Psychiatric healthcare utilisation among refugee adolescents and their peers in Denmark

Incidence of non-affective psychotic disorders in refugees and peers growing up in Denmark and Sweden: a registry linkage study

PURPOSE

Higher rates of non-affective psychotic disorders (NAPD) in minority groups have been reported in many countries. However, few studies have explored how rates differ between refugees and other minority groups and none with an international comparative angle. A comparative perspective makes it possible to relate group differences to aspects national context that underpin the social determinants of disease.

METHODS

We compared the incidence of treated NAPD among youth born in or who immigrated to Denmark/Sweden before turning 18. Youth aged 18-35 during 2006-2018 were included (NDenmark/NSweden = 1,606,423/2,614,721) and were followed until first NAPD treatment (cases [Denmark/Sweden] = 12,193/9,641), 36th birthday, emigration or death. Incidence rates (IR) and ratios (IRR) comparing refugees, non-refugee migrants, descendants of non-refugee migrants and majority youth were obtained through Poisson regression on data aggregated by country, sex and age, contrasted by sex and country. Complementary analyses on individual-level data adjusting for further socio-demographic factors were conducted in each country separately.

RESULTS

Incidence rates were higher in all groups compared with the majority group (IRRrange = 1.4-2.9, 95% CI[min, max] = 1.2-3.1). Relative differences between the three minority groups were smaller (IRRrange = 0.7-1.0, 95% CI[min, max] = 0.5-1.2). Although incidence rates were higher in Denmark than Sweden, relative group differences were similar.

CONCLUSION

Exposures shared between young refugees and other minority groups growing up in Denmark and Sweden may be especially important for their excess risk of NAPD. Further studies should investigate the mechanisms behind the elevated rates in minority groups with special paid attention to factors such as discrimination, social exclusion and acculturation stress.

"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.

Uses of Andersen health services utilization framework to determine healthcare utilization for mental health among migrants-a scoping review

Background

Migration is a worldwide occurrence that carries significant implications for healthcare systems, and it entails challenges to mental healthcare. The Andersen Behavioral Model is widely used by researchers to determine healthcare service utilization among many populations, including migrants. Our study aimed to explore the ways of using the Andersen Health System Utilization Framework in the literature to discover the utilization of mental healthcare by migrants.

Methods

This scoping review was based on Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases.

Results

A total of 12 articles from January 1992 to July 2023 identified various versions of the Andersen Behavioral Model to provide an overview of mental health services utilization among migrants. The analysis identified four significant trends in the literature. First, there is a predominant focus on individual characteristics over contextual factors. Second, researchers tend to integrate multiple versions of the Andersen Behavioral Model, and the most is the version from 1995. Third, additional factors specific to migrant populations are incorporated into the model, but the categorization is sometimes unclear. Finally, the majority of studies have used a quantitative approach and are based in North America, suggesting a focus on the significance of mental health in migrant communities in that context.

Conclusion

In summary, our scoping review calls for further research using the Andersen Behavioral Model to study mental healthcare utilization among migrants. Notable findings include the adaptation of the model to migrant populations, a focus on individual characteristics, a need for more diverse research methods, and the proposal of a new conceptual model to guide research and policy development in this field.

Infants born to first-time mothers with a refugee background faced an increased risk of regulatory problems

AIM

This study investigated the association between mothers' migration background and infant regulatory problems and analysed the mediating role of maternal mental health. We also explored whether the child's sex, parity and length of residence moderated the effect of a maternal migrant background.

METHODS

Child health surveillance data from the Danish home visiting programme were used. Community health nurses followed infants from birth to 12 months of age. The source population comprised 103 813 infants born between 1 January 2008 and 31 December 2018. The final sample comprised 62 964 infants, including 3.4% with a refugee background. A maternal migrant background was the primary exposure. The results are presented as risk ratios (RR) and 95% confidence intervals (CI).

RESULTS

A maternal refugee background increased the risk of regulatory problems in offspring (RR 1.34, 95% CI: 1.18-1.51). The effect was partially mediated by maternal postpartum mental health concerns. The association between maternal refugee background and infant regulatory problems was more pronounced in first-time mothers (RR 1.80, 95% CI: 1.51-2.15).

CONCLUSION

The risk of infant regulatory problems was higher in the first-born children of refugee mothers. First-time refugee parents may need tailored support to identify mental health needs and infants with regulatory problems.

Psychiatric Diagnoses Among HIV-Exposed and HIV-Unexposed Uninfected Children: A Danish Nationwide Cohort Study

This nationwide registry-based cohort study aimed to compare the risk of psychiatric diagnoses among HIV-exposed uninfected (HEU) children with a matched comparison group of HIV-unexposed uninfected (HUU) children, born in Denmark. We hypothesized that HEU children had an increased risk of psychiatric diagnoses and that this increased risk may differ by sex and age. All HEU children born in Denmark between year 2000 and 2020 were included. Each HEU child was matched by year of birth, maternal age at birth, and maternal immigration status to 10 HUU children. The primary outcome was risk of any psychiatric diagnosis (International Classification of Diseases, 10th Revision F00-F99). Incidence rate ratios (IRRs) were estimated using Poisson regression. Analyses stratifying by sex and age were also conducted. In total, 550 HEU children and 5500 HUU children were included. HEU children had an increased risk of any psychiatric disorder [IRR 1.45; 95% confidence interval (CI): 1.04-2.04] in the unadjusted analysis, but in the adjusted analysis, the risk was only significant for children aged 6-11 years [adjusted incidence rate ratio (aIRR) 1.93; 95% CI: 1.14-3.28]. Stratifying by sex, girls aged 6-11 years had an increased risk of any psychiatric disorder (aIRR 3.04; 95% CI: 1.27-7.28), while boys had an increased risk at age 12-20 years (aIRR 2.47; 95% CI: 1.18-5.17). In conclusion, HEU girls aged 6-11 years and HEU boys aged 12-20 years had an increased risk of any psychiatric disorder compared with HUU girls and boys, respectively. These findings highlight the importance of addressing the mental health needs of HEU children/adolescents.

Neighbourhood socioeconomic disadvantage and psychiatric disorders among refugees: a population-based, quasi-experimental study in Denmark

PURPOSE

Refugees are vulnerable to psychiatric disorders because of risk factors linked to migration. Limited evidence exist on the impact of the neighbourhood in which refugee resettle. We examined whether resettling in a socioeconomically disadvantaged neighbourhood increased refugees' risk of psychiatric disorders.

METHODS

This register-based cohort study included 42,067 adults aged 18 years and older who came to Denmark as refugees during 1986-1998. Resettlement policies in those years assigned refugees in a quasi-random fashion to neighbourhoods across the country. A neighbourhood disadvantage index was constructed using neighbourhood-level data on income, education, unemployment, and welfare receipt. Main outcomes were psychiatric diagnoses and psychiatric medication usage ascertained from nationwide patient and prescription drug registers, with up to 30-year follow-up. Associations of neighbourhood disadvantage with post-migration risk of psychiatric disorders were examined using Cox proportional hazards and linear probability models adjusted for individual, family, and municipality characteristics.

RESULTS

The cumulative risk of psychiatric diagnoses and medication was 13.7% and 46.1%, respectively. Refugees' risk of psychiatric diagnoses and psychiatric medication usage was higher among individuals assigned to high-disadvantage compared with low-disadvantage neighbourhoods in analyses including fixed effects for assigned municipality (psychiatric diagnoses: hazard ratio (HR) = 1.14, 95% CI 1.04, 1.25; psychiatric medication: HR = 1.05, 95% CI 1.00, 1.11). Consistent results were found using linear probability models. Results for diagnostic categories and subclasses of medications suggested that the associations were driven by neurotic and stress-related disorders and use of anxiolytic medications.

CONCLUSION

Resettlement in highly disadvantaged neighbourhoods was associated with an increase in refugees' risk of psychiatric disorders, suggesting that targeted placement of newly arrived refugees could benefit refugee mental health. The results contribute quasi-experimental evidence to support links between neighbourhood characteristics and health.

Risk of Psychiatric Disorders Among Refugee Children and Adolescents Living in Disadvantaged Neighborhoods

Importance

Refugee children and adolescents are at increased risk of mental health difficulties, but little is known about how the characteristics of the neighborhood in which they resettle may affect vulnerability and resilience.

Objective

To test whether neighborhood socioeconomic disadvantage is associated with risk of psychiatric disorders among refugee children and adolescents and examine whether the association differs by sex, age at arrival, and family structure.

Design, Setting, and Participants

This quasi-experimental register-based cohort study included refugees in Denmark aged 0 to 16 years at the time of resettlement from 1986 to 1998. A refugee dispersal policy implemented during those years assigned housing to refugee families in neighborhoods with varying degrees of socioeconomic disadvantage in a quasi-random (ie, arbitrary) manner conditional on refugee characteristics observed by placement officers. Cox proportional hazard models were used to examine the association between neighborhood disadvantage and risk of psychiatric disorders, adjusting for relevant baseline covariates.

Exposures

A neighborhood disadvantage index combining information on levels of income, education, unemployment, and welfare assistance in the refugees' initial quasi-randomly assigned neighborhood.

Main Outcomes and Measures

First-time inpatient or outpatient diagnosis of a psychiatric disorder before age 30 years.

Results

Median (IQR) baseline age in the sample of 18 709 refugee children and adolescents was 7.9 (4.7-11.7) years; 8781 participants (46.9%) were female and 9928 (53.1%) were male. During a median (IQR) follow-up period of 16.1 (10.2-20.8) years, 1448 refugees (7.7%) were diagnosed with a psychiatric disorder (incidence rate, 51.2 per 10 000 person-years). An increase of 1 SD in neighborhood disadvantage was associated with an 11% increase in the hazard of a psychiatric disorders (hazard ratio [HR], 1.11; 95% CI, 1.03-1.21). This association did not differ between male and female individuals, refugees who arrived at different ages, or those from single- vs dual-parent households. In secondary analyses using prescribed psychiatric medication as the outcome, a similar association with neighborhood disadvantage was found (HR, 1.08; 95% CI, 1.03-1.14).

Conclusions and Relevance

In this cohort study, neighborhood disadvantage was associated with an increase in risk of psychiatric disorders. The results suggest that placement of refugee families in advantaged neighborhoods and efforts to enhance the neighborhood context in disadvantaged areas may improve mental health among refugee children and adolescents.

Trends and Impact Factors of Mental Health Service Utilization among Resettled Humanitarian Migrants in Australia: Findings from the BNLA Cohort Study

Resettled humanitarian migrants (HMs) have high levels of mental disorders, but factors associated with the utilization of mental health services (MHS) are poorly understood. We aimed to explore trends and impact factors of MHS utilization among HMs in the process of resettlement in Australia. A total of 2311 HMs from the 1st (2013), 3rd, and 5th (2018) waves of a national cohort study were included. MHS utilization in the past year was assessed by two indicators: having MHS contacts and the frequency of MHS contacts. Trends were identified by Cochran-Armitage tests, and generalized linear mixed models and ordered logistic models were fitted to explore impact factors of MHS utilization. The proportion of having MHS contacts significantly rose from 13.0% to 29.4% over the five years. MHS utilization was mainly driven by perceived needs, such as post-traumatic stress disorders and the degree of post-migration stress. Unemployment and strong belongingness to the local community were also associated with having MHS contacts. No significant gender difference was found in having MHS contacts but females tended to contact MHS more frequently. Resettled HMs have a persistent dilemma of high mental illness prevalence and MHS underutilization. Sustainable mental health education and long-term resettlement services targeted at social integration that consider gender difference are urgently needed in host countries.

Are all children treated equally? Psychiatric care and treatment receipt among migrant, descendant and majority Swedish children: a register-based study

AIMS

Underutilisation of mental health services among migrant youth has been demonstrated repeatedly, but little is known about potential discrepancies in terms of treatment receipt for those who do reach services. This study examines the type and level of care received among migrant children and descendants of migrants, particularly investigating disparities in treatment receipt given a specific diagnosis.

METHODS

We used register data of the total population aged 6-17 years in Stockholm, followed from 2006 to 2015, comprising 444 196 individuals, categorised as refugees, non-refugee migrants, descendants of migrants and Swedish-born. To identify recommended treatments for specific diagnoses we used official clinical guidelines. We report logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) of diagnosis receipt, treatment provision and level of care where a diagnosis was first registered.

RESULTS

Migrant children had a lower likelihood of receiving a wide range of psychiatric diagnoses, including mood disorder (OR 0.58; 95% CI 0.52-0.64), anxiety disorder (OR 0.62; 95% CI 0.57-69) and neurodevelopmental disorder (OR 0.59; 95% CI 0.55-0.63). Moreover, when these diagnoses were set, migrant children had a lower likelihood of receiving the recommended treatments for these conditions compared to the majority individuals with the same diagnosis (OR of receiving psychotherapy for anxiety disorder and depression: 0.71; 95% CI 0.62-0.95 and 0.50; 95% CI 0.33-0.75, respectively; OR for receiving ADHD-medication: 0.49; 95% CI 0.43-0.54).

CONCLUSIONS

Migrant children risk underdiagnosis of various mental health conditions, and, when reaching mental health services, risk not receiving the optimal care available.

Parental Posttraumatic Stress and School Performance in Refugee Children

Refugee children in the Nordic countries have been reported to perform poorly in school and carry a high burden of familial posttraumatic stress. The present study aimed to investigate the impact of maternal and paternal posttraumatic stress on the school performance of refugee children. We used national register data on school grades at age 15-16 along with demographic and migration indicators during 2011-2017 in a population of 18,831 children in refugee families in Stockholm County, Sweden. Parental posttraumatic stress was identified in regional data from three levels of care, including a tertiary treatment center for victims of torture and war. Multivariable linear and logistic regression models were fitted to analyze (a) mean grade point averages as Z scores and (b) eligibility for upper secondary school. In fully adjusted models, children exposed to paternal posttraumatic stress had a lower mean grade point average, SD = -0.14, 95% CI [-0.22, -0.07], and higher odds of not being eligible for upper secondary education, OR = 1.37, 95% CI [1.14, 1.65]. Maternal posttraumatic stress had a similar crude effect on school performance, SD = -0.15, 95% CI [-0.22, -0.07], OR = 1.25, 95% CI [1.00, 1.55], which was attenuated after adjusting for single-parent households and the use of child psychiatric services. The effects were similar for boys and girls as well as for different levels of care. Parental posttraumatic stress had a small negative effect on school performance in refugee children, adding to the intergenerational consequences of psychological trauma.

Parental post-traumatic stress and psychiatric care utilisation among refugee adolescents

Parental psychiatric morbidity related to experiences of war and trauma has been associated with adverse psychological outcomes for children. The aim of this study was to investigate parental post-traumatic stress in relation to psychiatric care utilization among children of refugees with particular attention on the child's own refugee status, sex of both child and parents, and specific psychiatric diagnoses. This was a register study in a population of 16 143 adolescents from refugee families in Stockholm County born 1995-2000 and followed between 2011 and 2017 (11-18 years old). Parental post-traumatic stress, identified in three levels of care, was analysed in relation to child and adolescent psychiatric care use. Cox regression analysis was used to estimate hazard ratios (HR) and 95% confidence intervals (CI), adjusted for duration of residence and demographic and socioeconomic variables. Having a mother with post-traumatic stress was associated with higher psychiatric care utilization, with adjusted HR 2.44 (95% CI 1.90-3.14) among foreign-born refugee children and HR 1.77 (1.33-2.36) among Swedish-born children with refugee parents, with particularly high risks for children with less than five years of residence (HR 4.03; 2.29-7.10) and for diagnoses of anxiety and depression (HR 2.71; 2.11-3.48). Having a father with post-traumatic stress was not associated with increased HRs of psychiatric care utilization. Similar results were seen for boys and girls. Treatment for post-traumatic stress should be made available in refugee reception programmes. These programmes should use a family approach that targets both parents and children.

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.

Health outcomes in young adulthood among former child refugees in Denmark, Norway and Sweden: A cross-country comparative study

AIMS

This study aimed at comparing several health outcomes in young adulthood among child refugees who settled in the different immigration and integration policy contexts of Denmark, Norway and Sweden.

METHODS

The study population included refugees born between 1972 and 1997 who immigrated before the age of 18 and settled in the three Nordic countries during 1986-2005. This population was followed up in national registers during 2006-2015 at ages 18-43 years and was compared with native-born majority populations in the same birth cohorts using sex-stratified and age-adjusted regression analyses.

RESULTS

Refugee men in Denmark stood out with a consistent pattern of higher risks for mortality, disability/illness pension, psychiatric care and substance misuse relative to native-born majority Danish men, with risk estimates being higher than comparable estimates observed among refugee men in Norway and Sweden. Refugee men in Sweden and Norway also demonstrated increased risks relative to native-born majority population men for inpatient psychiatric care, and in Sweden also for disability/illness pension. With the exception of increased risk for psychotic disorders, outcomes among refugee women were largely similar to or better than those of native-born majority women in all countries.

CONCLUSIONS

The observed cross-country differences in health indicators among refugees, and the poorer health outcomes of refugee men in Denmark in particular, may be understood in terms of marked differences in Nordic integration policies. However, female refugees in all three countries had better relative health outcomes than refugee men did, suggesting possible sex differentials that warrant further investigation.