Post-traumatic stress disorder and suicidal behaviour in immigrants to Sweden

Sammanfattning: The aim of the investigation was to study definite & undetermined suicides in immigrants toSweden, as well as aspects of suicidal behaviour associated with Post-traumatic stress disorder(PTSD) among immigrants/refugees. We have also inquired in which modality immigrantsuicide victims had been in contact with psychiatric care. Likewise, psychosocial andsocioeconomic factors were studied with respect to differences in the suicide rate betweenimmigrants and native Swedes. The problem of the high number of undetermined forensicdiagnoses on suicide (UMSA) in Sweden, was also investigated. We tested the hypothesis thatUMSA and definite suicides may differ in positive blood alcohol analysis at autopsy (BAC)or in patho-anatomic autopsy findings associated with chronic alcohol consumption, beingthis possible difference ethnically-culturally related. Another aim was the study of suicidalbehaviour among refugees with post-traumatic stress disorder, PTSD (the study hypothesisbeing that the nature of certain trauma stressors, such as torture methods, would be reflectedin the content of post-traumatic self-destructive ideation). We also investigated whethercultural bias is determinant in the suicidal behaviour among refugees with PTSD. Immigrants were overrepresented in the Swedish suicide statistics (X2= 45.4, p = 0.0001) 15countries (60% of immigrant pop.) manifested more observed than expected cases. Thisoverrepresentation was statistically significant among immigrants from Russia, Finland,Germany, Denmark and Norway. The risk for an immigrant to die of a cause related tosuicide is 1.8 times higher than for a native Swede. Further, the increased suicide ratesobserved among the immigrant groups in Sweden, was found to be higher than in therespective countries of origin in 90% of the nationalities investigated (paired t-Test t = -3.8; p= 0.01), the rank order being generally the same in both the countries of origin and inSweden (Spearman rank correlation 0.74; p = 0.01). On the other hand, a covariationbetween suicide and immigrant status, unfavourable socioeconomic conditions and lack ofpsychiatric care was found. Immigrants are poorly represented in the psychiatric care ascompared with the native Swedish suicide victims; the proportion of psychiatric consultationsresulting in admissions was significantly lower among immigrants than among native Swedes(X2= 7, p = 0.008). These reports may thus be interrelated with the separate finding thatimmigrants are overrepresented in the suicide statistics for low income areas. With respect toforensic-diagnostics, non-Swedish nationality in the victim and high BAC/signs of alcoholabuse at autopsy did show to convey difficulties for the forensic pathologist to establish themode of death with optimal certainty Among suicide and UMSA cases, BAC differedsignificantly among the different ethnic groups (ANOVA, F = 3.50, p < .03). Comparison ofmean levels using the Fisher PLSD test showed significantly higher alcohol concentrations inFinnish immigrants than in either native Swedes or in immigrants from other groups. Thestudy has also suggested the identification of a new epidemiological subgroup in suicidalbehaviour, metasuicide. PTSD was found to prevail in 78% of all refugee cases with a history of trauma. Theprevalence of suicidal behaviour was significantly greater among refugees with PTSDdiagnoses than among the remainder no-PTSD cases (p = 0.04). The high frequency ofaffective symptoms found in our PTSD sample suggest that the increased suicidal behaviourmay be related also to depressive states. Among PTSD patients with a history of torture, arelationship appeared to exist between the torture methods that the victim had been exposedto, and the suicide method used in fantasies or attempts. The majority (78%) among thePTSD refugees with increased suicidal behaviour did not regard religious proscription asdeterrent of suicidal behaviour. Another noteworthy finding in the present study was thatsuicidal behaviour did not differ significantly between asylum applicants and refugeesgranted residence permits. The findings in this study indicate that immigrant status should be considered a potential suicide risk factor in Sweden.Key words: transcultural psychiatry, suicide, metasuicide,immigrants, refugees, post-traumatic stress disorder ISBN 91-628-1984-4