I feel that being an immigrant comes with a set of experiences other people native to a country may not have to consider. For example, having to navigate a new culture, new customs, new legal systems, new work environments, new social structures and so on. These experiences are far from simple.

When we think about mental health, I believe that it is common for most of us to forget how encounters of marginalisation and ostracisation may have a profound impact on individuals. For example, compulsory detention rates are higher for minority ethnic groups than their white counterparts in several countries in the global north (Selten et al, 2020; Rodrigues et al, 2020).

These discrepancies in psychiatric care have been linked to factors such as:

• institutional racism (Keating et al, 2002),
• varying cultural and social approaches to mental health services (Sharpley et al, 2001) and
• higher levels of social deprivation amongst minority communities (Weich et al., 2017).

A recent study by Terhune et al. (2020) examined how migration status and other socioeconomic factors can affect a person’s chance of compulsory admission at first diagnosis of psychosis in Sweden.

Methods

The researchers aimed to investigate differences in the rates of compulsory admission at the first diagnosis of psychosis between migrants and children of migrants compared with the native Swedish-born population. Data from Psychiatry Sweden, a nationwide, anonymised database was used. The study looked at a total of 12,000 individuals, excluding individuals with a recorded diagnosis of the psychotic disorder before their 16th birthday and those without permanent residency in Sweden.

The primary outcome was compulsory admission at first diagnosis of a psychotic disorder. One of the individual-level factors that may have affected compulsory admission was migrant status, which was set as the primary exposure. Information on migration was sourced from both the national immigration and emigration register (STATIV) and the multigenerational register. Individuals were sorted into 3 groups: Swedish-born nationals, migrants (first generation) and children of migrants (second generation). Additional exposure variables included region-of-origin, sex, age at diagnosis, and family disposable income. Data for family disposable income came from the Longitudinal Integration Database for Health Insurance and Labour Market Studies.

Neighbourhood-level variables were also identified. Small Area Market Statistics (SAMS) were devised by Statistic Sweden and grouped areas with similar socioeconomic status, deprivation in these areas was also measured. Another neighbourhood-level variable was own-group neighbourhood-level ethnic density.

The individuals involved, had to have been:

• Born between 1985 and 1997
• Diagnosed with either a non-affective or affective psychotic disorder in accordance with International Classification of Diseases, 10th Revision (World Health Organization, 1992)
• First diagnosis occurred after their 16th birthday
• A permanent Swedish resident from at least the time of diagnosis.

The authors conducted Pearson’s chi-squared tests to explore the distribution of compulsory admission, individual and neighbourhood-level factors by migrant status, while they conducted logistic regression models to examine the effect of migrant status, region-of-origin and own-region migrant density on risk of compulsory admission.

Results

The final sample consisted of 11,640 individuals after excluding those with missing data (3%). Of those, 1,298 (10.8%) underwent compulsory admission at their first diagnosis of psychosis. Among the migrant population this number was even higher (13.5% for first generation, 12.0%, for children of migrants), while for the Swedish-born group was significantly the lowest (9.6%). The majority of the sample were males and Swedish-born people. More densely populated and deprived areas were overrepresented, this trend was more apparent in the migrant and children of migrant’s groups. For the migrant groups, individuals were most likely to come from: Non-Nordic European countries (27.0%), Middle East and North Africa (25.9%) and Sub-Saharan Africa (20.8%).

Being a migrant or child of a migrant, was shown to be associated with an increased risk of compulsory admission, compared to being Swedish-born. After adjusting for all variables, other characteristics associated with an increased risk of compulsory admission were being older, male and being from a more deprived and densely populated area.

Region of origin was indicated to have a stronger correlation than migrant status, with respect to risk of compulsory admission. Individuals from Sub-Saharan Africa, the Middle East and North Africa and Non-Nordic Europe were at an increased risk of compulsory admission compared to the Swedish-born group. Swedish-Nordic children of migrants were also at an increased risk. Own-region migrant density also had an association with compulsory admission, even after adjusting for age group, sex, region-of-origin and population density.

Conclusions

According to this research, being an immigrant or being the child of an immigrant can increase an individual’s chances of compulsory psychiatric admission at the first episode of psychosis.

Those who had two Swedish-born parents faced the lowest risk of compulsory admission at the first episode psychosis. Any deviation away from this increased a person’s risk. Region-of-origin greatly influenced risk, as individuals from Sub-Saharan Africa, the Middle East and North Africa, non-Nordic Europe face a higher risk than the Swedish-born population.

The above findings were all independent of income, neighbourhood deprivation, age, population density and gender; alluding to the fact that the reasons for this are structural and cultural. This study has clearly shown that where you are from will influence your experience within psychiatric care and this needs to change.

Strengths and limitations

The study followed a robust methodology and had plenty of strengths:

• Inclusion and data extraction from a very large data set (11,640 individuals), which gave the opportunity to explore the outcomes extensively and accurately, allowing generalisation
• Missing data in the sample was 3%, this was a small amount, which decreased the chance of the pattern of missing data affecting the results attained
• There were a good number of variables accounted for. This allowed the analysis to be comprehensive when isolating variables in order to accurately discern the correlation with compulsory admission at the first diagnosis of psychosis
• The study focused on an overlooked population: migrants. Studies tend to look solely at ethnicity and not account for migrant status, so this offered a new perspective on how migration can affect an individuals experience in psychiatric care.

However, some limitations need to be highlighted including:

• Ethnicity isn’t recorded in Sweden’s registers, meaning region-of-origin was used when calculating individual-level risk as well as migrant density. Region-of-origin is not an accurate reflection of ethnicity, as a result the data may have grouped together individuals from multiple different ethnic and cultural backgrounds
• The use of register-based data meant the study was reliant only on the variables provided and could not provide further relevant data such as symptom severity at presentation
• It would be useful if the study was multinational and explored similar outcomes in other countries with different procedures for compulsory admission. However, Sweden has a very similar healthcare system with the UK, so the findings could be applied.

Implications for practice

In London the compulsory admission rate for first diagnosis of a psychotic disorder is 31-38% (Selten et al, 2020). This is compared to 10.5% amongst the Swedish population, in Sweden the final decision for compulsory detention is made by a psychiatrist. Here in the UK, this decision can be made by the following individuals: a police officer, a family member, your GP and a psychiatrist (Royal College of Psychiatrists, 2020). Maybe we need to reconsider how we carry out compulsory admissions, and why non-professionals are granted the same power as professionals in such a serious procedure.

There are many more questions that need to be asked and answered. What is it specifically about the migrant experience that increases the likelihood of compulsory admission? More importantly, why is it that Sub-Saharan Africans are almost twice as likely than the native born Swedish population to face compulsory admission? Immigrating to another country should not put you at greater risk. It makes me wonder why is it that the standard of care and experiences within mental health services varies so drastically between minority ethnic groups and native populations? Maybe our preconceived notions as health and social care providers are guiding us to treat people unequally.

Furthermore, the study highlights the importance of region-of-origin over migrant status. Migrants from the Middle East and Africa may experience more cultural differences or wider structural barriers which may also contribute. The role of structural and institutionalised racism should be considered here, such a trend is likely to be a reflection of how a group of people is viewed within a society (Davies et al, 1996). Practical barriers experienced, such as language and familiarity with the healthcare system, may also play a role. These are compounded by own-region migrant density, which could be a result of patterns of structural exclusion (Keating et al, 2002) and/or a different, culturally influenced understanding of mental health (Sharpley et al, 2001).

As long as we continue to operate within this societal structure, we will be perpetuating racism in some form or another. Institutional racism will continue to exist because we do not take the time to think about how we all contribute. We are all culpable, and we see its effects throughout healthcare. I think that if we all practiced critical consciousness we would begin to realise that our perceptions of others are in many cases leading to poorer treatment of specific groups within healthcare.

Statement of interests

None.

References

Primary paper

Terhune, J., Dykxhoorn, J., Mackay, E., Hollander, A., Kirkbride, J., & Dalman, C. (2020). Migrant status and risk of compulsory admission at first diagnosis of psychotic disorder: A population-based cohort study in Sweden. Psychological Medicine, 1-10. doi:10.1017/S0033291720002068

Other references

Being sectioned | Royal College of Psychiatrists. Royal College of Psychiatrists. 2020 [cited 27 November 2020].

Davies, Sara et al., 1996. Ethnic differences in risk of compulsory psychiatric admission among representative cases of psychosis in London. BMJ, 312(7030), pp.533–537.

Keating, Frank & Robertson, David, 2004. Fear, black people and mental illness: A vicious circle? Health & social care in the community, 12(5), pp.439–447.

Rodrigues, R., Macdougall, A. G., Zou, G., Lebenbaum, M., Kurdyak, P., Li, L., … Anderson, K. K. (2020). Risk of involuntary admission among first-generation ethnic minority groups with early psychosis: A retrospective cohort study using health administrative data. Epidemiology and Psychiatric Sciences, 29, e59.

Scott Weich, Orla McBride, Liz Twigg, Craig Duncan, Patrick Keown, David Crepaz-Keay, Eva Cyhlarova, Helen Parsons, Jan Scott, Kamaldeep Bhui, Variation in compulsory psychiatric inpatient admission in England: a cross-classified, multilevel analysis, The Lancet Psychiatry, Volume 4, Issue 8, 2017, Pages 619-626, ISSN 2215-0366, .

Selten JP, van der Ven E, Termorshuizen F. Migration and psychosis: a meta-analysis of incidence studies. Psychol Med. 2020;50(2):303-313. doi:10.1017/S0033291719000035

Sharpley, M., Hutchinson, G., Murray, R., & McKenzie, K. (2001). Understanding the excess of psychosis among the African-Caribbean population in England: Review of current hypotheses. British Journal of Psychiatry, 178(S40), S60-S68. doi:10.1192/bjp.178.40.s60

WHO. (1992). International statistical classification of diseases and related health problems, Tenth revision 1992 (ICD-10). Vol. 1: Tabular list. Vol. 2: Instruction manual. Vol. 3: Alphabetical index. Geneva: World Health Organisation.

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