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Confidential: for Review Only BMJ Confidential: For Review Only Refugee migration and risk of schizophrenia and other non - affective psychoses: a cohort study of 1.3m people in Sweden Journal: BMJ Manuscript ID BMJ.2015.029606 Article Type: Research BMJ Journal: BMJ Date Submitted by the Author: 26-Sep-2015 Complete List of Authors: Hollander, Anna-Clara; Karolinska Institutet, Dept. of Public Health Dal, Henrik; Centre for Epidemiology and Community Medicine Lewis, Glyn; UCL Psychiatric Epidemiology, Mental Health Sciences Unit Magnusson, Cecilia; Karolinska Institutet, Public Health Sciences; Centre for Epidemiology and Community Medicine Kirkbride, James; UCL Psychiatric Epidemiology, Mental Health Sciences Unit Dalman, Christina; Karolinska Institutet, Public Health Sciences; Centre for Epidemiology and Community Medicine refugees, migrants, schizophrenia, psychotic disorder, incidence, cohort Keywords: study https://mc.manuscriptcentral.com/bmj Page 1 of 26 BMJ 1 2 3 Refugee migration and risk of schizophrenia and other non-affective 4 5 psychoses: a cohort study of 1.3m people in Sweden 6 Anna-Clara Hollander, Henrik Dal, Glyn Lewis, Cecilia Magnusson, James B Kirkbride, ‡ Christina 7 ‡ 8 Confidential:Dalman For Review Only 9 Department of Public Health Sciences, Karolinska Institutet, 171 77 Stockholm, Sweden: Anna-Clara 10 Hollander, postdoctoral researcher; Cecilia Magnusson, Professor of Public Health Epidemiology; 11 12 Christina Dalman, Professor of Public Health Epidemiology 13 14 Centre for Epidemiology and Community Medicine, Stockholm County Council, SE-171 77 Stockholm, 15 Sweden: Henrik Dal, statistician, Cecilia Magnusson, Professor of Public Health Epidemiology; 16 Christina Dalman, Professor of Public Health Epidemiology 17 18 Division of Psychiatry, UCL, London, W1T 7NF, UK: James B Kirkbride, Sir Henry Dale Fellow; Glyn 19 Lewis, Professor of Psychiatric Epidemiology 20 21 Correspondence to: Anna-Clara Hollander, [email protected] 22 ‡Joint senior authors 23 24 25 Key words: refugees, migrants, schizophrenia, psychotic disorder, incidence, cohort study 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 https://mc.manuscriptcentral.com/bmj BMJ Page 2 of 26 1 2 3 Abstract 4 5 Objective 6 To determine whether refugees are at elevated risk of schizophrenia and other non-affective 7 psychotic disorders, relative to non-refugee migrants from similar regions of origin and the Swedish- 8 Confidential:born population. For Review Only 9 10 11 Design 12 Cohort study of people living in Sweden, born after 1 January 1984, and followed from their 14 th 13 birthday or arrival in Sweden, if later, until diagnosis of a non-affective psychotic disorder, 14 emigration, death or 31 December 2011. 15 16 17 Setting 18 Linked Swedish national register data. 19 20 21 Participants 22 1 348 602 persons, including people born in Sweden to two Swedish-born parents (88.3%), refugees 23 (1.8%) and non-refugee migrants (9.9%) from four major refugee-generating regions: the Middle 24 East & North Africa, Sub-Saharan Africa, Asia, Eastern Europe and Russia. 25 26 27 Main outcome measures 28 Cox regression analysis was used to estimate adjusted hazard ratios (aHR) for non-affective 29 psychotic disorders by refugee status and region of origin, controlling for age-at-risk, sex and 30 31 disposable income. 32 33 Results 34 We identified 3 704 cases during 8.9m person-years of follow-up. Compared with the crude 35 36 incidence in the Swedish-born population (38.6 per 100 000 person-years; 95% confidence interval: 37 37.3 to 39.9), there were 41.8 excess cases (33.6 to 50.0) in non-refugee migrants and 87.8 (62.1 to 38 113.5) excess cases in refugees per 100 000 person-years. Refugees were at increased psychosis risk 39 compared with both the Swedish-born population (aHR: 2.9; 2.3 to 3.7) and non-refugee migrants 40 41 (aHR: 1.6; 1.3 to 2.0) in our adjusted models. The increased rate in refugees compared with non- 42 refugees was more pronounced in men (χ2-test: 13.3; p=0.001), and present for refugees from all 43 regions, except from Sub-Saharan Africa, where both groups experienced similarly high rates relative 44 to the Swedish-born population. 45 46 47 Conclusions 48 Refugees face an increased risk of schizophrenia and other non-affective psychotic disorders 49 compared with non-refugee immigrants from similar regions of origin and the native-born Swedish 50 51 population. Clinicians and health service planners in refugee-receiving countries should be aware of 52 raised psychosis risk in addition to other mental and physical health inequalities experienced by 53 refugees. 54 55 56 57 58 59 60 2 https://mc.manuscriptcentral.com/bmj Page 3 of 26 BMJ 1 2 3 What this paper adds 4 5 Section 1: What is already known on this subject 6 Immigrant populations are at elevated risk of schizophrenia and other non-affective psychotic 7 8 Confidential:disorders. It is unclear whether refugees experiencFore rates Review of these disorders over andOnly above those 9 typically observed in non-refugee immigrant groups. 10 11 12 13 Section 2: What this study adds 14 Using a national cohort study of over 1.3m people in Sweden, we found that the risk of a non- 15 16 affective psychotic disorder was 60% higher amongst refugees than non-refugees immigrants from 17 18 similar regions of origin, and nearly three times greater than in the native-born Swedish population. 19 These patterns were apparent for men and women, although were stronger in men. Refugees from 20 21 all regions of origin experienced higher rates of psychotic disorder than non-refugee migrants, 22 except for people from Sub-Saharan Africa, where both groups experienced similarly high rates 23 24 relative to the Swedish-born population. Clinicians and health service planners should be aware of 25 26 early signs of psychosis in vulnerable migrant populations, who may benefit from timely and early 27 interventions. More broadly, our research is consistent with the possibility that traumatic life events 28 29 contribute to the aetiology of schizophrenia and other non-affective psychoses. 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3 https://mc.manuscriptcentral.com/bmj BMJ Page 4 of 26 1 2 3 Introduction 4 5 Schizophrenia and other psychotic disorders lead to lifelong health and social adversities, 6 culminating in a reduced life expectancy of 10 to 25 years. 1 Immigrants and their descendants are, 7 8 Confidential:on average, 2.5 times more likely to experience For a psychotic Review disorder than the majority Only ethnic group 9 2 3 in a given setting, although exact risk varies by ethnicity and setting. For example, in Europe, 10 11 incidence rates for people of black Caribbean or African descent are approximately five times higher 12 2 4 13 than experienced in the white European population. These marked differences persist after 14 adjustment for age, sex and socioeconomic position,5 are maintained in the descendants of first 15 16 generation migrants, 2 and do not appear to be attributable to higher incidence rates in people’s 17 6 7 8 9 18 country of origin, or selective migration. Putative explanations centre on various social 19 determinants of health, including severe or repeated exposure to psychosocial adversities such as 20 21 trauma, abuse, socioeconomic disadvantage, discrimination and social isolation. If true, people 22 granted refugee status may be particularly vulnerable to psychosis, given their increased exposure to 23 24 these risk factors. 10 11 25 26 27 While refugees experience more mental health problems than their non-refugee counterparts, 11 12 28 29 including posttraumatic stress disorder (PTSD) 13 and common mental disorders, 14 little is known 30 about psychosis risk in refugees. One previous longitudinal study from Denmark observed that 31 32 refugees were at elevated psychosis risk compared with the native-born Danish population.15 33 34 However, the risk in refugees was not compared with other non-refugee migrants, known to be at 35 increased risk, 16 making it impossible to attribute this excess directly to a refugee effect. More 36 37 recently, a Canadian cohort study found that refugees had a modestly increased risk of 38 17 39 schizophrenia compared with other migrants, but neither group were at elevated risk compared 40 with an ethnically-diverse Canadian-born background population, making this finding difficult to 41 42 interpret, and contrary to a large literature on immigration and psychosis. 2 43 44 45 Here, we clarify the risk of non-affective psychotic disorders, including schizophrenia, in refugees 46 47 compared with both non-refugee migrants and the native-born Swedish population in a national 48 population-based cohort of 1.3m people. Sweden experienced high levels of labour immigration 49 50 between 1940 and 1970, followed by substantial refugee immigration. On a per capita basis Sweden 51 18 52 grants more refugee applications than any other high income country, which combined with 53 national linked register data, makes it an excellent setting to conduct this research. We hypothesised 54 55 that refugees would have a higher risk of non-affective psychotic disorders than non-refugee 56 migrants, and that risk for both groups would be elevated compared with the Swedish-born 57 58 59 60 4 https://mc.manuscriptcentral.com/bmj Page 5 of 26 BMJ 1 2 3 population. We also hypothesised that risk in refugees compared with non-refugee migrants would 4 5 vary by region of origin, given putative differences in the pre-migratory experiences of non-refugee 6 immigrants from different regions.
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