Migration, mental health and suicide : An epidemiological, psychiatric and cross-cultural study

Sammanfattning: Background: In spite of restrictions in Swedish immigration policy duringthe 1990s, the foreign-born population (10.7% in 1996) is steadily increasing becauseof immigration of relatives of refugees and labor migrants. Migration forced by violence,war or economic factors, the encounter with a new society and acculturation mightcause stress and result in mental illness with suicide as an ultimate action. Existentialquestions about life and death, meaning and meaninglessness are always present inevery human life and are specially activated during migration, and this activationinfluences thoughts and actions concerning mental health, illness and suicidal behavior. Airns: The central aim of the work is to study migration, health, suicideand their relation to each other from epidemiological, psychiatric and cross-culturalperspectives. This complex relationship is influenced by many other dimensions, suchas existential, cultural and social aspects, which are also taken into considerationin the research project. Methods: In the first part of the thesis, suicide is analyzed from an epidemiologicalperspective. Ethnicity, defined as being foreign-born, and its relation to suicideis investigated. Foreign-born individuals have been mostly treated as a group, butthey are also divided into particular ethnic subgroups. The health status, basedon self-reported long-term illness, of those who later committed suicide is alsoexamined. The data are obtained from the Cause of Death Register, from the 1985 census,and from interviews. In the second part, hospitalized foreign-born individuals andnative Swedes are compared concerning internal migration, number of admissions, daysof care and the risk of a second admission. In the final part, a qualitative studyis in focus concentrating the data gathering process in two areas: (1) suicidal patients'meaning making systems (religion, view of life) and (2) interactions between self-and object-relations among these patients. Ten female patients with depression andsuicidal behavior have been included. Results: The main finding in the first part is that ethnicity is a significantrisk factor for suicide in both sexes and in all age groups except for males aged30-49. The highest risk ratios for suicide in Sweden, adjusted for age, have beenfound among males born in Russia and Finland. They also show increased suicide riskscompared with their countries of birth. Females born in Hungary, Russia, Finlandand Poland all have an increased risk of committing suicide in Sweden, and they alsohave higher risks than in their countries of birth. Foreign-born individuals runa twofold risk of committing suicide compared to Swedes and adjusted for socioeconomicfactors. Foreign-born males and females under 45 and 35 respectively have significantlyincreased hospital admission rates compared with native-born Swedes. Native Swedesin nearly all age groups were hospitalized for a longer time than foreign-born persons.The last part confirms the common risk factors for suicide (such as psychiatric disorder,especially depression and earlier suicide attempts) but points to the need for thesefactors to be assessed in relation to a lack of self-esteem and a limited sense ofself-identity. An essential finding of this research is that intervention and support,especially coupled with the individual's development of self identity, self-esteemand a sense of relating and belonging, can effectively motivate the movement of a"suicidal" person toward the "healthy" person category. Thishappens when there is an internal and existential change whereby the individual isable to find and have respect for him/herself as a person worthy of self-care. Conclusions: Ethnicity is an independent risk factor for suicide and forhigh psychiatric hospital admission rates. Specific subgroups, e.g. Finnish males,have higher suicide rates in Sweden than in their country of origin. Access to patients'meaning-making systems provides culture specific information of value for diagnosticand therapeutic assessment processes. Key words: ethnicity; suicide; Finns; psychiatric admissions; self-reportedhealth; meaning making systems. ISBN 91-628-2641-7