The association of immigrant- and non-immigrant-specific factors with mental ill health among immigrants in Sweden.

BACKGROUND: It has often been shown that immigrants are particularly at risk for mental ill health. The aim of the study was to investigate the association of immigrant- and non-immigrant-specific factors with mental ill health within a diverse immigrant population. METHOD: An extensive questionnaire was sent out to a stratified random sample of three immigrant populations from Finland, Iraq and Iran. The 720 respondents completed a Swedish, Arabic or Farsi (Persian) version of the questionnaire including the WHO (10) Well-Being Index and the HSCL-25. RESULTS: The results indicate that mental ill health among immigrants is independently associated with non-immigrant-specific factors (i.e. high number of types of traumatic episodes, divorced/widowed, poor social network, economic insecurity and being female) and immigrant-specific factors (i.e. low level of sociocultural adaptation). These results were obtained regardless of whether mental ill health was operationalized as low subjective well-being or a high symptom level of anxiety/depression. CONCLUSIONS: These findings support the notion that mental ill health among immigrants is a multi-faceted phenomenon that needs to be tackled within a wide range of sectors - e.g. the healthcare system, the social service sector and, of course, the political arena.

Integrating rehabilition of torture victims into the public health of Iraq.

For the last three decades torture has been highly prevalent in Iraq. Surveys indicate that close to 50% of households have family members who have been tortured. The traumas of two subsequent wars further add to the traumatisation of the population as does the persistent violence. Re-traumatisation makes healing difficult. As a result trauma-related disorders are likely to be the number one public health problem in Iraq. In December 2004, the author was tasked with the responsibility of planning and implementing rehabilitation activities for victims of torture in Iraq. Basra, in southern Iraq, was chosen as the place for the first clinical treatment and rehabilitation Centre, the Al-Fuad Centre for Rehabilitation of Torture Victims (FRCT). The Centre was to function as a training institution for the entire country. In a effort to bridge the gap between vast needs and limited resources, the Centre has begun applying a public health perspective, which means to develop its work in relation to the concepts of illness prevention and health promotion. Treatment and rehabilitation, i.e the secondary and tertiary levels of prevention, can be multiplied through the training of professionals who will be able to establish treatment facilities in new areas of Iraq. By training GPs, psychiatrists and physicians and by expanding FRCT services to victims' families, signs and symptoms of trauma can be addressed at early stages of disorder and long-term illness averted. Human Rights advocacy and legal work at the Centre will address the primary level of prevention through diminishing human rights abuses. Finally, engaging in the reconstruction of the civil society alongside other NGOs and government authorities is to build democracy, which is a cornerstone of health promotion, especially so when the illness panorama is related to violence.

The influence of the patients' ethnicity, socio-demographic conditions and strain on psychiatric diagnoses given at an outpatient clinic.

Although psychiatric diagnoses are influenced by cultural and social conditions, with large global variations, the ICD and DSM systems are applied worldwide. The aims of this study were to describe the distribution of different ethnic patient groups in psychiatric outpatient services and the influence of ethnicity, demographic conditions and social strain on psychiatric diagnoses. An entire year's cohort of psychiatric outpatients (n = 839) in an outpatient register was divided into nine groups, according to country of birth. The proportion of each group in the outpatient population was compared with its corresponding proportion in the catchment area. In order to examine the relationship between socio-demographic variables and strain on the one hand, and DSM-III-R diagnoses on the other, stepwise logistic regression analyses were carried out. Swedes were the only group under-represented as outpatients (P < 0.001). Africans ran a higher risk (OR = 5.55, 95% CI = 2.56-12.04) than other ethnic groups of receiving a diagnosis of psychotic disorder--except schizophrenia--and Greek patients were more likely to receive a diagnosis of somatoform disorder (OR = 8.81, 95% CI = 4.41-17.59). Swedes were twice as likely to receive a diagnosis of personality disorder (OR = 2.16, 95% CI = 1.55-3.15). Schizophrenia was related to male gender (OR = 1.75, 95% CI = 1.04-2.94) and affective disorders to age >40 years (OR = 1.71, 95% CI = 1.22-2.40). Ethnicity has a strong impact on how diagnoses are given in cross-cultural settings. We could not confirm earlier findings of under-representation of ethnic minorities in outpatient services.

The aetiology of posttraumatic stress disorder in four ethnic groups in outpatient psychiatry.

BACKGROUND: PTSD is one of few diagnoses to be defined by its aetiology. At treatment centres specialising in a certain type of trauma, like war, torture or sexual abuse, the aetiology may be regarded as self-explanatory. Recent surveys of general populations reveal high rates of PTSD, often following exposure to multiple traumatic events. Traumas are frequently overlooked in general psychiatric settings and PTSD is underestimated. Such findings indicate the need to conceptualise trauma in terms of multiple events and to examine the aetiology of PTSD amongst patients in everyday psychiatric practice. The present study examines aetiological factors of PTSD in three minority groups at a general psychiatric outpatient clinic. Arabs, Iranians and Turks selected from an entire year's cohort of patients-and a sample of Swedish patients of similar age and gender distribution. METHODS: Histories were collected from 115 patients, both regarding their own traumas and traumas involving relatives and close friends, by means of a questionnaire. A self-rating instrument for PTSD, with no reference to a specific trauma, was used in order to study the relationship between trauma and PTSD outcome. RESULTS: Of the patients, 89% had experienced at least one trauma, and 77% multiple traumatic events. The prevalence of probable PTSD varied between ethnic groups: Iranians 69%, Arabs 59%, Turks 53% and Swedes 29%. In a logistic regression analysis, probable PTSD outcome was associated with multiplicity of relatives' traumas (OR = 3.14), multiplicity of own traumas (OR = 2.56) and belonging to an ethnic minority (OR = 2.44), but not with gender. No patient without a trauma history was positively assessed for probable PTSD. CONCLUSION: The symptomatic syndrome of probable PTSD does not appear in the absence of extreme trauma, lending empirical support to the definition of PTSD. Prevalence increases with multiplicity of traumas, including those involving a relative or close friend. The high prevalence of probable PTSD found in this study warrants screening for trauma among patients, their relatives and close friends, in outpatient psychiatry.

Long-term consequences of unrecognised PTSD in general outpatient psychiatry.

BACKGROUND: Although a number of studies have shown a high prevalence of PTSD in the population, the diagnosis has hardly been recognised in general psychiatric practice. This raises two important questions. How widespread is extreme trauma and PTSD in the general psychiatry population? How does the long-term outcome among patients with PTSD differ from that of other psychiatric patients? The present study examines a psychiatry outpatient population in which none of the patients have received the primary diagnosis of PTSD. METHOD: The 233 patients from four ethnic groups who, during a period of 1 year, visited a psychiatric outpatient clinic were asked, 3-4 years later, to complete a questionnaire that included the Self-rating Inventory for Posttraumatic Stress Disorder. Patients were divided into probable PTSD and non-PTSD. Subjects with probable PTSD were compared with non-PTSD, regarding outcome at follow-up. RESULTS: The response rate was 56%. Fifty-three patients fulfilled the instrument's diagnostic criteria for PTSD, whereas 62 did not. In the foreign-born groups PTSD patients constituted a majority (53-69 %) compared to 29% of Swedish-born patients. Although the clinic's original diagnoses and assessment of immediate treatment outcome did not differ between the two groups, PTSD patients did not report improvement to the same extent and had poorer self-rated health at follow-up (p < 0.001) as well as lower participation in working life. CONCLUSIONS: A high proportion of PTSD and poorer outcome for PTSD patients compared to other psychiatric patients warrants a primary focus upon PTSD in outpatient psychiatry.