National Prescription Register and the duration of drug use was estimated using PRE2DUP method. The main outcomes were long-term use of BZDR, polytherapy and time until discontinuation of BZDR use. Sociodemographic variables and information on preceding psychiatric diagnoses were included as covariates. Logistic and Cox regression analyses were the statistical methods used. RESULTS Only migrants from Sub-Saharan Africa were more likely to discontinue the medication once initiated than Finnish-born users. Migrants were significantly less likely to be long-term users (adjusted odds ratio 0.79, 95% CI 0.70-0.89) or polytherapy users (aOR 0.90, 95% CI 0.84-0.97) of BZDR compared with Finnish-born participants. CONCLUSIONS Migrants had less long-term and concomitant use of several BZDR than Finnish-born participants. The pattern of use is more optimal among migrants, but it may also reflect poorer access to mental health treatment.
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Affiliation(s)
- Venla Lehti
- Finnish Institute for Health and Welfare, Equality Unit, Finland
- University of Helsinki and Helsinki University Hospital; Department of Psychiatry, Finland
| | - Essi Salama
- Doctoral Programme for Clinical Investigation, Faculty of Medicine, University of Turku, Finland
- Department of Child Psychiatry, Turku University Hospital, Finland
| | - Solja Niemelä
- Department of Psychiatry, University of Turku, Finland
- Department of Psychiatry, Addiction Psychiatry Unit, Turku University Hospital, Finland
| | - Antti Tanskanen
- University of Eastern Finland, Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
- Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden
- Finnish Institute for Health and Welfare, Impact Assessment Unit, Finland
| | - Mika Gissler
- Karolinska Institutet, Department of Molecular Medicine and Surgery and Region Stockholm, Academic Primary Health Care Centre, Sweden
- Finnish Institute for Health and Welfare, Department of Knowledge Brokers, Helsinki, Finland
- University of Turku, Research Centre for Child Psychiatry, Finland
| | - Jaana Suvisaari
- Finnish Institute for Health and Welfare, Equality Unit, Finland
| | - Heidi Taipale
- Finnish Institute for Health and Welfare, Equality Unit, Finland
- University of Eastern Finland, Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
- Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden
- University of Eastern Finland, School of Pharmacy, Kuopio, Finland
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Lehti V, Taipale H, Gissler M, Tanskanen A, Elonheimo M, Tiihonen J, Suvisaari J. Continuity of antipsychotic medication use among migrant and Finnish-born populations with a psychotic disorder: a register-based study. Psychol Med 2023; 53:833-843. [PMID: 34074352 DOI: 10.1017/s003329172100218x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Higher incidence of psychotic disorders and underuse of mental health services have been reported among many migrant populations. This study examines the initiation and continuity of antipsychotic treatment among migrants and non-migrants with a non-affective psychosis during a new treatment episode. METHODS This study is based on a nationwide sample of migrants and Finnish-born controls. Participants who were diagnosed with a psychotic disorder in 2011-2014 were identified from the Care Register for Health Care (n = 1693). Information on purchases of antipsychotic drugs in 2011-2015 was collected from the National Prescription Register. The duration of antipsychotic treatment since diagnosis was estimated using the PRE2DUP model. Cox regression analysis was used to study factors that are associated with discontinuing the use of medication. RESULTS There were fewer initiators of antipsychotic treatment after being diagnosed with psychosis among migrants (68.1%) than among Finnish-born patients (73.6%). After controlling for sociodemographic background and factors related to the type of disorder and treatment, migrants were more likely to discontinue medication (adjusted hazard ratio 1.28, 95% confidence interval 1.08-1.52). The risk of discontinuation was highest among migrants from North Africa and the Middle East and Sub-Saharan Africa and among recent migrants. Non-use of antipsychotic treatment before being diagnosed with psychosis, involuntary hospitalization and diagnosis other than schizophrenia were associated with earlier discontinuation both among migrants and non-migrants. CONCLUSIONS Migrants with a psychotic disorder are less likely to continue antipsychotic treatment than non-migrants. The needs of migrant patients have to be addressed to improve adherence.
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Affiliation(s)
- Venla Lehti
- Equality Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Heidi Taipale
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Mika Gissler
- Research Centre for Child Psychiatry, University of Turku, Turku, Finland
- Information Services Department, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Antti Tanskanen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Impact Assessment Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Martta Elonheimo
- Equality Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Specialized Psychiatric Services, Helsinki, Finland
- Doctoral Programme in Clinical Research, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Jaana Suvisaari
- Equality Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
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Honkaniemi H, Juárez SP, Rostila M. Mental health by native–immigrant intermarriage in Sweden: a register-based retrospective cohort study. Eur J Public Health 2022; 32:877-883. [DOI: 10.1093/eurpub/ckac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
Native–immigrant intermarriage is often regarded as a proxy for integration, given that intermarried immigrants are more socioeconomically and culturally similar to natives than intramarried immigrants. This study aimed to assess whether integration affects mental health and care-seeking behaviours, examining prescription hazards for psychotropic medications by native–immigrant marital composition in Sweden.
Methods
Total population register data were used to identify first-time married couples residing in Sweden between 31 December 2005 and 31 December 2016. Index persons were distinguished by gender and partners’ origin (native vs. immigrant), as well as by immigrants’ regions of origin, with intramarried natives as references. Using Cox regression, hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated for antidepressant and anxiolytic prescriptions and adjusted for socioeconomic factors, presence of children and length and quality of marriage.
Results
Intramarried immigrant women had higher psychotropic prescription hazards than intramarried native references (HR 1.11, 95% CI 1.10–1.12), whereas intermarried immigrant women had equal hazards. Immigrant women’s hazards were lower than native references after adjustment. Intramarried immigrant men had the greatest prescription hazards (HR 1.33, 95% CI 1.32–1.34), and intermarried immigrant men slightly higher hazards (HR 1.11, 95% CI 1.10–1.13), than intramarried natives. All were partly attenuated after adjustment. Intermarriage hazards increased by similarities in regions of origin, especially among men.
Conclusions
Integration indicated by intermarriage appears to be protective for the mental health of immigrants, especially for immigrant men. Future research should empirically disentangle the social, cultural and socioeconomic mechanisms underlying these health differences.
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Affiliation(s)
- Helena Honkaniemi
- Department of Public Health Sciences, Stockholm University , Stockholm, Sweden
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet , Stockholm, Sweden
| | - Sol Pía Juárez
- Department of Public Health Sciences, Stockholm University , Stockholm, Sweden
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet , Stockholm, Sweden
| | - Mikael Rostila
- Department of Public Health Sciences, Stockholm University , Stockholm, Sweden
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet , Stockholm, Sweden
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Lehti V, Suvisaari J, Gissler M, Markkula N. Purchases of psychotropic drugs among the migrant population in Finland: a nationwide register-based cohort study. Eur J Public Health 2020; 30:1152-1157. [DOI: 10.1093/eurpub/ckaa117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Migrant populations may have different mental health service needs when compared with native populations. One indicator of service use is the use of psychotropic medication. The aim of this study was to compare the purchases of psychotropic drugs among different migrant populations with the native population in Finland.
Methods
Foreign-born participants (n = 184 805) and their Finnish-born controls (n = 185 183) were identified from the Finnish Central Population Register. Information on their purchases of psychotropic drugs in 2011–15 was collected from the National Prescription Register. A washout period of 2009–10 was used to define incident purchases. Cox regression analysis was the statistical method used.
Results
At least one incident purchase of a psychotropic drug was identified for 11.1% of migrant women, 11.4% of Finnish-born women, 8.7% of migrant men and 9.8% of Finnish-born men. When controlled for age, sex, marital status, socioeconomic status and social assistance, migrants were less likely to purchase psychotropic drugs (adjusted hazard ratio 0.96, 95% confidence interval 0.93–0.98), but there was variation between different drug categories. Recent migrants and migrants from Asia and Sub-Saharan Africa were least likely to purchase drugs. Migrants from Nordic countries and other Western countries most closely resembled the Finnish-born controls.
Conclusions
Recent migrants in Finland appear to use fewer psychotropic drugs than native Finns. It is important to analyze the reasons for this pattern, as they may indicate delays in access to care or benefits. The heterogeneity of migrant populations must also be considered when developing services to better address their needs.
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Affiliation(s)
- Venla Lehti
- Mental Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Centre for Child Psychiatry, University of Turku, Turku, Finland
| | - Jaana Suvisaari
- Mental Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Mika Gissler
- Research Centre for Child Psychiatry, University of Turku, Turku, Finland
- Information Services Department, Finnish Institute for Health and Welfare, Helsinki, Finland
- Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Niina Markkula
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
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Termorshuizen F, Heerdink ER, Selten JP. The impact of ethnic density on dispensing of antipsychotic and antidepressant medication among immigrants in the Netherlands. Soc Sci Med 2018; 211:87-94. [PMID: 29913304 DOI: 10.1016/j.socscimed.2018.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/02/2018] [Accepted: 06/09/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE A higher own-group ethnic density in the area of residence is often associated with a lower risk for psychotic disorder. For common mental disorders the evidence is less convincing. This study explores whether these findings are mirrored in data on dispensing of antipsychotics and antidepressants. METHODS Health insurance data on dispensed medication among all adults living in the four largest Dutch cities were linked to demographic data from Statistics Netherlands. Dispensing of antipsychotics and antidepressants in 2013 was analyzed in relation to the proportion of the own ethnic group in the neighborhood. RESULTS Higher own-group ethnic density was associated with lower dispensing of antipsychotics among the Moroccan-Dutch (N = 115,455), after adjusting for age, gender, and SES of the neighborhood (ORadj for the highest vs. the lowest density quintile = 0.72 [0.66-0.79]). However, this association vanished after adjustment for household composition (ORadj = 0.93 [0.85-1.03]). Similar results were found for the Turkish-Dutch (N = 105,460) (ORadj = 0.86 [0.76-0.96] and 1.05 [0.94-1.18]). For those of Surinamese (N = 147,123) and Antillean origin (N = 41,430), in contrast, the association between ethnic density and lower risk remained after each adjustment (P < 0.001). For antidepressants, a negative association with own-group ethnic density was consistently found for those of Antillean origin (ORadj = 0.62 [0.52-0.74]) only. CONCLUSION These data on dispensing of psychomedication confirm the ethnic density hypothesis for psychosis alongside earlier equivocal findings for other mental disorders. The negative association between own-group ethnic density and dispensing of antipsychotics among the Moroccan- and Turkish-Dutch may be explained, at least in part, by a favourable household composition (i.e., living in a family) in high-density neighborhoods.
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Affiliation(s)
- Fabian Termorshuizen
- Rivierduinen, Institute for Mental Health Care, Sandifortdreef 19, 2333 ZZ, Leiden, the Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, P.O. Box 80082, 3508 TB, Utrecht, the Netherlands.
| | - Eibert R Heerdink
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, P.O. Box 80082, 3508 TB, Utrecht, the Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Jean-Paul Selten
- Rivierduinen, Institute for Mental Health Care, Sandifortdreef 19, 2333 ZZ, Leiden, the Netherlands; Department of Psychiatry and Psychology, School for Mental Health and Neuroscience MHeNS, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands
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Abstract
PURPOSE OF REVIEW Arguably, the strongest evidence of an environmental contribution to the cause of psychosis is the increased risk for certain groups of migrants and ethnic minorities. This article summarizes findings published since 2016. RECENT FINDINGS Two studies suggested that migration or minority status are proxies for exposure to an inferior social status. A study from Bologna, Italy, showed that the psychosis risk for internal migrants from Southern Italy was as much increased as that for international migrants. A report from New Zealand reported a higher risk for Maoris than for the remainder of the population.Furthermore, a Danish investigation showed that own-group ethnic density of the neighbourhood at age 15 strongly modified the psychosis risk at adult age. This rules out differential mobility during the prodromal phase as an explanation for the ethnic density effect. Preliminary evidence suggests that the psychotogenic effect of migration may be mediated by elevated dopamine in the striatum. SUMMARY An increasing body of evidence suggests that the higher psychosis risk for certain migrant or ethnic minority groups is due to an inferior social status. Neuroimaging of the dopamine system appears to be a promising avenue for research into pathogenesis.
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