Marcello Ferrada-Noli

Post-traumatic stress disorder and suicidal behaviour in immigrants to Sweden. – Stockholm : Karolinska Institutet, 1996. – 138 s.

Abstract

The aim of the investigation was to study definite and undetermined suicides in immigrants to Sweden, as well as aspects of suicidal behaviour associated with Post-traumatic stress disorder (PTSD) among immigrants.

We have also inquired in which modality immigrant suicide victims had been in contact with psychiatric care. Likewise, psychosocial and socio-economic factors were studied with respect to differences in the suicide rate between immigrants and native Swedes.

The problem of the high number of undetermined forensic diagnoses on suicide (UMSA) in Sweden, was also investigated. We tested the hypothesis that UMSA and definite suicides may differ in positive blood alcohol analysis at autopsy (BAC) or in patho-anatomic autopsy findings associated with chronic alcohol consumption, being this possible difference ethnically-culturally related. Another aim was the study of suicidal behaviour among refugees with post-traumatic stress disorder, PTSD (the study hypothesis being that the nature of certain trauma stressors, such as torture methods, would be reflected in the content of post-traumatic self-destructive ideation).

We also investigated whether cultural 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) 15 countries (60% of immigrant pop.) manifested more observed than expected cases. This overrepresentation was statistically significant among immigrants from Russia, Finland, Germany, Denmark and Norway.

The risk for an immigrant to die of a cause related to suicide is 1.8 times higher than for a native Swede. Further, the increased suicide rates observed among the immigrant groups in Sweden, was found to be higher than in the respective 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 in Sweden (Spearman rank correlation 0.74; p = 0.01).

On the other hand, a covariation between suicide and immigrant status, unfavourable socio-economic conditions and lack of psychiatric care was found. Immigrants are poorly represented in the psychiatric care as compared with the native Swedish suicide victims; the proportion of psychiatric consultations resulting 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 that immigrants are overrepresented in the suicide statistics for low income areas. With respect to forensic-diagnostics, non-Swedish nationality in the victim and high BAC/signs of alcohol abuse at autopsy did show to convey difficulties for the forensic pathologist to establish the mode of death with optimal certainty Among suicide and UMSA cases, BAC differed significantly among the different ethnic groups (ANOVA, F = 3.50, p < .03). Comparison of mean levels using the Fisher PLSD test showed significantly higher alcohol concentrations in Finnish immigrants than in either native Swedes or in immigrants from other groups.

The study has also suggested the identification of a new epidemiological subgroup in suicidal behaviour, meta suicide.

PTSD was found to prevail in 78% of all refugee cases with a history of trauma. The prevalence of suicidal behaviour was significantly greater among refugees with PTSD diagnoses than among the remainder no-PTSD cases (p = 0.04). The high frequency of affective symptoms found in our PTSD sample suggest that the increased suicidal behaviour may be related also to depressive states. Among PTSD patients with a history of torture, a relationship appeared to exist between the torture methods that the victim had been exposed to, and the suicide method used in fantasies or attempts.

The majority (78%) among the PTSD refugees with increased suicidal behaviour did not regard religious proscription as deterrent of suicidal behaviour. Another noteworthy finding in the present study was that suicidal behaviour did not differ significantly between asylum applicants and refugees granted residence permits.

The findings in this study indicate that immigrant status should be considered a potential suicide risk factor in Sweden.

Transcultural psychiatry, Suicide, Metasuicide, Immigrants, Refugees, Post-traumatic stress disorder