Suicide Attempts among Immigrants in Europe

Sammanfattning: Introduction and Aims: Immigrants comprise about 10% of the total population of Europe, but our knowledge about their suicidal behaviour is still insufficient. This study presents an overview of suicidal behaviour of immigrants in Europe compared to host populations focusing on: (I) The frequencies of attempted suicide, compared between immigrants and their hosts, between different immigrant groups, and between immigrants and their countries of origin, (II) the variations of these frequencies across gender, (III) the recommendations of care given in medical services after the attempted suicide and (IV) the repetition patterns of attempted suicide within 12 months following the index (baseline) suicide attempt as well as the timing of the repetition. Materials and methods: The material, with almost 30,000 persons, of which more than 4,000 immigrants, originates from the WHO/EURO Multicentre Study on Suicidal Behaviour, collected from 11 European Centres in 1989-2010. (I) Differences in person-based suicide-attempt rates (SARs) of immigrants and host groups were tested for significance. Also, completed-suicide rates of the countries of origin were compared to the SARs of the immigrant groups using rank correlations. (II) Female-to-male SAR ratios were compared between the groups. (III) The relationship between immigrant status and the type of aftercare recommended was analysed with binary logistic regression, adjusting for gender, age, the method of the attempt, and the Centre that collected the data, and, finally (IV) the relationship between immigrant status and the repetition of suicide attempt was analysed with binary logistic regression, with controls for gender, age, and the method of attempt. The timing of the repetition was controlled for gender, age, and the recommended type of aftercare. Results: (I) 27 of 56 immigrant groups showed significantly higher SARs than their hosts. Immigrant groups also tended to show similar rates across different Centres. A positive correlation between the immigrant SAR and the country-of-origin suicide rate was found. However, Chileans, Iranians, Moroccans, and Turks displayed high SARs as immigrants despite low suicide rates in the home countries. (II) High SARs were found in non-European immigrant females compared to males. Generalized estimating equation analysis yielded a highly significant difference (p < 0.0005) in gender ratios of suicide attempts between hosts (ratio 1.52) and both non-European (ratio 2.32) and Russian immigrants (0.68), but not the Western immigrants. Excluding male-majority groups, the correlation between female and male SARs was relatively high among the European immigrants (r = 0.74, p < 0.0005) and lower among the non-European immigrants (r = 0.55, p < 0.03). (III) Eastern European and non-European immigrants were more often than host populations discharged without further recommendation of care. If care was offered, non-European immigrants were more likely to be recommended non-psychiatric care. The chance to be recommended inpatient care was significantly lower for non-European immigrants. Sex, age, and the method of the attempted suicide had mostly significant crude effects on the type of recommended care, but they could not explain immigrants' probability of being recommended different types of care. However, clear disparities were found in the recommendations of care between the European Centres included in the study. (IV) Lower odds to repeat attempted suicide were found in Eastern European (OR=0.50, p<0.001) and non-European immigrants (OR=0.68, p<0.05) as compared to the hosts. Similar patterns were identified in the gender-specific analysis. Repetition also tended to decrease with age and among females, it was more likely among those using harder methods in their index attempt (OR=1.26, p<0.01). Large variations in the general repetition frequency were found between the data-collecting Centres, which influenced the results. In general, 32% of all repetition occurred within 30 days. Eastern European immigrants tended to repeat their attempt later than hosts (OR=0.58, p<0.05). Conclusions: Suicidal behaviour is strongly related to culture but it seems also to be influenced by the immigration process itself. Immigrants tend to show a higher risk of suicidal behaviour compared to non-immigrant populations. The higher suicide-attempt rates among immigrants, and especially in non-European females, compared to the host populations, may be indicative of difficulties in acculturation processes. On the other hand, the fact that non-European and East European immigrants repeat their suicide attempts less often than both hosts and Western immigrants comes in clear contrast to their generally higher tendency to attempt suicide. It is possible that immigrants who harm themselves do so impulsively in response to stresses related to their experiences as immigrants, rather than in association with a persistent psychiatric illness or other known risk factors for suicide. In addition, clear disparities exist in the care recommendations for immigrants and hosts after a suicide attempt. This compilation of studies mapping the suicide attempts rates of immigrant groups, indicating their distinct repetition patterns, identifying specific risk groups, and showing possible inequalities in the care management of immigrants provide a contribution to the existing evidence base.