Common mental disorders among young refugees in Sweden: The role of education and duration of residency

Journal of Affective Disorders 266 (2020) 563–571

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Research paper

Common mental disorders among young refugees in Sweden: The role of education and duration of residency

T

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Emma Björkenstama,b, , Magnus Helgessona, Marie Norredamc,d, Marit Sijbrandije, Christopher Jamil de Montgomeryc, Ellenor Mittendorfer-Rutza a

Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden c Danish Research Centre for Migration, Ethnicity, and Health (MESU), Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen K, Denmark d Section of Immigrant Medicine, Department of Infectious Diseases, University Hospital Hvidovre, Copenhagen, Denmark e Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands b

A R T I C LE I N FO

A B S T R A C T

Keywords: Young refugees Common mental disorders Health care Migration Cohort Sweden Epidemiology Education

Background: Studies investigating risks of common mental disorders (CMDs) in refugee youth are sparse. The current study examined health care use due to CMDs in unaccompanied and accompanied refugee youth and Swedish-born, and the role of education and residency duration. Methods: This longitudinal cohort study included 746,517 individuals (whereof 36,347 refugees) between 19 and 25 years, residing in Sweden in 2009. Refugees were classified as unaccompanied/accompanied. Risk estimates of CMDs, measured as health care use and antidepressant treatment, between 2010–2016 were calculated as adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Highest attained education in 2009, and residency duration were examined as potential modifiers. Results: Compared to Swedish-born youth, refugees had a lower risk of treated major depressive and anxiety disorders (aHR): 0.67 (95% CI 0.63–0.72) and 0.67 (95% CI 0.63–0.71) respectively), but a higher risk for posttraumatic stress disorders (PTSD). Compared to Swedish-born, unaccompanied had a nearly 6-fold elevated risk for PTSD (aHR: 5.82, 95% CI 4.60–7.34) and accompanied refugees had a 3-fold risk of PTSD (aHR: 3.08, 95% CI 2.54–3.74). Rates of PTSD decreased with years spent in Sweden. The risk of CMDs decreased with increasing education. Limitations: The study lacked information on pre-migration factors. There may further be a potential misclassification of untreated CMDs. Conclusion: Refugees had a lower risk of treated depressive and anxiety disorders but a higher risk for PTSD. In refugees, the rates of anxiety disorders increased slightly over time whereas the rates of PTSD decreased. Last, low education was an important predictor for CMDs.

1. Introduction There has been a dramatic increase in migration globally over the last decade (United Nations, 2017). In 2017, there were 258 million migrants worldwide, including 25.9 million refugees and asylum seekers (Migration Agency, 2018; United Nations, 2017). It has further been estimated that refugee minors, i.e. refugee children below 18 years, constitute 50% of the refugee population worldwide (Gadeberg et al., 2017; Gadeberg and Norredam, 2016; United Nations High Commissioner for Refugees, 2017), and this proportion has continued to increase during the last years (Fazel, 2018; Kadir et al., 2019;

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Kien et al., 2018). A considerable proportion of refugee youth has been exposed to traumatic events in their country of origin or during flight to their host country (Giacco et al., 2018; Hebebrand et al., 2016). Such experiences may be more harmful for mental health in refugee youth, and particularly unaccompanied refugee youth as they are enduring these adversities during their formative years (Eide and Hjern, 2013; Kien et al., 2018). As a consequence, refugee youth often face an elevated risk of mental disorders (Manhica et al., 2017), and more specifically of common mental disorders (CMDs) in terms of post-traumatic stress disorder (PTSD), anxiety and depressive disorders (Bronstein and

Corresponding author at: Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm SE-171 77, Sweden. E-mail address: [email protected] (E. Björkenstam).

https://doi.org/10.1016/j.jad.2020.02.015 Received 4 November 2019; Received in revised form 27 January 2020; Accepted 1 February 2020 Available online 04 February 2020 0165-0327/ © 2020 Elsevier B.V. All rights reserved.

Journal of Affective Disorders 266 (2020) 563–571

E. Björkenstam, et al.

attainment with regard to subsequent specific CMDs in refugee youth is unclear to date. The current study aimed to examine the risk of health care use related to CMDs in young refugees who came to Sweden as unaccompanied or accompanied youth, compared with that of young individuals born in Sweden. Furthermore, we investigated whether educational attainment and duration of residency modified the association between refugee status and subsequent CMDs. Last, we examined if the studied associations could be explained by LMM factors.

Montgomery, 2011; Fazel, 2018; Fazel et al., 2012; Kien et al., 2018; Montgomery, 2011; Norredam et al., 2018). However, to date, studies investigating the long-term risk (follow-up from youth into young adulthood) of health care use due to specific CMDs in refugee youth are sparse (Barghadouch et al., 2018; Norredam et al., 2018). Investigations of diagnosis-specific health care use are important, as refugees are known to be less inclined to seek for health for mental health complaints than their counterparts born in the respective host countries. The literature is even more restricted when it comes to comparing health care use due to mental disorders of unaccompanied and accompanied refugee youth (Barghadouch et al., 2018; Norredam et al., 2018). The term unaccompanied refugee youth (URM) refers to forcibly displaced children under the age of 18 who are ‘separated from both parents and […] not being cared for by an adult who by law or custom has the responsibility to do so’ (UNHCR, 2020). Existing studies have shown that unaccompanied youth are particularly at risk with respect to health care use due to anxiety disorders (Barghadouch et al., 2018; Norredam et al., 2018), which may among others be due to higher levels of trauma exposure, loss, and forced separation compared to accompanied refugee youth and the lack of family supports (Bean et al., 2007). This study will therefore investigate if this difference is also found from diagnosis-specific health care use. With respect to health care use due to CMDs in refugees, studies in which duration of residency has been taken into account are lacking. Some longitudinal studies based on self-reported data have shown slowly decreasing levels of depressive disorders (Beiser and Hou, 2001; Schick et al., 2018) and anxiety disorders (Schick et al., 2018)over time, often as a result of some sort of mental health intervention in the host country (Beiser and Hou, 2001; Schick et al., 2018). At the same time, increasing rates of self-reported anxiety disorders (Laban et al., 2005) and psychotropic drug use (Brendler-Lindqvist et al., 2014) with longer duration of residence have been reported. Increasing rates have among others been attributed to the fact that health in general in refugees tends to converge to the native population (De Maio, 2010). It has further been shown that refugees utilize mental health care to a lesser extent than individuals in the host population, but that the mental health care utilization in refugees increases, the longer the refugees have resided in a country (Manhica et al., 2017). Barriers to access mental health care may partly explain this phenomenon (BrendlerLindqvist et al., 2014; McCrone et al., 2005). Still, surprisingly few studies have examined the aspect of duration of residency in investigations of mental health problems in general and no study has up to date investigated health care use due to CMDs in this respect. Worsening mental health with time spent in the new host country might also be related to poor social integration and lack of fulfilled expectations. This in turn might lead to social marginalization, e.g. marginalization at the labor market, which is often conceptualized as long-term unemployment, sickness absence (SA) and disability pension (DP) (Helgesson et al., 2019). Research has shown that refugees in general have an elevated risk of labor market marginalization (LMM), when compared to individuals in the host population (Helgesson et al., 2019), but still the role of LMM in CMDs risk in refugee youth is less clear. Refugee youth are a heterogeneous group and despite reports describing their vulnerability, studies have shown that young refugees also possess resilience and have resources to manage a successful life in the new host country (Eide and Hjern, 2013; Sleijpen et al., 2016a). Moreover, other social characteristics, such as socio-economic status, might be relevant in determining their subsequent health development. According to a recent systematic review on health, education and employment outcomes in young refugees in the Nordic countries, refugee adolescents performed worse in school than native-born, and few progressed to higher education (Borsch et al., 2018). Another recent Swedish study of young adults who came to Sweden as teenage refugees showed that the use of psychiatric care services increased with the level of education (Manhica et al., 2017). Still, the role of educational

2. Methods 2.1. Study population The study population was defined as all individuals, between 19 and 25 years, alive and residing in Sweden on December 31st, 2009 (n = 852,768). We excluded refugees with incomplete information on their reason for settlement in Sweden (n = 28,437), and non-refugee immigrants (n = 72,797). Those for which information on year of immigration was missing (n = 243) were also excluded. Last, those who arrived in Sweden when they were between the ages of 18 and 25 were excluded (n = 4,774) as the study focused on refugees who came to Sweden as unaccompanied/accompanied minor below 18 years of age when arriving in Sweden. Applying these exclusion criteria, the final study population included 746,517 individuals, whereof 36,347 refugees. We used the unique (de-identified) Swedish personal identity number14 to link information from several population-based registers. The Longitudinal Integration Database for Health Insurance and Labor Market Studies (LISA) contains data from the labor market and from the educational and social sectors, and also sociodemographics. The STATIV register holds migration-related information, including reasons for settlement, e.g. refugee status. The National Patient Register (NPR) includes information on inpatient care since 1987 and for specialized outpatient care since 2001. Diagnoses in NPR are coded according to the International Classification of Diseases version 10 (ICD-10). The Cause of Death Register (CDR) comprises information on all deaths of Swedish residents since 1952. The Prescribed Drug Register (PDR) contains patient identities for all dispensed prescribed drugs to the entire Swedish population since July 2005. Pharmaceuticals in PDR are grouped according to the Anatomical Therapeutic Chemical Classification System (ATC). Families were linked together through the Multi-Generation Register, which contains all known relationships between children and parents (born 1932 or later) since 1961. 2.2. Measures Refugee status: In this study, a refugee was defined as an individual receiving a residence permit in Sweden as a refugee (according to the Geneva Convention of Refugees), or an individual who has been granted residence permit due to “in need of protection” or on “humanitarian grounds”. Refugees were further classified as unaccompanied or accompanied, i.e. refugees who were below 18 years of age when arriving in Sweden. The refugees were categorized as accompanied if they obtained residency because they were related to a family member who was a refugee, according to STATIV, or had at least one parent in the Multi-Generation Register who had received residency in Sweden the same year or the year before the young refugee. Young refugees who did not fulfil either of these two criteria were categorized as unaccompanied. In total, 9,147 refugees came as unaccompanied youth and 27,200 came as accompanied. Outcome: Health care due to CMDs was defined as having a primary diagnosis for major depressive disorders (code according to the International Classification of Diseases version 10, ICD-10: F32-33), phobic anxiety disorders (ICD-10: F40), other anxiety disorders (ICD10: F41), obsessive-compulsive disorders (ICD-10: F42) and reaction to 564

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Table 1 Sociodemographic and health characteristics of the study cohort of individuals aged 19–25 years residing in Sweden in 2009. Absolute numbers and column percent. Swedish-born individuals

All, (n, row percent) Sociodemographic factors at baseline Sex Women Men Mean age (years, SD) Educational level Compulsory school (≤ 9 years) High school (10–12 years) College or university (>12 years) Missing Country of birth Horn of Africa1 Afghanistan Iraq Iran Former Yugoslavia Others Duration of formal residency in Sweden 0–5 years 6–10 years > 10 years Family situation Married/living with partner without children2 Married/living with partner with children2 Single/divorced/separated/widowed without children2 Single/divorced/separated/widowed with children2 Children (≤20 years old)2 Type of residential area Big city area Intermediate (>90,000 inhabitants) Small (rural municipalities) Health-related factors at baseline Psychiatric morbidity3 Common Mental Disorders4 Somatic morbidity5 Labor market marginalization factors at baseline No unemployment Unemployment ≤ 180 days/year Unemployment >180days/year No sickness absence (SA) SA ≤90 days/year SA >90 days/year No disability pension (DP) DP 1 2 3 4 5

Refugees All

Unaccompanied

Accompanied

710,170 (95)

36,347 (5)

9,147 (1)

27,200 (4)

344,820 (49) 365,350 (51) 21.8 (2.0)

16,588 (46) 19,759 (54) 22.0 (2.0)

3,664 (40) 5,483 (60) 22.6 (1.9)

12,924 (48) 14,276 (52) 21.8 (2.0)

89,032 (13) 456,728 (64) 155,137 (22) 9,273 (1)

9,778 (27) 16,554 (46) 6,655 (18) 3,360 (9)

3,757 (41) 2,220 (24) 962 (11) 2,208 (24)

6,021 (22) 14,334 (53) 5,693 (21) 1,152 (4)

– – – – – –

3,681 (10) 1,320 (4) 7,373 (20) 1,627 (4) 15,373 (42) 6,973 (19)

2 870 (31) 730 (8) 3 294 (36) 241 (3) 412 (5) 1 600 (17)

811 (3) 590 (2) 4 079 (15) 1 386 (5) 14 961 (55) 5 373 (20)

– – –

10,966 (30) 4,694 (13) 20,687 (57)

7,546 (82) 924 (10) 677 (7)

3,420 (13) 3,770 (14) 20,010 (74)

6 372 (1) 31 455 (4) 488 273 (69) 8 599 (1) 175 471 (25)

1,961 (5) 3,108 (9) 23,246 (64) 1,036 (3) 6,996 (19)

594 (6) 1 110 (12) 6 732 (74) 564 (6) 147 (2)

1 367 (5) 1 998 (7) 16 514 (61) 472 (2) 6 849 (25)

250 671 (35) 274 637 (39) 184 862 (26)

14,244 (39) 15,546 (43) 6,557 (18)

3 582 (39) 3 567 (39) 1 998 (22)

10 662 (39) 11 979 (44) 4 559 (17)

28,114 (4) 38,491 (5) 167,526 (24)

1,050 (3) 1,246 (3) 8,987 (25)

289 (3) 351 (4) 2,241 (24)

761 (3) 895 (3) 6,746 (25)

543,624 (77) 155,817 (22) 10,729 (2) 684,887 (96) 20,697 (3) 4,586 (1) 691,602 (97) 18,568 (3)

24,372 (67) 10,311 (28) 1,664 (5) 35,473 (98) 721 (2) 153 (0) 35,670 (98) 677 (2)

5,589 (61) 2,757 (30) 801 (9) 9,010 (99) 109 (1) 28 (0) 9,083 (99) 64 (1)

18,783 (69) 7,554 (28) 863 (3) 26,463 (97) 612 (2) 125 (0) 26,587 (98) 613 (2)

Somalia, Eritrea and Ethiopia. Living at home. Defined by ICD-10 codes: F00-99. Defined by ICD-10 codes: F32-33; F40-43 and/or ATC-codes: N06A. Defined by ATC-codes A10, N03A excluding mood stabilizers; and/or any ICD-10 code, excluding codes F00-99, O80 and R00-99.

outpatient care with a main diagnosis for somatic disease, or utilization of certain prescribed medications. For diagnoses, all ICD-10 codes were considered, with the exception of codes related to mental disorder (ICD10: F00-F99), codes related to pregnancy and childbirth (i.e. ICD-10: O80), and symptoms, signs and abnormal clinical and laboratory findings (ICD-10: R00-R99). For prescribed medication use, the following drugs were considered: antidiabetics (ATC: A10), antiepileptic medication (ATC: N03A, excluding mood stabilizers). Other psychiatric morbidity was defined as having a diagnosis during psychiatric in- or specialized outpatient care in 2009 (codes included in ICD-10 chapter F), as recorded in the NPR. Long-term SA (LTSA) (>90 net days per year), DP (any length), and long-term unemployment (>180 days per year), measured in 2009, were used as LMM indicators.

severe stress and adjustment disorders (ICD-10: F43) (PTSD (ICD-10: F43.1) studied separately), in inpatient care or specialized outpatient care; or being prescribed antidepressants (Anatomical Therapeutic Chemical (ATC) code: N06A) during the follow-up period (i.e. January 1st 2010 through December 31st 2016). An individual was considered to have received drug treatment if at least one prescription was dispensed. Highest attained educational level, measured on December 31, 2009, was categorized as compulsory school (<9 years), high school (10–12 years) and college or university (>12 years). Duration of residence was categorized into three groups: <5 years, 5–10 years, and >10 years. Potential confounders: A range of potential covariates, measured in 2009, were considered. Adjustments were made for age, sex, family situation and type of residential area (please see Table 1 for information on categorization of the confounders). Adjustments were also made for somatic morbidity at baseline, defined as inpatient or specialized

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significantly elevated risk for reaction to severe stress and adjustment disorders (aHR: 1.31, 95% CI 1.22–1.41). Highest HR was observed for diagnoses of PTSD, refugees had a nearly 4-fold increased risk compared to Swedish-born individuals (aHR: 3.80, 95% CI 3.25–4.45). Unaccompanied refugees tended to have a higher risk of reaction to severe stress and adjustment disorders compared to accompanied refugees and Swedish-born, and especially PTSD (Table 2). Moreover, compared to Swedish-born individuals, unaccompanied refugees had a nearly 6-fold risk for being diagnosed with PTSD (aHR: 5.82, 95% CI 4.60–7.34). The corresponding HR for accompanied refugees was 3.08 (95% CI 2.54–3.74). The analyses of associations between duration of formal residency (refugees) and health care use due to CMDs presented in Table 3 show that, for refugees, the rates and risk estimates for anxiety disorders increased with increasing time spend in Sweden. This was true for both unaccompanied and accompanied refugees. For reaction to severe stress and adjustment disorders, the pattern was the opposite, the risk decreased as the number of years spent in Sweden increased. For PTSD, compared to Swedish-born individuals, refugees with less than five years of formal residency in Sweden had a 5-fold elevated risk (aHR: 5.37, 95% CI 4.28–6.74). The corresponding HR for refugees with more than 10 years of formal residency was 2.66 (95% CI 2.10–3.38). Patterns for unaccompanied and accompanied refugees were similar (data not shown). In Table 4, associations between educational level and health care use due to CMDs, in Swedish-born and refugees are presented. In both Swedish-born and refugees, there was a graded relationship between education and CMDs, with decreasing risk with increasing years in education. In Swedish-born individuals, those in the group of nine years or less of education had a 2-fold risk of CMDs (aHR: 1.94, 95% CI 1.91–1.98). The corresponding HR in refugees in the same educational group was 1.59 (95% CI 1.45–1.73). When unaccompanied and accompanied refugees were studied separately, with respect to CMD risk, a similar gradient was seen for both groups, however, with overlapping CIs for unaccompanied refugees (data not shown). A series of sensitivity analyses were carried out. First, we reran the main analysis in refugees only and added a regression model where we also adjusted for country of birth and duration of formal residency (Supplementary Table 1). The results showed that these covariates had little effect on the estimates. Second, we reran all analyses, excluding individuals treated for CMDs in 2006–2009 (i.e. three years prior to baseline). Results, presented in Supplementary Table 2, show that, although the CMD rates were lower in all groups, associations were similar to those in the main analyses. Last, we conducted a sensitivity analysis separating diagnosis-based and medication-based outcome respectively (Supplementary Table 3). Findings showed that the associations were similar for each outcome. Last, in the sensitivity analysis where we excluded individuals who were granted residence permit on ‘humanitarian grounds’ or ‘in need of protection’, results were similar to the main analyses.

2.3. Statistical analyses Statistical analyses were conducted using SAS, v.9.4. Crude and multivariate analyses were performed using Cox regression models of time to first prescription of antidepressants, hospitalization or specialized outpatient visit for CMDs. The entry date was defined as January 1st, 2010, and the exit date as the date of first outcome, date of death, date of emigration, or the end of follow-up (December 31st, 2016). Separate analyses were performed for depressive disorders, anxiety disorders, stress-related disorders and PTSD. We examined the associations between refugee status and each outcome in one crude and two adjusted regression models. Model 2 was adjusted for age, sex, education, family situation, type of residential area, and factors reflecting LMM. Model 3 was further adjusted for CMDs and other psychiatric and somatic morbidity at baseline. Sensitivity analyses: A number of sensitivity analyses were conducted. First, we conducted a sensitivity analysis of the main analysis in which we only included refugees and compared unaccompanied with accompanied refugees, also adjusting for country of birth and duration of residence. Second, we conducted analyses in which individuals with a history of CMDs (in the period 2006 through 2009) were excluded. In these analyses the study cohort was restricted to those who were residing in Sweden not only in 2009 but also in 2006–2008 (n = 668,730, whereof 28,083 refugees). We further analyzed diagnosis-based and medication-based outcomes separately. Last, we conducted a sensitivity analysis, in which individuals who were granted residence permits due to ‘in need of protection’ and on ‘humanitarian grounds’ were excluded from the refugee category. 3. Results Cohort characteristics of the study population, stratified by refugee status are presented in Table 1. Compared to Swedish-born youth, refugee youth were more likely to be living in larger cities of Sweden, to have a lower educational level, and to be living with children. Unemployment was more common among refugees. On the other hand, Swedish-born individuals were more likely to be on SA or DP. When comparing unaccompanied and accompanied refugee youth, unaccompanied refugees were more likely to be males (60 vs. 52%) and to have lower educational level (41 vs. 22% with less than nine years of education). Moreover, unaccompanied were more likely to be unemployed than Swedish-born individuals and accompanied refugee youth. A large proportion of unaccompanied refugees came from Iraq (36%) and the Horn of Africa (31%), whereas a majority (55%) of accompanied youth came from former Yugoslavia. Both unaccompanied and accompanied refugees received health care due to mental disorders to a lesser extent than Swedish-born youth, both at baseline and during follow-up. With regard to the duration of formal residency in Sweden, over 80% of unaccompanied refugees had been in Sweden less than 5 years (mean duration was 3.4 years), whereas, of accompanied refugees, 74% had resided in Sweden for over 10 years (mean duration was 12.7 years). Table 2 presents the crude and adjusted hazard ratios (HRs and aHRs) with 95% CI for CMDs by refugee status. HRs are presented for any CMD (i.e. diagnosis or prescribed medication) and for different subtypes (i.e. depressive disorders, anxiety disorders, stress disorders and PTSD) separately. With respect to different types of CMDs, depressive and anxiety disorders were more common in Swedish-born youth whereas reaction to severe stress and adjustment disorders were more common in refugees, in particular in unaccompanied refugees. In general, refugees had lower rates and risk of health care use due to any CMD compared to Swedish-born individuals (crude HR: 0.75, 95% CI 0.73–0.77). These associations remained after adjustments were made for important background variables, LMM and psychiatric and somatic morbidity. When different types of CMDs were studied separately, refugees had

4. Discussion 4.1. Key results Our findings indicated that, compared to Swedish-born youth, refugees had a lower risk of health care due to major depressive disorders and anxiety disorders, but a higher risk for reaction to severe stress and adjustment disorders, especially PTSD. Compared to accompanied refugee youth, unaccompanied had an elevated risk for reaction to severe stress and adjustment disorders, including PTSD. The lowest rates of anxiety disorders were observed among recently settled refugees. On the other hand, rates of reaction to severe stress and adjustment disorders appeared to decrease with years spend in Sweden in both unaccompanied and accompanied refugees. In both Swedish-born and refugees, there was a graded relationship between education and CMDs, 566

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Table 2 Risk of health care due to common mental disorders (CMD)1 in Swedish-born individuals and refugees, aged 19–25 years old residing in Sweden in 2009. Hazard ratios (HRs) with 95% confidence intervals (CIs). Model 1a

n (rate per 10,000 person-years)

Swedish-born individuals Refugees Unaccompanied Accompanied Swedish-born individuals Refugees Unaccompanied Accompanied Swedish-born individuals Refugees Unaccompanied Accompanied Swedish-born individuals Refugees Unaccompanied Accompanied Swedish-born individuals Refugees Unaccompanied Accompanied 1 a b c

Any common mental disorder (CMD) 145,188 (337.7) 1 (REF) 5,760 (253.4) 0.75 (0.73–0.77) 1,311 (230.3) 0.69 (0.65–0.72) 4,449 (261.2) 0.78 (0.75–0.80) Major depressive disorders 23,732 (49.4) 1 (REF) 837 (34.0) 0.69 (0.64–0.74) 196 (31.9) 0.65 (0.56–0.74) 641 (34.7) 0.70 (0.65–0.76) Anxiety disorders 30,543 (64.0) 1 (REF) 1,082 (44.2) 0.69 (0.65–0.73) 207 (33.7) 0.53 (0.46–0.60) 875 (47.7) 0.75 (0.70–0.80) Reaction to severe stress and adjustment disorders 10,894 (22.4) 1 (REF) 855 (34.8) 1.55 (1.45–1.66) 282 (46.2) 2.06 (1.83–2.31) 573 (31.0) 1.38 (1.27–1.50) Post-Traumatic Stress Disorder 1,092 (2.2) 1 (REF) 213 (8.6) 3.84 (3.31–4.45) 95 (15.4) 6.86 (5.57–8.46) 118 (6.3) 2.83 (2.34–3.43)

Model 2b

Model 3c

1 (REF) 0.64 (0.62–0.65) 0.50 (0.47–0.53) 0.69 (0.67–0.71)

1 (REF) 0.69 (0.67–0.71) 0.55 (0.52–0.58) 0.74 (0.72–0.76)

1 (REF) 0.59 (0.55–0.63) 0.48 (0.42–0.56) 0.63 (0.59–0.69)

1 (REF) 0.67 (0.63–0.72) 0.55 (0.48–0.64) 0.71 (0.66–0.77)

1 (REF) 0.58 (0.55–0.62) 0.38 (0.33–0.44) 0.66 (0.62–0.71)

1 (REF) 0.67 (0.63–0.71) 0.44 (0.38–0.51) 0.75 (0.70–0.81)

1 (REF) 1.20 (1.12–1.29) 1.25 (1.10–1.41) 1.18 (1.09–1.29)

1 (REF) 1.31 (1.22–1.41) 1.38 (1.22–1.56) 1.28 (1.18–1.40)

1 (REF) 3.16 (2.70–3.69) 4.69 (3.72–5.91) 2.58 (2.12–3.13)

1 (REF) 3.80 (3.25–4.45) 5.82 (4.60–7.34) 3.08 (2.54–3.74)

Defined by ICD-10 codes: F32-33; F40-43 and/or ATC-codes: N06A. Model 1: Crude. Model 2: Adjusted for age, sex, education, family situation, type of residential area, unemployment, sickness absence and disability pension. Model 3: Model 2 with additional adjustments for CMD and other psychiatric and somatic morbidity at baseline.

Table 3 Risk of health care due to common mental disorders (CMD)1 in Swedish-born individuals and refugees by duration of formal residency in Sweden. Individuals aged 19–25 years old residing in Sweden in 2009. Hazard ratios (HRs) with 95% confidence intervals (CIs).

Any common mental disorder (CMD) Swedish-born individuals Refugees with <5 years of formal residency in Sweden Refugees with 5–10 years of formal residency in Sweden Refugees with >10 years of formal residency in Sweden Major depressive disorders Swedish-born individuals Refugees with <5 years of formal residency in Sweden Refugees with 5–10 years of formal residency in Sweden Refugees with >10 years of formal residency in Sweden Anxiety disorders Swedish-born individuals Refugees with <5 years of formal residency in Sweden Refugees with 5–10 years of formal residency in Sweden Refugees with >10 years of formal residency in Sweden Reaction to severe stress and adjustment disorders Swedish-born individuals Refugees with <5 years of formal residency in Sweden Refugees with 5–10 years of formal residency in Sweden Refugees with >10 years of formal residency in Sweden Post-Traumatic Stress Disorder Swedish-born individuals Refugees with <5 years of formal residency in Sweden Refugees with 5–10 years of formal residency in Sweden Refugees with >10 years of formal residency in Sweden 1 a b c

n (rate per 10,000 person-years)

Model 1a

Model 2b

Model 3c

145,188 (337.7) 1,586 (231.4) 813 (280.9) 3,361 (259.0)

1 (REF) 0.69 (0.66–0.72) 0.83 (0.78–0.89) 0.77 (0.74–0.80)

1 (REF) 0.52 (0.49–0.55) 0.64 (0.60–0.69) 0.71 (0.68–0.73)

1 (REF) 0.57 (0.55–0.60) 0.68 (0.64–0.73) 0.75 (0.73–0.78)

23,732 (49.4) 255 (34.5) 122 (38.6) 460 (32.7)

1 (REF) 0.70 (0.62–0.79) 0.78 (0.65–0.93) 0.66 (0.61–0.73)

1 (REF) 0.54 (0.47–0.61) 0.61 (0.51–0.73) 0.62 (0.56–0.68)

1 (REF) 0.63 (0.55–0.71) 0.69 (0.58–0.82) 0.69 (0.63–0.76)

30,543 (64.0) 254 (34.4) 137 (43.4) 691 (49.5)

1 (REF) 0.54 (0.47–0.61) 0.68 (0.57–0.80) 0.77 (0.72–0.83)

1 (REF) 0.40 (0.35–0.45) 0.51 (0.43–0.61) 0.72 (0.67–0.77)

1 (REF) 0.46 (0.41–0.53) 0.59 (0.50–0.69) 0.81 (0.75–0.87)

10,894 (22.4) 352 (48.0) 133 (42.2) 370 (26.3)

1 (REF) 2.14 (1.92–2.38) 1.88 (1.58–2.23) 1.17 (1.06–1.30)

1 (REF) 1.36 (1.21–1.52) 1.33 (1.12–1.58) 1.06 (0.96–1.18)

1 (REF) 1.50 (1.34–1.68) 1.47 (1.23–1.74) 1.15 (1.03–1.27)

1,092 (2.2) 102 (13.7) 37 (11.6) 74 (5.2)

1 (REF) 6.13 (5.00–7.51) 5.18 (3.73–7.19) 2.34 (1.85–2.95)

1 (REF) 4.29 (3.43–5.37) 3.91 (2.80–5.45) 2.26 (1.78–2.87)

1 (REF) 5.37 (4.28–6.74) 4.77 (3.42–6.66) 2.66 (2.10–3.38)

Defined by ICD-10 codes: F32-33; F40-43 and/or ATC-codes: N06A. Model 1: Crude. Model 2: Adjusted for age, sex, education, family situation, type of residential area, unemployment, sickness absence and disability pension. Model 3: Model 2 with additional adjustments for CMD and other psychiatric somatic morbidity at baseline.

with decreasing risk with increasing years in education. Last, adjusting for LMM factors had little effect on the studied associations.

4.2. Risk of heath care use due to CMDs in refugees compared to Swedishborn individuals Earlier studies have shown that the prevalence rates of mental 567

568

b

a

1

3.67 (3.54–3.80) 2.42 (2.32–2.52) 3,235 (53.8) 3.88 (3.65–4.13) 3.12 (2.91–3.35) 377 (6.2) 5.62 (4.57–6.91) 3.85 (3.05–4.85)

5,979 (19.1) 1.38 (1.30–1.46) 1.41 (1.33–1.50) 580 (1.8) 1.68 (1.38–2.05) 1.83 (1.49–2.26)

2.98 (2.86–3.11) 2.00 (1.91–2.10)

1.28 (1.23–1.32) 1.22 (1.17–1.27)

1.30 (1.26–1.35) 1.26 (1.22–1.31)

6,094 (103.5)

13,668 (44.1)

8,858 (153.8)

2.62 (2.57–2.66) 1.94 (1.91–1.98)

1.14 (1.13–1.16) 1.17 (1.15–1.19)

16,777 (54.4)

32,821 (701.5)

Compulsory school (≤9 years)

84,560 (300.3)

High school (10–12 years)

2.60 (1.58–4.27) 1.61 (0.95–2.73)

18 (2.9)

2.40 (2.07–2.77) 2.07 (1.76–2.43)

207 (33.2)

2.05 (1.88–2.25) 1.33 (1.21–1.47)

524 (86.0)

1.51 (1.35–1.69) 1.20 (1.06–1.36)

323 (52.4)

1.86 (1.79–1.94) 1.24 (1.19–1.30)

2,524 (494.3)

Missing

1 (REF) 1 (REF)

14 (3.2)

1 (REF) 1 (REF)

86 (19.0)

1 (REF) 1 (REF)

154 (34.1)

1 (REF) 1 (REF)

111 (24.5)

1 (REF) 1 (REF)

846 (199.0)

Refugees College or university (>12 years)

1.87 (1.05–3.33) 1.92 (1.07–3.46)

65 (5.7)

1.52 (1.20–1.93) 1.60 (1.25–2.04)

324 (28.8)

1.25 (1.04–1.50) 1.28 (1.06–1.55)

478 (42.7)

1.25 (1.01–1.55) 1.28 (1.03–1.60)

346 (30.8)

1.21 (1.12–1.31) 1.27 (1.17–1.37)

2,525 (241.6)

High school (10–12 years)

4.75 (2.71–8.31) 3.92 (2.19–7.03)

97 (14.6)

2.77 (2.19–3.51) 2.63 (2.05–3.38)

345 (52.7)

1.67 (1.38–2.01) 1.55 (1.27–1.90)

372 (56.9)

1.87 (1.51–2.33) 1.84 (1.46–2.33)

302 (46.0)

1.63 (1.50–1.77) 1.59 (1.45–1.73)

1,927 (325.2)

Compulsory school (≤9 years)

Defined by ICD-10 codes: F32-33; F40-43 and/or ATC-codes: N06A. Model 1: Crude. Model 2: Adjusted for age, sex, family situation, type of residential area, unemployment, sickness absence, disability pension, CMD and other psychiatric and somatic morbidity at baseline.

Any common mental disorder (CMD) n (rates per 10,000 person25,283 (262.1) years) Model 1a 1 (REF) Model 2b 1 (REF) Major Depressive Disorders n (rates per 10,000 person3,647 (34.6) years) Model 1a 1 (REF) Model 2b 1 (REF) Anxiety Disorders n (rates per 10,000 person4,384 (41.7) years) a Model 1 1 (REF) Model 2b 1 (REF) Reaction to severe stress and adjustment disorders n (rates per 10,000 person1,473 (13.9) years) Model 1a 1 (REF) Model 2b 1 (REF) Post-Traumatic Stress Disorders (PTSD) n (rates per 10,000 person117 (1.1) years) Model 1a 1 (REF) Model 2b 1 (REF)

Swedish-born individuals College or university (>12 years)

5.28 (2.86–9.77) 4.52 (2.38–8.56)

13 (16.3)

2.34 (1.76–3.13) 2.29 (1.69–3.09)

100 (44.5)

1.01 (0.77–1.33) 0.84 (0.63–1.12)

78 (34.5)

1.40 (1.05–1.88) 1.31 (0.97–1.78)

78 (34.5)

1.11 (0.99–1.24) 1.04 (0.92–1.17)

462 (220.2)

Missing

Table 4 Associations between educational level and health care due to common mental disorders (CMD)1 in Swedish-born individuals and refugees, aged 19–25 years old residing in Sweden in 2009. Hazard ratios (HRs) with 95% confidence intervals (CIs).

E. Björkenstam, et al.

Journal of Affective Disorders 266 (2020) 563–571

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E. Björkenstam, et al.

studies have reported gaps between these care needs and psychiatric care utilization in refugees in general (Barghadouch et al., 2016; Kohlenberger et al., 2019; Lindert et al., 2008; Rechel et al., 2013; Satinsky et al., 2019). Given the existing evidence, studies on health in migrant children and youth suggest that the main health care needs concerns mental health (Kadir et al., 2019), this unmet need is of great concern. Moreover, these gaps have among others been explained by barriers to health care (Barghadouch et al., 2016; Manhica et al., 2017). These barriers may include language difficulties, lack of knowledge about the health care system, which may be particularly problematic for unaccompanied refugees (Brendler-Lindqvist et al., 2014). Adequate care in refugees might also be hampered by differences in the clinical manifestation and symptomatology of the underlying disease and consequently in its diagnostics (Bhugra et al., 2014; BrendlerLindqvist et al., 2014; Satinsky et al., 2019). Furthermore, cultural and contextual factors may contribute to determining the way refugees experience and express mental health problems, and reflect upon their needs for mental health care. Large-scale introduction of health literacy programs and training for physicians in transcultural psychiatry are therefore central parts in the aim to decrease these strong gaps in health care use and treatment.

disorders are high in young refugees (Eide and Hjern, 2013; Fazel, 2018; Fazel et al., 2012; Kien et al., 2018; Montgomery, 2011; Nesterko et al., 2019; Sierau et al., 2019b), and that refugee youth arriving as unaccompanied have elevated risk for mental disorders compared to youth in the host population (Manhica et al., 2017; Norredam et al., 2018). On the other hand, health care use due to mental disorders appears to differ when comparing refugee youth to youth in the host population (Manhica et al., 2017). Our findings are in line with previous results showing lower levels of health care due to depressive and anxiety disorders in refugees compared to the host population (Barghadouch et al., 2018; Manhica et al., 2017). Our study Here it is important to bear in mind that specialized health care use due to CMDs among young people in Sweden has steadily increased over the past decade (Bremberg, 2015) and that refugees in general and young refugees in particular are less inclined to be treated in specialized health care than individuals of the host population (Barghadouch et al., 2016; Satinsky et al., 2019). Our study extends these earlier findings by showing that refugees had a higher risk for health care due to reaction to severe stress and adjustment disorders, especially for PTSD. Previous reports showed high prevalence rates of PTSD (Fazel, 2018; Giacco et al., 2018; Huemer et al., 2009; Kien et al., 2018) and we could now also show that this applies for specialized health care as well. Providing scalable low-intensity interventions to address CMDs including posttraumatic stress are an important first step in order to prevent prolonged suffering and persistence of PTSD (Sijbrandij et al., 2017).

4.4. Duration of residency and CMDs in refugees We found that the risk of CMDs tended to increase with longer duration of residence in both unaccompanied and accompanied refugee youth. This is consistent with results from another Swedish study, which reported that, the longer the refugees had resided in the country, the more likely they were to utilize psychiatric care (Manhica et al., 2017). Our study further showed that, when we examined CMDs based on medication only (defined as pharmacological treatment with antidepressants), the HR for antidepressant use increased with longer duration of residence, which is in line with another Swedish study on duration of residence and antidepressant use in refugees (BrendlerLindqvist et al., 2014). These findings have among others been explained by the fact that, over time, newly arrived refugees become more familiar with accessing mental healthcare services in the host country (De Maio, 2010; Norredam et al., 2010). On the contrary, rates of reaction to severe stress and adjustment disorders appeared to decrease with years spent in Sweden in both unaccompanied and accompanied refugees. In unaccompanied refugees, rates of specialized health care due to PTSD were particularly high during the first years after resettlement, which is in line with earlier research (Eide and Hjern, 2013; Fazel et al., 2012; Reavell and Fazil, 2017). Among others, the reduction in reaction to severe stress and adjustment disorders over time can been attributed to the natural course of PTSD symptoms showing a natural decrease over time since the traumatic events (Muller et al., 2019), improved daily living conditions, and improvement in language skills enabling refugees to take advantage of educational and work opportunities (Montgomery, 2011). Moreover, studies on resilience in young refugees have emphasized the importance of social support and family security as factors promoting a decrease in PTSD over time (Reavell and Fazil, 2017; Sierau et al., 2019a; Sleijpen et al., 2016a, 2016b).

4.3. Unaccompanied vs accompanied Within the refugee youth group, unaccompanied refugee youth had a slightly lower risk of treatment for depressive and anxiety disorders than their accompanied counterparts. This is in contrast to a previous study, where a higher risk of anxiety but not depressive disorders, when compared to accompanied refugee children (Norredam et al., 2018). Discrepancies with our findings are most likely due to differences in the way the outcomes were defined, i.e. Norredam et al. included stressrelated disorders and PTSD in the group of anxiety disorders. Our study therefore highlights the need to specifically focus on stress-related mental disorders in studies on refugees as risk estimates might differ. To the best of our knowledge, this is the first study showing estimates for specialized health care use due to PTSD and other stress-related disorders in unaccompanied and accompanied refugees. Earlier studies (Fazel et al., 2012; Huemer et al., 2009; Kien et al., 2018) have showed that unaccompanied refugee youth have an elevated risk for measures of reaction to severe stress and adjustment disorders, including PTSD, compared to accompanied refugee youth. Our findings add to the international literature that even specialized health care due to these diagnoses is strongly increased in unaccompanied refugees. Reasons for a high risk of specialized health care due to PTSD in unaccompanied refugee youth include experiences of extreme traumatic events, forced separation from their family and the associated loss of major supports (Bean et al., 2007; Huemer et al., 2009). According to a review study on mental health in unaccompanied refugee youth, in terms of number of traumatic experiences, 54% had experienced one to three traumatic events, and 37% reported four or more traumatic experiences (Huemer et al., 2009). Also of importance here is that differences between unaccompanied and accompanied refugees may be due to sociodemographics. For instance, these groups differed considerably with respect to country of birth and duration of formal residency. Still, consideration of these factors in sensitivity analyses did not alter our main conclusion. The findings therefore call for a specific focus on unaccompanied refugee youth in early intervention projects in order to reduce posttraumatic stress symptoms. The poor mental health reported among refugee youth suggests that the need for psychiatric care would be greater than that of the general youth population (Fazel et al., 2012; Montgomery, 2011). However,

4.5. The role of educational attainment Other aspects that may play an important role in the CMD risk in both Swedish-born and refugees include socio-economic factors, and it has been shown that exposure to stressors after resettlement, such as socioeconomic disadvantage also impacts mental health (Rousseau and Frounfelker, 2019). Moreover, education has been pointed out as an important source of resilience in refugees, with positive aspects including a sense of control and hope (Sleijpen et al., 2016a). Our results showed, first of all, that refugees, and especially unaccompanied had lower educational level compared to Swedish-born individuals. These 569

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findings are in line with earlier research (Manhica et al., 2017, 2018). Our findings further revealed a graded relationship between educational level and CMDs in both Swedish-born and refugees, where those with low educational level had the highest risk for health care due to all types of CMD.

Supplementary material Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jad.2020.02.015. References

4.6. Strengths and limitations

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This study has several methodological strengths, including the longitudinal population-based design, use of national registers with high completeness and practically no loss to follow up. Furthermore, the large cohort size allowed for detailed analyses of different types of CMDs, and with ability to adjust for important confounders. Nevertheless, our findings should be interpreted in the context of the following limitations. First, information on health care due to CMDs relied solely on register data, and thus we have likely captured the most severe cases. This may lead to misclassification of undiagnosed and/or untreated individuals as unexposed, especially in refugees where the prevalence of psychological distress often is very high. Second, prescription of antidepressants was used as proxy for CMDs. Even though most prescriptions of antidepressants is for CMDs, these drugs may also be used for other indications (Mark, 2010). Third, potential differences in health care seeking behavior in Swedish-born and refugees may also affect our findings (e.g. poor language skills may prevent refugees from seeking health care, especially for unaccompanied refugee youth). The Swedish registers lack information on pre-migration factors, including reason for migration, which may have been relevant. 5. Conclusion Young refugees had a lower risk of health care due to major depressive and anxiety disorders but a higher risk for reaction to severe stress and adjustment disorders than their Swedish-born peers. In refugees, the rates of reaction to severe stress and adjustment disorders decreased over time. Last, low educational level seemed to be an important predictor for CMDs in both Swedish-born and refugees. Ethics approval Approved by the ethical committee in Stockholm, Sweden (dnr: 2016/1533–32). Author contributions Ellenor Mittendorfer-Rutz and Emma Björkenstam originated the idea. Emma Björkenstam analyzed the data and wrote the manuscript draft. All authors contributed to the study design, the interpretation of the results and to the writing of the final article. Role of funding source This work was supported by a grant from the Swedish Research Council (Grant no. 2018–05,783). The funders had no role in the analyses interpretation of results or the writing of this manuscript. Declaration of Competing Interest On behalf of all authors, the corresponding author states that there is no conflict of interest. Acknowledgements None 570

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