Risk of non-affective psychotic disorder and post-traumatic stress disorder by refugee status in Sweden

BACKGROUND: Refugees have different experiences of obtaining a refugee status, however it remains unclear if this affects their risk of psychiatric disorders. The aim of this study was to investigate whether risk for non-affective psychotic disorder (NAPD) and post-traumatic stress disorder (PTSD) differs between quota refugees (resettled from refugee camps) and non-quota refugees (former asylum seekers). METHOD: A register-based cohort with a sample size of 52 561 refugees in Sweden starting 1 January 1997 ending 31 December 2011. EXPOSURE: refugee status (quota or non-quota refugees). Cox regression models estimated adjusted HRs with 95% CIs for NAPD (International Classification of Diseases, Tenth Revision (ICD-10), F20-29) and PTSD (ICD-10, F43.1) by refugee status. RESULTS: There were more non-quota refugees (77.0%) than quota refugees (23.0%). In total we identified 401 cases of NAPD, 1.0% among quota refugees and 0.7% among non-quota refugees, and 1070 cases of PTSD, 1.9% among quota refugees and 2.1% among non-quota refugees. Male quota refugees were at increased risk for NAPD compared with male non-quota refugees (HRmale=1.41, 95% CI 1.09 to 1.82 and HRfemale=0.65, 95% CI 0.42 to 1.00). All quota refugees were at a reduced risk of PTSD compared with non-quota refugees (HR=0.74, 95% CI 0.64 to 0.87). CONCLUSIONS: This study suggests that risk of NAPD and PTSD varies for quota and non-quota refugees, highlighting the possibility that different experiences of the migration process differentiate the risk of psychiatric disorders among refugees

Association of neighbourhood migrant density and risk of non-affective psychosis: a national, longitudinal cohort study

BACKGROUND: Elevated risk of psychotic disorders in migrant groups is a public mental health priority. We investigated whether living in areas of high own-region migrant density was associated with reduced risk of psychotic disorders among migrants and their children, and whether generation status, probable visible minority status, or region-of-origin affected this relationship. METHODS: We used the Swedish registers to identify migrants and their children born between Jan 1, 1982, and Dec 31, 1996, and living in Sweden on or after their 15th birthday. We tracked all included participants from age 15 years or date of migration until emigration, death, or study end (Dec 31, 2016). The outcome was an ICD-10 diagnosis of non-affective psychosis (F20-29). We calculated own-region and generation-specific own-region density within the 9208 small areas for market statistics neighbourhoods in Sweden, and estimated the relationship between density and diagnosis of non-affective psychotic disorders using multilevel Cox proportional hazards models, adjusting for individual confounders (generation status, age, sex, calendar year, lone dwelling, and time since migration [migrants only]), family confounders (family income, family unemployment, and social welfare), and neighbourhood confounders (deprivation index, population density, and proportion of lone dwellings), and using the Akaike information criterion (AIC) to compare model fit. FINDINGS: Of 468 223 individuals included in the final cohort, 4582 (1·0%) had non-affective psychotic disorder. Lower own-region migrant density was associated with increased risk of psychotic disorders among migrants (hazard ratio [HR] 1·05, 95% CI 1·02-1·07 per 5% decrease) and children of migrants (1·03, 1·01-1·06), after adjustment. These effects were stronger for probable visible minority migrants (1·07, 1·04-1·11), including migrants from Asia (1·42, 1·15-1·76) and sub-Saharan Africa (1·28, 1·15-1·44), but not migrants from probable non-visible minority backgrounds (0·99, 0·94-1·04). Among migrants, adding generation status to the measure of own-region density provided a better fit to the data than overall own-region migrant density (AIC 36 103 vs 36 106, respectively), with a 5% decrease in generation-specific migrant density corresponding to a HR of 1·07 (1·04-1·11). INTERPRETATION: Migrant density was associated with non-affective psychosis risk in migrants and their children. Stronger protective effects of migrant density were found for probable visible minority migrants and migrants from Asia and sub-Saharan Africa. For migrants, this risk intersected with generation status. Together, these results suggest that this health inequality is socially constructed. FUNDING: Wellcome Trust, Royal Society, Mental Health Research UK, University College London, National Institute for Health Research, Swedish Research Council, and FORTE

Refugee migration and risk of schizophrenia and other non-affective psychoses: cohort study of 1.3 million people in Sweden.

OBJECTIVE:  To determine whether refugees are at elevated risk of schizophrenia and other non-affective psychotic disorders, relative to non-refugee migrants from similar regions of origin and the Swedish-born population. DESIGN:  Cohort study of people living in Sweden, born after 1 January 1984 and followed from their 14th birthday or arrival in Sweden, if later, until diagnosis of a non-affective psychotic disorder, emigration, death, or 31 December 2011. SETTING:  Linked Swedish national register data. PARTICIPANTS:  1 347 790 people, including people born in Sweden to two Swedish-born parents (1 191 004; 88.4%), refugees (24 123; 1.8%), and non-refugee migrants (132 663; 9.8%) from four major refugee generating regions: the Middle East and north Africa, sub-Saharan Africa, Asia, and Eastern Europe and Russia. MAIN OUTCOME MEASURES:  Cox regression analysis was used to estimate adjusted hazard ratios for non-affective psychotic disorders by refugee status and region of origin, controlling for age at risk, sex, disposable income, and population density. RESULTS:  3704 cases of non-affective psychotic disorder were identified during 8.9 million person years of follow-up. The crude incidence rate was 38.5 (95% confidence interval 37.2 to 39.9) per 100 000 person years in the Swedish-born population, 80.4 (72.7 to 88.9) per 100 000 person years in non-refugee migrants, and 126.4 (103.1 to 154.8) per 100 000 person years in refugees. Refugees were at increased risk of psychosis compared with both the Swedish-born population (adjusted hazard ratio 2.9, 95% confidence interval 2.3 to 3.6) and non-refugee migrants (1.7, 1.3 to 2.1) after adjustment for confounders. The increased rate in refugees compared with non-refugee migrants was more pronounced in men (likelihood ratio test for interaction χ(2) (df=2) z=13.5; P=0.001) and was present for refugees from all regions except sub-Saharan Africa. Both refugees and non-refugee migrants from sub-Saharan Africa had similarly high rates relative to the Swedish-born population. CONCLUSIONS:  Refugees face an increased risk of schizophrenia and other non-affective psychotic disorders compared with non-refugee migrants from similar regions of origin and the native-born Swedish population. Clinicians and health service planners in refugee receiving countries should be aware of a raised risk of psychosis in addition to other mental and physical health inequalities experienced by refugees

Combined endovascular and open operative approach for mycotic carotid aneurysm

Mycotic aneurysms of the extracranial carotid artery are rare and warrant surgical intervention. Management involves open and endovascular approaches. We report the case of a 67-year-old woman with an Escherichia coli soft-tissue infection of the right retropharyngeal space and subsequent mycotic carotid aneurysm and thrombosis of the internal jugular vein. The patient presented with a pulsatile mass and right middle cerebral artery stroke. Our surgical management involved coil embolization of the aneurysm to provide for vascular control, with resection of the common carotid artery, internal carotid artery, and extracranial carotid artery branches, along with the internal jugular vein

Doxycycline exposure during adolescence and future risk of non-affective psychosis and bipolar disorder: a total population cohort study

Doxycycline has been hypothesized to prevent development of severe mental illness (SMI) through the suppression of microglia, especially if administered during the intense synaptic pruning period of adolescence. However, results from register studies on potential benefits differ considerably. The aim of the present study was to determine whether doxycycline exposure during adolescence is associated with reduced SMI risk, and to investigate if a direct and specific causality is plausible. This is a Swedish national population register-based cohort study of all individuals born from 1993 to 1997, followed from the age of 13 until end of study at the end of 2016. The primary exposure was cumulative doxycycline prescription ≥3000 mg and outcomes were first diagnosis of non-affective psychosis (F20–F29) and first diagnosis of bipolar disorder (F30–F31). Causal effects were explored through Cox regressions with relevant covariates and secondary analyses of multilevel exposure and comparison to other antibiotics. We found no association between doxycycline exposure and risk of subsequent non-affective psychosis (adjusted hazard ratio (HR) 1.15, 95% CI 0.73–1.81, p = 0.541) and an increased risk of subsequent bipolar disorder (adjusted HR 1.95, 95% CI 1.49–2.55, p < 0.001). We do not believe the association between doxycycline and bipolar disorder is causal as similar associations were observed for other common antibiotics

Prevalence and risk factors for HIV, hepatitis B, and hepatitis C in people with severe mental illness: a total population study of Sweden

BACKGROUND: Severe mental illness is associated with increased morbidity and mortality. The elevated risk of blood-borne viruses (BBVs) in people with severe mental illness is of concern, but the full extent of this problem is unclear. We aimed to determine the prevalence of and risk factors for BBVs in people with severe mental illness. METHODS: In this nationwide, population-based, cross-sectional study, we estimated the point prevalence of HIV, hepatitis B (HBV), and hepatitis C (HCV) in people with severe mental illness, including the total adult (≥18 years) Swedish population. We defined severe mental illness as a clinical diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or other psychotic illness according to the Swedish version of the International Statistical Classification of Diseases version 8, 9, or 10. We used multivariable logistic regression to determine the odds of BBVs in individuals with severe mental illness, relative to the general population, and to identify independent risk factors (age, sex, immigration status, socioeconomic status, education, and substance misuse) for BBV infection. We also did a sensitivity analysis excluding BBV diagnoses made before the introduction of the Register for Infection Disease Control (1997). FINDINGS: Of 6 815 931 adults in Sweden, 97 797 (1·43%) individuals had a diagnosis of severe mental illness. Prevalence of BBVs was elevated in people with severe mental illness, of which 230 (0·24%) had HIV, 518 (0·53%) had HBV, and 4476 (4·58%) had HCV. After accounting for sociodemographic characteristics, the odds of HIV were 2·57 (95% CI 2·25-2·94, p<0·0001) times higher in people with severe mental illness than in the general population, whereas the odds of HBV were 2·29 (2·09-2·51, p<0·0001) times higher and the odds of HCV were 6·18 (5·98-6·39, p<0·0001) times higher. Substance misuse contributed most to the increased risk of BBV: after adjustment, odds ratios were 1·61 (1·40-1·85, p<0·0001) for HIV, 1·28 (1·16-1·41, p<0·0001) for HBV, and 1·72 (1·67-1·78, p<0·0001) for HCV. INTERPRETATION: Our results highlight the need to address the issue of higher prevalence of BBVs in people with severe mental illness and identify interventions preventing infection. Targeting of comorbid substance misuse would have particular effect on reduction of BBV prevalence in this population. FUNDING: Medical Research Council and Swedish Research Council

Suicide risk in people with post-traumatic stress disorder: a cohort study of 3.1 million people in Sweden

BACKGROUND: It is unclear whether post-traumatic stress disorder [PTSD] is associated with suicide risk in the general population, whether this differs by sex, or what the population impact of PTSD is for suicide. METHODS: We constructed a nationwide cohort of all people living in Sweden, born 1973-1997, followed from their 14th birthday (or immigration, if later) until suicide, other death, emigration or 31 December 2016. We used Cox proportional hazards regression to estimate hazard ratios [HR], and calculated the population impact of PTSD on suicide. We included sensitivity analyses to explore effects of outcome and exposure definitions, and to account for potential competing risks. RESULTS: Of 3,177,706 participants, 22,361 (0•7%) were diagnosed with PTSD, and 6,319 (0•2%) died by suicide over 49•2 million person-years. Compared with women and men without PTSD, suicide rates were 6•74 (95%CI: 5•61-8•09) and 3•96 (95%CI: 3•12-5•03) times higher in those with PTSD, respectively, after sociodemographic adjustment. Suicide rates remained elevated in women (HR: 2•61; 95%CI: 2•16-3•14) and men (HR: 1•67; 95%CI: 1•31-2•12) after adjustment for previous psychiatric conditions; attenuation was driven by previous non-fatal suicide attempts. Findings were insensitive to definitions or competing risks. If causal, 1•6% (95%CI: 1•2-2•1) of general population suicides could be attributed to PTSD, and up to 53.7% (95%CI: 46.1-60.2) in people with PTSD. LIMITATIONS: Residual confounding remains possible due to depressive and anxiety disorders diagnosed in primary care but unrecorded in these registers. CONCLUSIONS: Clinical guidelines for the management of people with PTSD should recognise increased suicide risk

Inequalities in Psychiatric Service Use and Mortality by Migrant Status Following a First Diagnosis of Psychotic Disorder: A Swedish Cohort Study of 1.3M People

It is unclear whether inequalities in mental healthcare and mortality following the onset of psychosis exist by migrant status and region-of-origin. We investigated whether (1) mortality (including by major causes of death); (2) first admission type (inpatient or outpatient); (3) in-patient length of stay (LOS) at first diagnosis for psychotic disorder presentation, and; (4) time-to-readmission for psychotic disorder differed for refugees, non-refugee migrants, and by region-of-origin. We established a cohort of 1 335 192 people born 1984-1997 and living in Sweden from January 1, 1998, followed from their 14th birthday or arrival to Sweden, until death, emigration, or December 31, 2016. People with ICD-10 psychotic disorder (F20-33; N = 9399) were 6.7 (95% confidence interval [95%CI]: 5.9-7.6) times more likely to die than the general population, but this did not vary by migrant status (P = .15) or region-of-origin (P = .31). This mortality gap was most pronounced for suicide (adjusted hazard ratio [aHR]: 12.2; 95% CI: 10.4-14.4), but persisted for deaths from other external (aHR: 5.1; 95%CI: 4.0-6.4) and natural causes (aHR: 2.3; 95%CI: 1.6-3.3). Non-refugee (adjusted odds ratio [aOR]: 1.4, 95%CI: 1.2-1.6) and refugee migrants (aOR: 1.4, 95%CI: 1.1-1.8) were more likely to receive inpatient care at first diagnosis. No differences in in-patient LOS at first diagnosis were observed by migrant status. Sub-Saharan African migrants with psychotic disorder were readmitted more quickly than their Swedish-born counterparts (adjusted sub-hazard ratio [sHR]: 1.2; 95%CI: 1.1-1.4). Our findings highlight the need to understand the drivers of disparities in psychosis treatment and the mortality gap experienced by all people with disorder, irrespective of migrant status or region-of-origin

Objective and subjective neighbourhood characteristics and suicidality: a multilevel analysis

BACKGROUND: Characteristics of the neighbourhood environment, including population density, social fragmentation, and trust, have been linked to mental health outcomes. Using a longitudinal population-based cohort, we explored the relationship between objective and subjective neighbourhood characteristics and the odds of suicidal thoughts and attempts. METHODS: We conducted a longitudinal study of 20764 participants living in Stockholm County who participated in the Stockholm Public Health Survey. We used multilevel modelling to examine if suicidal thoughts and attempts were associated with neighbourhood characteristics, independent of individual associations. We included objective and subjective measures to explore if there was a different relationship between these measures of the neighbourhood environment and suicidality. RESULTS: Associations between neighbourhood factors and suicidality were predominantly explained by individual characteristics, with the exception of neighbourhood-level deprivation and average residential trust. Each unit increase of deprivation was linked to increased odds of suicidal thoughts [Odds ratio (OR) 1.04, 95% confidence interval (CI) 1.00–1.07] and attempts (OR 1.11, 95% CI 1.06–1.17). Decreasing residential trust was associated with increased odds of suicide attempts (OR 1.09, 95% CI 1.02–1.17). There was no evidence that neighbourhood-level fragmentation or average trust in public and political institutions had an independent effect on suicidality once individual and sociodemographic factors were accounted for. CONCLUSIONS: This study showed that much of the neighbourhood-level variation in suicidal thoughts and attempts could be explained by compositional factors, including sociodemographic clustering within neighbourhoods. The independent effect of neighbourhood-level deprivation and average residential trust provide evidence that the neighbourhood context may exert an independent effect on suicidality beyond the impact of individual characteristics

Suicide risk among refugees compared with non-refugee migrants and the Swedish-born majority population

BACKGROUND: It has been hypothesised that refugees have an increased risk of suicide. AIMS: To investigate whether risk of suicide is higher among refugees compared with non-refugee migrants from the same areas of origin and with the Swedish-born population, and to examine whether suicide rates among migrants converge to the Swedish-born population over time. METHOD: A population-based cohort design using linked national registers to follow 1 457 898 people born between 1 January 1970 and 31 December 1984, classified by migrant status as refugees, non-refugee migrants or Swedish-born. Participants were followed from their 16th birthday or date of arrival in Sweden until death, emigration or 31 December 2015, whichever came first. Cox regression models estimated adjusted hazard ratios for suicide by migrant status, controlling for age, gender, region of origin and income. RESULTS: There were no significant differences in suicide risk between refugee and non-refugee migrants (hazard ratio 1.28, 95% CI 0.93-1.76) and both groups had a lower risk of suicide than Swedish born. During their first 5 years in Sweden no migrants died by suicide; however, after 21-31 years their suicide risk was equivalent to the Swedish-born population (hazard ratio 0.94, 95% CI 0.79-1.22). After adjustment for income this risk was significantly lower for migrants than the Swedish-born population. CONCLUSIONS: Being a refugee was not an additional risk factor for suicide. Our findings regarding temporal changes in suicide risk suggest that acculturation and socioeconomic deprivation may account for a convergence of suicide risk between migrants and the host population over time. DECLARATION OF INTEREST: None