Initiation of antidepressant use among refugee and Swedish-born youth after diagnosis of a common mental disorder: findings from the REMAIN study

Exploring "Language of Suffering": Idioms of Distress Among Eritrean Refugees Living in Israel

In this paper, we explore idioms of distress among Eritrean refugees currently living in Israel, a refugee population that has experienced profound forms of violence and upheaval in their country of origin, yet largely overlooked in clinical research. A significant portion of Eritrean refugees have, over the past decade, sought asylum in Israel, and Eritrean refugees make up Israel's largest refugee population. To explore their unique idioms of distress, data collection methods included 200 hours of participant observation. It also involved in-depth interviews with Eritrean refugees (n = 26) and key informant interviews (n = 9) with people of Eritrean descent, who were not only active in the Eritrean community but also engaged in service provision for community members. Findings uncovered four groups of idioms of distress for our Eritrean sample including mind-head-related idioms (Bzuh mhasab, Ab aemroy selam ysen, Bzuh hasabat nab resey ymetseni, Hamam Resi), distress-related idioms (Chincket, Tsekti, and Tsulul), trauma-related idioms (Sineaemrawi Smbrat), and supernatural-related idioms (Buda and Tabib). Our findings reveal that Eritrean refugees possess distinct idiomatic expressions rooted in broader cultural frameworks and systems of knowledge. These idioms reference a range of both pathological and non-pathological states, with meanings that may vary based on factors such as education, gender, duration of stay in the host country, and context of use. We argue that clinicians need to take the time to listen to refugees' "language of suffering" and its cultural and contextual complexities in order to better understand their patients' distress and provide more culturally appropriate and effective care.

Refugee Migration Background and Healthcare Contacts Prior to First-Episode Psychosis in Young Adults in Denmark and Sweden: Are Patterns Consistent Across Countries?

INTRODUCTION

The objective of this study was to examine group differences in healthcare contacts prior to a first diagnosis of non-affective psychotic disorders (NAPDs) comparing young refugees settled in Denmark and Sweden before turning 18 non-refugee migrants and native-born individuals.

METHODS

Using nationwide register data, we identified all individuals aged 18-35 who received an NAPD diagnosis during 2006-2018. Healthcare contacts for other psychiatric disorders were categorised as inpatient, outpatient (grouped by discharge diagnosis) or dispensed antidepressant medication. Logistic regression was used in each country to compare contacts within 12 months prior to NAPD diagnosis, yielding odds ratios (OR) and corresponding 95% confidence intervals (CI), while standardised prevalence ratios (SPR), reported in percentages, were used to compare healthcare contact across countries.

RESULTS

We included 11,679 individuals in Denmark and 11,088 in Sweden. The likelihood of prior contact of any type was lower in both countries for both refugees [Denmark: OR = 0.75(CI: 0.63, 0.90); Sweden: OR = 0.61(CI: 0.55, 0.68)] and non-refugee migrants [Denmark: OR = 0.78(CI: 0.64, 0.95); Sweden: OR = 0.55(CI: 0.49, 0.62)] compared with majority peers. The largest differences were observed for dispensed antidepressants in both countries [Denmark: ORrefugees = 0.58(CI: 0.47, 0.71); Sweden: ORrefugees = 0.52(CI: 0.45, 0.61)]. Outpatient contacts in particular were more common in Sweden than in Denmark across all groups [SIRrefugees = 151% (CI: 125, 180)].

CONCLUSION

Young refugees and non-refugee migrants in both Denmark and Sweden were less likely to have healthcare contact for other psychiatric disorders prior to NAPD onset than host populations. As healthcare contacts offer opportunities to identify treatment needs early, these groups may be vulnerable to delays in the pathway to treatment.

Specialized mental healthcare use for common mental disorders and prescription of antidepressants before and during the COVID-19 pandemic among working-age refugees and Swedish-born individuals - a nationwide register-based study

BACKGROUND

It is known that refugees have an elevated risk of common mental disorders (CMDs, including depression, anxiety, and stress-related disorders). The effect of the coronavirus disease pandemic on healthcare use due to CMDs in refugees is yet unknown, especially in socioeconomically deprived groups. We conducted a population-wide study comparing specialized healthcare use for CMDs and antidepressant prescriptions before and during the pandemic in refugees and Swedish-born, and investigated differences by labor market marginalization and education.

METHODS

An interrupted time series analysis of quarterly cohorts (2018.01.01-2021.12.31) of all refugees and Swedish-born, aged 19 to 65 was applied. Information on outcome measures and covariates were linked individually from administrative registers. We applied interrupted time series and estimated incidence rate ratios (IRR) of the incidence rates (IR) and their corresponding confidence intervals (CI) before and during the pandemic.

RESULTS

A total of 4,932,916 individuals, of whom 488,299 (9.9%) were refugees, were included at baseline. We observed a 3% (95% CI: 1%, 5%) quarterly increase in trends of healthcare use due to CMDs in refugees, but no changes in Swedish-born individuals. The IRRs were larger in refugees whose labor market position was marginalized (IRR: 6%, (3%, 9%)), and refugees with low education level (IRR: 4% (1%, 7%)). There were no substantial changes in antidepressant prescription.

CONCLUSION

Refugees, especially those already in a marginalized position, had increased CMD-related mental healthcare use during the pandemic. Strategies to meet the mental health care needs of marginalized refugees are of outmost public health importance.

Access to medicines among asylum seekers, refugees and undocumented migrants across the migratory cycle in Europe: a scoping review

INTRODUCTION

Access to essential medicines is a critical element of health systems and an important measure of their performance. Migrants may face barriers in accessing healthcare, including essential medicines, throughout the migration cycle, which includes the stages of departure from home or residence countries, transit through non-European or European countries, reception and settlement in a country in Europe and deportation. We aim to provide an overview of research and grey literature concerning access to essential medicines for asylum seekers, refugees and undocumented migrants in or heading to Europe (European Union, European Economic Area, Switzerland and the UK).

METHODS

To delineate and conceptualise access to medicines, we considered the definition of the Lancet Commission on Essential Medicines and the Pharmaceutical Management framework. These frameworks were combined to guide several critical steps in our review, including defining the search terms, data extraction, data analyses and reporting. Relevant studies and reports were identified through searches in bibliographic and grey literature databases.

RESULTS

Out of 5760 studies and 66 grey literature reports, 108 met the inclusion criteria, with 72 focusing on medicine access. Overall, medicine use and medicine expenditure were found to be lower in migrant populations compared with the host population in many European countries. Although many studies focused on the use of infectious disease and psychotropic medicines, the most frequently used medicines by migrants were analgesics, hypertension and diabetes medicines. Determinants of medicine access were legal restrictions, language and transit times, which all contributed to interruption of and inequities in access to medicines among this population. This scoping review also indicated significant gaps in the literature regarding the evidence on access to medicine at different stages of the migration cycle, specifically in departure, transit and deportation stages.

CONCLUSION

Overall, our findings highlighted significant unmet medicine needs among migrants in or on the way to Europe and access disparities attributable to various interconnected barriers. Urgent access is needed to address such inequities, particularly legal barriers, including registration of certain medicines required for treatment. Future research should prioritise investigating medicine access during departure, transit and deportation stages. Policy discussions around migrants' access to medicines should be centred on framing healthcare as a fundamental right.

Association of medication clusters and subsequent labor market marginalization in refugee and Swedish-born young adults with common mental disorders in Sweden

Little is known about the association between common mental disorders (CMD) and labor market integration among refugee and Swedish-born young adults. Socially disadvantaged patients such as refugees are more likely to discontinue their medication use prematurely. This study aimed to identify clusters of individuals with similar psychotropic medication patterns; and examine the relationship between cluster membership with labor market marginalization (LMM) in refugee and Swedish-born young adults with CMD. The study uses a longitudinal matched cohort aged 18-24 years with CMD diagnoses from Swedish registers covering 2006-2016. Dispensed psychotropic medications (antidepressants, antipsychotics, anxiolytics, sedative-hypnotics, mood stabilizers) were collected one year before and after CMD diagnosis. Clusters of patients with similar time courses of prescribed dosages were algorithmically identified. The association of cluster membership with subsequent LMM, (long-term sickness absence, SA, disability pension, DP, or long-term unemployment, UE) was assessed using Cox regression. Among 12,472 young adults with CMD, there were 13.9% with SA, 11.9% with DP, and 13.0% with UE during a mean follow-up of 4.1 years (SD 2.3 years). Six clusters of individuals were identified. A cluster with a sustained increase in all medication types yielded the highest hazard ratio (HR [95% CI]) 1.69 [1.34, 2.13] for SA and 2.63 [2.05, 3.38] for DP. The highest HRs of UE give a cluster with a concentrated peak in antidepressants at CMD diagnosis (HR 1.61[1.18, 2.18]). Refugees and Swedish-born showed similar associations between clusters and LMM. To prevent LMM, targeted support and early assessment of CMD treatment are needed for individuals with a sustained increase in psychotropic medication after CMD diagnosis and for refugees in high-risk clusters for UE characterized by a rapid lowering of treatment dosages, which could be an indicator for premature medication discontinuation.

The role of sociodemographic and clinical factors in the initiation and discontinuation of attention deficit hyperactivity disorder medication among young adults in Sweden

Introduction

Long-term medication use is a recommended treatment for attention-deficit/hyperactivity disorder (ADHD), however, discontinuation is common. Non-medical factors which might influence initiation and discontinuation are understudied. Therefore, we investigated how different sociodemographic factors and comorbidities were associated with the initiation and discontinuation of ADHD medication use among young adults.

Methods and results

We conducted a population-based prospective cohort study using individually linked administrative register data, in which we included all individuals residing in Sweden, between the age of 19 and 29 who were first diagnosed with ADHD between January 2006 and December 2016 (n = 59224). ADHD medication initiation was defined as the first prescription of ADHD medication in the period from 3 months before to 6 months after the cohort entry date. Those who initiated ADHD medication were followed up for medication use until discontinuation, death/emigration, or until 2019. Logistic and Cox regression models were used to investigate the associations between sociodemographics, health-related predictors and initiation, as well as discontinuation. Overall, 48.7% of the 41399 individuals initiated ADHD medication, most often methylphenidate (87%). Among the initiators, 15462 (77%) discontinued medication use during the follow-up (median time: 150 days). After mutually adjusting all other predictors, initiation was positively associated with older age, male sex, higher level of education, and negatively associated with living at home with parents, immigrant status, being unemployed during the year before inclusion, being on disability pension, having autism, substance use, schizophrenia-spectrum disorders, other mental disability/developmental disorders, cardiovascular diseases or previous accidents. Discontinuation was positively associated with being born abroad, living in big cities, being unemployed during the year before inclusion, having cancer, and negatively associated with a higher educational level, having depression, anxiety or stress-related disorder, autism spectrum disorder or diabetes.

Conclusion

Besides medical factors, sociodemographics, such as educational attainment and immigrant status might also play a role in the initiation and discontinuation of ADHD medication use among young adults newly diagnosed with ADHD.

Antidepressant use among immigrants with depressive disorder living in Finland: A register-based study

BACKGROUND

The aim of this study was to examine differences in the initiation and discontinuation of antidepressants between immigrants and the Finnish-born population diagnosed with depression in specialized health care.

METHODS

The study utilized register-based data, which includes all immigrants living in Finland at the end of 2010 and matched Finnish-born controls. For this study, we selected individuals who had received a diagnosis of depression during 2011-2014 (immigrants n = 2244, Finnish-born n = 2773). Their antidepressant use was studied for a one-year period from initiation. A logistic regression was used to predict initiation and a Cox regression was used to predict discontinuation.

RESULTS

Immigrants were more likely to initiate the use of antidepressants than the Finnish-born controls (adjusted OR = 1.25, 95% CI = 1.07-1.46), but they also discontinued the medication earlier than the Finnish-born controls (adjusted HR = 1.48, 95% CI = 1.31-1.68). Immigrants from Sub Saharan Africa, the Middle East and Northern Africa were most likely to discontinue antidepressants earlier. More severe depression, a longer length of residence in Finland and more intensive psychiatric treatment were associated with decreased risk of discontinuation.

LIMITATIONS

The registers do not provide information on the perceived reasons for the discontinuation.

CONCLUSIONS

Immigrants with depression initiate antidepressants more often than the Finnish-born population, but they also discontinue them earlier. Early discontinuation may be a sign of insufficient treatment suggesting that there could be a need for improvement in mental health care for immigrants in Finland.

Trajectories of antidepressant use and characteristics associated with trajectory groups among young refugees and their Swedish-born peers with diagnosed common mental disorders-findings from the REMAIN study

PURPOSE

This study aimed to (1) identify the trajectories of prescribed antidepressants in refugee youth and matched Swedish-born peers diagnosed with common mental disorder (CMD) and (2) characterize the trajectories according to sociodemographic and medical factors.

METHODS

The study population comprised 2,198 refugees and 12,199 Swedish-born individuals with both Swedish-born parents, aged 16-25 years in 2011, residing in Sweden and treated in specialised healthcare for CMD 2009-11. Group-based trajectory modelling was used to identify different trajectory groups of antidepressant use-based on annual defined daily dosages (DDDs). Multinomial logistic regression was applied to investigate the association of sociodemographic and medical characteristics with the identified trajectories. Nagelkerke pseudo-R² values were estimated to evaluate the strength of these associations.

RESULTS

Four trajectory groups of antidepressant use among young refugees were identified with following proportions and DDD levels in 2011: 'low constant' (88%, < 100), 'low increasing' (2%, ≈710), 'medium decreasing' (8%, ≈170) and 'high increasing' (2%, ≈860). Similar trajectories, however, with different proportions were identified in Swedish-born: 67%, 7%, 21% and 5%, respectively. The most influential factors discriminating the trajectory groups among refugees were 'duration of stay in Sweden' (R² = 0.013), comorbid 'other mental disorders' (R² = 0.009) and 'disability pension' (R² = 0.007), while 'disability pension' (R² = 0.017), comorbid 'other mental disorders' (R² = 0.008) and 'educational level' (R² = 0.008) were the most important determinants discriminating trajectory groups among Swedish-born youth.

CONCLUSION

The lower use of antidepressants in refugees with CMDs compared to their Swedish-born counterparts warrants health literacy programs for refugees and training in transcultural psychiatry for healthcare professionals.

The association between postpartum hemorrhage and postpartum depression: A Swedish national register-based study

Background

Postpartum hemorrhage is an important cause of maternal death and morbidity. However, it is unclear whether women who experience postpartum hemorrhage are at an increased risk of postpartum depression.

Objectives

To examine whether postpartum hemorrhage is associated with postpartum depression.

Methods

We conducted a national register-based cohort study of 486,476 Swedish-born women who had a singleton livebirth between 2007 and 2014. We excluded women with pre-existing depression or who filled a prescription for an antidepressant before childbirth. We classified postpartum depression up to 12 months after giving birth by the presence of an International Classification of Diseases, version 10 (ICD-10) diagnosis code for depression or a filled outpatient prescription for an antidepressant. We used Cox proportional hazard models, adjusting for maternal sociodemographic and obstetric factors.

Results

Postpartum depression was identified in 2.0% (630/31,663) of women with postpartum hemorrhage and 1.9% (8601/455,059) of women without postpartum hemorrhage. In our unadjusted analysis, postpartum hemorrhage was not associated with postpartum depression (unadjusted hazard ratio (HR) = 1.06, 95% confidence interval (CI) 0.97–1.15). After adjusting for maternal age, parity, education, cohabitation status, maternal smoking status, and early pregnancy maternal BMI, gestational age, and birthweight, the association did not appreciably change, with confidence intervals overlapping the null (adjusted HR = 1.08, 95% CI 0.99, 1.17).

Conclusions

Within a population-based cohort of singleton women in Sweden with no prior history of depression, postpartum hemorrhage was not associated with postpartum depression.

Disability pension and mortality in individuals with specific somatic and mental disorders: examining differences between refugees and Swedish-born individuals

BACKGROUND

More than half a million refugees have arrived to Sweden during the last decade. The aim was to investigate differences between refugees and Swedish-born individuals regarding different specific somatic and mental disorders, and subsequent disability pension and mortality.

METHODS

All refugees (n=239 742) and Swedish-born individuals (n=4 133 898), aged 19-60 years, resident in Sweden on 31st of December in 2009 were included in this population-based prospective cohort study. Data from six nationwide Swedish registers were linked by the unique anonymised identification number. HRs with 95% CIs were computed for disability pension and mortality 2010-2013 by Cox regression models.

RESULTS

Compared with their Swedish-born counterparts with mental or somatic diagnoses, refugees with these diagnoses had a higher risk of subsequent disability pension and a lower risk of mortality. Highest estimates for disability pension were seen for refugees with neoplasm (HR: 1.72; 95% CI: 1.56 to 1.91), musculoskeletal disorders (HR: 1.57; 95% CI: 1.47 to 1.67), diseases of the circulatory system (HR: 1.33; 95% CI: 1.22 to 1.45), depressive disorders (HR: 1.31; 95% CI: 1.21 to 1.41) and diabetes mellitus (HR: 1.30; 95% CI: 1.15 to 1.47). The risk of mortality was lowest for refugees with regard to bipolar disorders (HR: 0.37; 95% CI: 0.16 to 0.82), post-traumatic stress disorder (HR: 0.37; 95% CI: 0.25 to 0.54) and least pronounced in regard to neoplasm (HR: 0.69; 95% CI: 0.61 to 0.77) compared with Swedish-born with similar disorders.

CONCLUSION

Refugees have a generally higher risk of disability pension compared with Swedish-born with specific somatic and mental disorders. Despite this, refugees with all specific disorders have lower risk estimates of mortality, probably due to a healthy selection. The higher risk of disability pension might therefore be due to other causes besides poor health.

Trajectories of antidepressant use before and after a suicide attempt among refugees and Swedish-born individuals: a cohort study

Background

To identify key information regarding potential treatment differences in refugees and the host population, we aimed to investigate patterns (trajectories) of antidepressant use during 3 years before and after a suicide attempt in refugees, compared with Swedish-born. Association of the identified trajectory groups with individual characteristics were also investigated.

Methods

All 20–64-years-old refugees and Swedish-born individuals having specialised healthcare for suicide attempt during 2009–2015 (n = 62,442, 5.6% refugees) were followed 3 years before and after the index attempt. Trajectories of annual defined daily doses (DDDs) of antidepressants were analysed using group-based trajectory models. Associations between the identified trajectory groups and different covariates were estimated by chi²-tests and multinomial logistic regression.

Results

Among the four identified trajectory groups, antidepressant use was constantly low (≤15 DDDs) for 64.9% of refugees. 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 their association, discriminated with different covariates, were fairly similar among refugees and Swedish-born, with the exception of previous hypnotic and sedative drug use being more important in refugees.

Conclusions

Despite previous reports on refugees being undertreated regarding psychiatric healthcare, no major differences in antidepressant treatment between refugees and Swedish-born suicide attempters were found.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01460-z.