Migrants from Africa and the Middle East and their children are more likely to be placed under compulsory care than the Swedish-born population when admitted to hospital for psychosis for the first time. That is according to a large, nationwide study by researchers at Karolinska Institutet in Sweden and University College London in the U.K., published in the journal Psychological Medicine.
“We saw that the increased risk of compulsory admission among migrant groups in Sweden was largely concentrated in those from the Middle East and Africa,” says Anna-Clara Hollander, senior researcher in the Department of Global Public Health, Karolinska Institutet, and co-author of the study. “We believe both cultural and structural factors play a role in maintaining these disproportionate rates of involuntary care and that further investigation on what may drive these ongoing differences is vital.”
Previous studies in Canada, U.K. and the Netherlands have also demonstrated a higher risk of compulsory admission for migrants and ethnic minorities diagnosed with psychiatric disorders. In this Swedish study, the researchers looked at almost 12,000 men and women diagnosed with psychosis between 2001 and 2016. Nearly 1,300 (10.8 percent) of those were involuntarily admitted to a healthcare facility during their first diagnostic instance.
Higher risk of compulsory care during first admission
The analysis showed that the risk of being compulsory admitted due to psychosis increased by 48 percent for migrants and by 27 percent for children to migrants compared with the Swedish-born population. Migrants from sub-Saharan Africa had a 94 percent elevated risk of compulsory admission while migrants from Middle East and North Africa and non-Nordic European backgrounds had an increased risk of 46 and 27 percent, respectively. Living in communities with clusters of migrants from the same region were associated with even higher risk of compulsory admission. The findings were independent of age, gender, family income, neighborhood-level deprivation and population density.
“Our results demonstrate the importance of considering region-of-origin, over and above migrant status, to understand patterns of compulsory admission in Sweden,” says James B. Kirkbride, Reader in Epidemiology at the Division of Psychiatry at UCL, and the study’s lead author. “This finding suggests that the shared experience of migration may be less salient to elevated risk of involuntary care for psychotic disorder than cultural or structural forces which affect some groups.”
Cultural and structural factors
Plausible explanations for the differences include language barriers, inadequate provision of culturally-appropriate care, distrust of institutionalized care, and cultural differences in attitudes toward psychiatric disorders. These mechanisms may result in a delayed first contact with services for psychosis, which may increase the likelihood that their presentation will be judged to require involuntary care. Other explanations may be linked to structural and institutional racism. However, the researchers emphasize that further investigation is needed to understand the mechanisms that drive variations in the treatment of first episode psychosis.
Sweden is one of only a handful of countries where the final decision on compulsory detention is made by a psychiatrist. This may explain why the prevalence of compulsory admission at first diagnosis of psychotic disorder in this sample was lower than observed elsewhere.
“Compulsory care is used when a person with psychosis is judged to constitute a threat toward oneself or others yet resists voluntary care,” says Christina Dalman, professor in the Department of Global Public Health, Karolinska Institutet, and the study’s senior author. “Compulsory care is often a traumatic experience and may worsen the psychotic symptoms. Providing health care earlier for migrants in need while increasing awareness of mental health and confidence in care may go some way toward alleviating the situation.”
The study was funded by the Sir Henry Dale Fellowship jointly funded by the Wellcome Trust and the Royal Society, the Mental Health Research UK, the National Institute for Health Research, University College London Hospital, Biomedical Research Centre, the Swedish Research Council for Health, Working Life and Welfare (FORTE) and the Swedish Research Council.
“Migrant status and risk of compulsory admission at first diagnosis of psychotic disorder: a population-based cohort study in Sweden,” Terhune, J., Dykxhoorn, J., Mackay, E., Hollander, A., Kirkbride, J., & Dalman, C., Psychological Medicine, online June 24, 2020, doi: 10.1017/S0033291720002068