Migration, mental health and suicide : an epidemiological, psychiatric and cross-cultural study

Abstract: Background: In spite of restrictions in Swedish immigration policy during the 1990s, the foreign-born population (10.7% in 1996) is steadily increasing because of immigration of relatives of refugees and labor migrants. Migration forced by violence, war or economic factors, the encounter with a new society and acculturation might cause stress and result in mental illness with suicide as an ultimate action. Existential questions about life and death, meaning and meaninglessness are always present in every human life and are specially activated during migration, and this activation influences thoughts and actions concerning mental health, illness and suicidal behavior. Aims: The central aim of the work is to study migration, health, suicide and their relation to each other from epidemiological, psychiatric and cross-cultural perspectives. This complex relationship is influenced by many other dimensions, such as existential, cultural and social aspects, which are also taken into consideration in the research project. Methods: In the first part of the thesis, suicide is analyzed from an epidemiological perspective. Ethnicity, defined as being foreign-born, and its relation to suicides investigated. Foreign-born individuals have been mostly treated as a group, but they are also divided into particular ethnic subgroups. The health status, based on self-reported long-term illness, of those who later committed suicide is also examined. The data are obtained from the Cause of Death Register, from the 1985 census, and from interviews. In the second part, hospitalized foreign-born individuals and native Swedes are compared concerning internal migration, number of admissions, days of care and the risk of a second admission. In the final part, a qualitative study is in focus concentrating the data gathering process in two areas: (1) suicidal patients' meaning making systems (religion, view of life) and (2) interactions between self- and object-relations among these patients. Ten female patients with depression and suicidal behavior have been included. Results: The main finding in the first part is that ethnicity is a significant risk factor for suicide in both sexes and in all age groups except for males aged 30-49. The highest risk ratios for suicide in Sweden, adjusted for age, have been found among males born in Russia and Finland. They also show increased suicide risks compared with their countries of birth. Females born in Hungary, Russia, Finland and Poland all have an increased risk of committing suicide in Sweden, and they also have higher risks than in their countries of birth. Foreign-born individuals run a twofold risk of committing suicide compared to Swedes and adjusted for socioeconomic factors. Foreign-born males and females under 45 and 35 respectively have significantly increased hospital admission rates compared with native-born Swedes. Native Swedes in nearly all age groups were hospitalized for a longer time than foreign-born persons. The last part confirms the common risk factors for suicide (such as psychiatric disorder, especially depression and earlier suicide attempts) but points to the need for these factors to be assessed in relation to a lack of self-esteem and a limited sense of self-identity. An essential finding of this research is that intervention and support, especially coupled with the individual's development of self-identity, self-esteem and a sense of relating and belonging, can effectively motivate the movement of a "suicidal" person toward the "healthy" person category. This happens when there is an internal and existential change whereby the individual is able to find and have respect for him/herself as a person worthy of self-care. Conclusions: Ethnicity is an independent risk factor for suicide and for high psychiatric hospital admission rates. Specific subgroups, e.g. Finnish males, have higher suicide rates in Sweden than in their country of origin. Access to patients' meaning-making systems provides culture specific information of value for diagnostic and therapeutic assessment processes.