"I had no idea there were psychiatric clinics for children": A qualitative study of how migrant parents reach Swedish mental health services for their children.

Migrant children have repeatedly been shown to underutilize psychiatric services and to face barriers to care, yet few studies have examined the experience of migrant parents who are successful in their help-seeking efforts for their children's mental health. The aim of this study was to gain a deeper understanding of facilitators and obstacles to reaching care among migrant parents in contact with child psychiatric services. We explored how migrant parents in Stockholm, Sweden, experienced the process of reaching child mental health services. Participants were recruited from out-patient mental health clinics. Ten in-depth interviews were conducted; qualitative analysis of transcripts was undertaken using thematic content analysis. Parents described a desire to reach services but difficulties doing so on their own. We identified a strong dependence on referring agents, such as schools and child health centers, for parents to gain contact. Informants expressed a high degree of trust toward these agents. Contrary to previous studies, stigma was not described as an obstacle to help-seeking but was recognized by informants as a potential barrier to care had they not emigrated. Although participants in our study had differing educational backgrounds and residency times in Sweden, a common experience of reliance on others for reaching services was evident in the data. Our findings highlight the role of referring agents as bridging contacts between different welfare services. Understanding the specific local resources and services that are available to migrant parents, and strengthening these across different sectors, could potentially help reduce barriers to care.

Prenatal maternal PTSD as a risk factor for offspring ADHD: A register-based Swedish cohort study of 553 766 children and their mothers.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is highly heritable, though environmental factors also play a role. Prenatal maternal stress is suggested to be one such factor, including exposure to highly distressing events that could lead to post-traumatic stress disorder (PTSD). The aim of this study is to investigate whether prenatal maternal PTSD is associated with offspring ADHD. METHOD: A register-based retrospective cohort study linking 553 766 children born in Sweden during 2006-2010 with their biological parents. Exposure: Prenatal PTSD. Outcome: Offspring ADHD. Logistic regression determined odds ratios (ORs) with 95% confidence intervals (CIs) for ADHD in the offspring. Adjustments were made for potential covariates, including single parenthood and possible indicators of heredity measured as parental ADHD and maternal mental disorders other than PTSD. Subpopulations, excluding children with indicators of heredity, were investigated separately. RESULTS: In the crude results, including all children, prenatal PTSD was associated with offspring ADHD (OR: 1.79, 95% CI: 1.37-2.34). In children with indicators of heredity, the likelihood was partly explained by it. Among children without indicators of heredity, PTSD was associated with offspring ADHD (OR: 2.32, 95% CI: 1.30-4.14), adjusted for confounders. CONCLUSIONS: Prenatal maternal PTSD is associated with offspring ADHD regardless of indicators of heredity, such as parental ADHD or maternal mental disorder other than PTSD. The association is partly explained by heredity and socioeconomic factors. If replicated in other populations, preferably using a sibling design, maternal PTSD could be identified as a risk factor for ADHD.

Refugee status and the incidence of affective psychotic disorders and non-psychotic bipolar disorder: A register-based cohort study of 1.3m people in Sweden.

BACKGROUND: Refugees are at increased risk of non-affective psychotic disorders, but it is unclear whether this extends to affective psychotic disorders [APD] or non-psychotic bipolar disorder [NPB]. METHODS: We conducted a nationwide cohort study in Sweden of all refugees, non-refugee migrants and the Swedish-born population, born 1 Jan 1984-31 Dec 2016. We followed participants from age 14 years until first ICD-10 diagnosis of APD or NPB. We fitted Cox proportional hazards models to estimate hazard ratios [HR] and 95 % confidence intervals [95%CI], adjusted for age, sex and family income. Models were additionally stratified by region-of-origin. RESULTS: We followed 1.3 million people for 15.1 million person-years, including 2428 new APD cases (rate: 16.0 per 100,000 person-years; 95%CI: 15.4-16.7) and 9425 NPB cases (rate: 63.8; 95%CI: 62.6-65.1). Rates of APD were higher in refugee (HRadjusted: 2.07; 95%CI: 1.55-2.78) and non-refugee migrants (HRadjusted: 1.40; 95%CI: 1.16-1.68), but lower for NPBs for refugee (HRadjusted: 0.24; 95%CI: 0.16-0.38) and non-refugee migrants (HRadjusted: 0.34; 95%CI: 0.28-0.41), compared with the Swedish-born. APD rates were elevated for both migrant groups from Asia and sub-Saharan Africa, but not other regions. Migrant groups from all regions-of-origin experienced lower rates of NPB. LIMITATIONS: Income may have been on the causal pathway making adjustment inappropriate. CONCLUSIONS: Refugees experience elevated rates of APD compared with Swedish-born and non-refugee migrants, but lower rates of NPB. This specificity of excess risk warrants clinical and public health investment in appropriate psychosis care for these vulnerable populations.

Are the estimated needs for mental health care among adolescents from different socioeconomic backgrounds met equally in Sweden? A longitudinal survey-registry linkage study.

Evidence of inequality in the utilisation of mental health care (MHC) by adolescents in Nordic countries is mixed. This study aims to investigate if there are socioeconomic differences in the utilisation of MHC, while accounting for adolescents' mental health status. We analysed a cohort of 3517 adolescents, followed from 7 to 9th grade (ages 13-16), to examine the association between parental socioeconomic position (SEP: education and disposable income), adolescents' estimated needs, and the utilisation of MHC (defined as visits to secondary psychiatric care or receipt of psychotropic medication). Logistic and negative binomial regression models, with mental health status as moderator, were used to predict utilisation during each grade. Lower SEP predicted higher odds of utilising MHC in adolescents with no/mild symptoms (e.g., odds ratio, OR = 1.33, 95% CI 1.04-1.72, lower vs highest education), but not in those with moderate-to-severe symptoms (estimates close to one and non-significant). This pattern was largely explained by treatment of attention deficit hyperactivity disorder/autism spectrum disorders (ADHD/ASD) in boys. For girls with severe symptoms, lower SEP predicted reduced odds of utilising MHC for other mental disorders (OR = 0.48, 95% CI 0.25-0.92, lower education), and fewer outpatient visits when in contact with such care, although non-significant (incidence rate ratio, IRR = 0.51, 95% CI 0.25-1.05, lowest vs highest income). Our findings suggest a more equitable use of MHC for treating ADHD/ASD, but not other mental disorders such as depression and anxiety, particularly among girls.

Changes in anxiety and depression during the COVID-19 pandemic in the European population: A meta-analysis of changes and associations with restriction policies.

BACKGROUND: Early studies of common mental disorders (CMDs) during the COVID-19 pandemic mainly report increases; however, more recent findings have been mixed. Also, studies assessing the effects of restriction measures on CMDs show varied results. The aim of this meta-analysis was to assess changes in levels of CMDs from pre-/early to during the pandemic and the effects of restriction policies in the European population. METHODS: We searched for studies assessing both pre-pandemic and peri-pandemic self-reported emotional distress and symptoms of depression or anxiety among nationally/regionally representative samples in Europe and collected microdata from those studies. Estimates of corona containment index were related to changes in CMDs using random-effects meta-regression. RESULTS: Our search strategy resulted in findings from 15 datasets drawn from 8 European countries being included in the meta-analysis. There was no evidence of change in the prevalence of emotional distress, anxiety, or depression from before to during the pandemic; but from early pandemic periods to later periods, there were significant decreases in emotional distress and anxiety. Increased school restrictions and social distancing were associated with small increases in self-reported emotional distress. CONCLUSIONS: Despite initial concerns of increased emotional distress and mental illness due to the COVID-19 pandemic, the results from this meta-analysis indicate that there was a decrease in emotional distress and no change in anxiety or depression in the general population in Europe. Overall, our findings support the importance of strong governance when implementing periodic and robust restriction measures to combat the spread of COVID-19.

Indications of alcohol or drug use disorders in five different national registers in Sweden: a cross-sectional population-based study.

OBJECTIVE: The purpose of this study is to examine the prevalence of indications of alcohol or drug use disorders in five different national Swedish registers and to investigate the correlation between these registers. Furthermore, the intent is to investigate whether combining data from different registers increases the prevalence of these indications in the population due to the identification of different demographic groups in different registers. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Individuals living in Sweden aged 20-64 years in 2006, n=5 453 616. PRIMARY OUTCOME: National registers included the Registers of Inpatient Care, Outpatient Care, Medications, Social Insurance and Convictions. Demographic variables were sex, age, migrant status, education and civil status. Indications of alcohol or drug use disorders were presented as prevalence in percentage (%), correlation was examined using phi correlation coefficients and differences across demographic factors were studied using logistic regression. RESULTS: The prevalence of an indication of alcohol or drug use disorder varied between registers, meaning that prevalence increased when all registers were considered together. The prevalence of alcohol use disorder increased by 60% and 66% among men and women, respectively, while the prevalence of drug use disorder increased by 45% and 80% among men and women, respectively, when all registers were combined, compared with only using the register with the highest prevalence. Registers contributed different indications of drug and alcohol use disorders. CONCLUSIONS: Accurate estimates of alcohol or drug use disorders are critical for healthcare and rehabilitation. This study shows that using a single register alone underestimates the burden of disease unevenly, while combining a range of registers can provide a more accurate picture.

Prevalence of children under five with disabilities in Sierra Leone in 2017: Insights from a population-based multiple indicator cluster survey.

BACKGROUND: Children with disabilities have been low on the agenda of child health, including in Sierra Leone, and there are still many gaps in our knowledge and understanding of the issue. OBJECTIVE: To estimate the prevalence of children with disabilities in Sierra Leone using functional difficulty as a proxy and to understand the factors associated with disabilities among children two to four years living in Sierra Leone. METHODS: We used cross-sectional data from the Sierra Leone 2017 Multiple Indicator Cluster Survey. Disability was defined using a functional difficulty definition with additional thresholds used to define children with severe functional difficulty and multiple disabilities. Logistic regression models estimated odds ratios (ORs) of childhood disability and how they were associated with socioeconomic factors and living conditions. RESULTS: Prevalence of children with disabilities was 6.6% (95% confidence interval (CI) 5.8-7.6%) and there was a high risk of comorbidity between different functional difficulties. Children with disabilities were less likely to be girls (adjusted odds ratio (AOR) 0.8 (CI 0.7-1.0) and older (AOR 0.3 (CI 0.2-0.4)), but more prone to be stunted (AOR 1.4 (CI 1.1-1.7)) and have younger caregivers (AOR 1.3 (CI 0.7-2.3)). CONCLUSION: The prevalence of disabilities in young Sierra Leonean children was comparable to other countries in West and Central Africa when using the same measure of disability. Preventive as well as early detection and intervention efforts are recommended to be integrated with other programs, e.g vaccinations, nutrition, and poverty reducing programs.

Sickness absence around contact with outpatient mental health care services - differences between migrants and non-migrants: a Norwegian register study.

BACKGROUND: Mental disorders are a leading cause of sickness absence. Some groups of migrants are at higher risk of both mental disorder and sickness absence. Yet, research on sickness absence in relation to mental disorders among migrants is limited. This study investigates differences in sickness absence in the twelve-month period around contact with outpatient mental health services between non-migrants and various migrant groups with different length of stays. It also considers whether these differences are similar for men and women. METHODS: Using linked Norwegian register data, we followed 146,785 individuals, aged 18-66 years, who had attended outpatient mental health services and who had, or had recently had, a stable workforce attachment. The number of days of sickness absence was calculated for the 12-month period surrounding contact with outpatient mental health services. We applied logistic regression and zero-truncated negative binomial regression to assess differences in any sickness absence and number of days of absence between non-migrants and migrants, including refugees and non-refugees. We included interaction terms between migrant category and sex. RESULTS: Refugee men and other migrant men from countries outside the European Economic Area (EEA) had a higher probability of any sickness absence in the period surrounding contact with outpatient mental health services than their non-migrant counterparts. Women from EEA countries with stays of less than 15 years had a lower probability than non-migrant women. Additionally, refugees, both men and women, with 6-14 years in Norway had more days of absence while EEA migrants had fewer days than their non-migrant counterparts. CONCLUSIONS: Refugee men and other non-EEA migrant men appear to have higher sickness absence than non-migrant men around the time of contact with services. This finding does not apply to women. Several probable reasons for this are discussed, though further research is required to understand why. Targeted strategies to reduce sickness absence and support the return to work for refugees and other non-EEA migrant men are needed. Barriers to timely help-seeking should also be addressed.

Is legal status associated with mental illness among newly arrived refugees in Sweden: an epidemiological study.

BACKGROUND: There are about 80 million forcibly displaced people globally. Migrants are at heightened risk for mental illness compared to host country populations. While previous research highlights the need to adequately assess mental illness, few have taken the diversity among newly arrived migrants into account. This study aims to estimate the prevalence and associated risk factors of mental illness among asylum seekers, quota and other refugees in Stockholm, Sweden. METHODS: Using a cross-sectional design, data was collected as part of a mental health screening initiative integrated into routine health examinations in two health care clinics in Stockholm. Screening was done with the Refugee Health Screener, RHS-13, a validated instrument for assessing mental health in refugee populations. RESULTS: A total of 1163 individuals were eligible for screening, of whom 566 participated (response rate 48.6%). Among the participants, 47.9% indicated symptoms of mental illness. Compared with asylum seekers, the risk of mental illness was lower among quota and other refugees (adjusted odds ratio 0.60, 95% confidence interval 0.37-1.00). Female sex, higher age, coming from a middle-income country and low probability of being granted asylum were significant predictors of mental illness. CONCLUSION: Refugee legal status is associated with mental illness. Asylum seekers are at greater risk of mental illness compared to quota and other refugees. Our findings call for screening for mental illness among newly arrived migrants, especially among those with pending residence permits.

Association of trauma, post-traumatic stress disorder and non-affective psychosis across the life course: a nationwide prospective cohort study.

BACKGROUND: We aimed to examine the temporal relationships between traumatic events (TE), post-traumatic stress disorder (PTSD) and non-affective psychotic disorders (NAPD). METHODS: A prospective cohort study of 1 965 214 individuals born in Sweden between 1971 and 1990 examining the independent effects of interpersonal and non-interpersonal TE on incidence of PTSD and NAPD using data from linked register data (Psychiatry-Sweden). Mediation analyses tested the hypothesis that PTSD lies on a causal pathway between interpersonal trauma and NAPD. RESULTS: Increasing doses of interpersonal and non-interpersonal TE were independently associated with increased risk of NAPD [linear-trend incidence rate ratios (IRR)adjusted = 2.17 [95% confidence interval (CI) 2.02-2.33] and IRRadjusted = 1.27 (95% CI 1.23-1.31), respectively]. These attenuated to a relatively small degree in 5-year time-lagged models. A similar pattern of results was observed for PTSD [linear-trend IRRadjusted = 3.43 (95% CI 3.21-3.66) and IRRadjusted = 1.45 (95% CI 1.39-1.50)]. PTSD was associated with increased risk of NAPD [IRRadjusted = 8.06 (95% CI 7.23-8.99)], which was substantially attenuated in 5-year time-lagged analyses [IRRadjusted = 4.62 (95% CI 3.65-5.87)]. There was little evidence that PTSD diagnosis mediated the relationship between interpersonal TE and NAPD [IRRadjusted = 0.92 (percentile CI 0.80-1.07)]. CONCLUSION: Despite the limitations to causal inference inherent in observational designs, the large effect-sizes observed between trauma, PTSD and NAPD in this study, consistent across sensitivity analyses, suggest that trauma may be a component cause of psychotic disorders. However, PTSD diagnosis might not be a good proxy for the likely complex psychological mechanisms mediating this association.

Epidemiology of posttraumatic stress disorder: A prospective cohort study based on multiple nationwide Swedish registers of 4.6 million people.

BACKGROUND: Experiencing exceptionally threatening or horrifying traumas can lead to posttraumatic stress disorder (PTSD). Increasing political unrest/war/natural disasters worldwide could cause more traumatic events and change the population burden of PTSD. Most PTSD research is based on surveys, prone to selection/recall biases with inconsistent results. The aim was therefore, to use register-based data to identify the occurrence of PTSD and contributing factors in the Swedish general population. METHODS: This register-based cohort study used survival analysis. Individuals born between 1960-1995, aged ≥15 years, registered and living in Sweden, not emigrating, anytime between 1990-2015, not receiving specialized care for PTSD before 2006 were included (N = 4,673,764), and followed from their 15th/16th birth date until first PTSD diagnosis between 2006-2016 or study endpoint (31-December-2016). PTSD cases (ICD-10: F43.1) were identified from the national patient register. Mean follow-up time was 18.8 years. RESULTS: Between 2006-2016, the incidence of specialized healthcare utilization for PTSD nearly doubled, and 0.7% of the study population received such care. The highest risk was observed for refugees [aHR 8.18; 95% CI:7.85-8.51] and for those with depressive disorder [aHR 4.51; 95% CI:3.95-5.14]. Higher PTSD risk was associated with female sex, older age, low education, single parenthood, low household income, urbanicity, and being born to a foreign-born parent. CONCLUSIONS: PTSD is more common among refugee migrants, individuals with psychiatric disorders, and the socioeconomically disadvantaged. It is important that provision of services for PTSD are made available, particularly to these higher risk, and often hard-to-reach groups.

[Long term outcome of children diagnosed with resignation syndrome in the Stockholm Region 2005-2012]. / Långtidsuppföljning av barn med uppgivenhetssyndrom.

In the early 2000s, some children in asylum seeking families in Sweden showed severe reduction in function, including pervasive refusal to eat, drink, walk, talk or care for themselves. In 2014 this was to be named the resignation syndrome (ICD-10 F32.3A). The purpose of our study was to compare education and health-related outcomes over time between those with and without these symptoms, in a group of children from Central Asia who have been asylum seekers and received a residence permit in Sweden. We found that between the years 2005-2012, in the child and adolescent mental health services (CAMHS) in the Stockholm Region, 103 children showed symptoms of resignation, of whom 43 (43%) showed the most severe symptoms. Children with resignation syndrome assessed and cared for by CAMHS had similar need of outpatient care as other children of the same origin who had been treated by CAMHS for other conditions. They did not have an increased need for inpatient care compared with other children of the same origin, and they passed upper secondary school and past-secondary education to the same extent as other children of the same origin.

Are all children treated equally? Psychiatric care and treatment receipt among migrant, descendant and majority Swedish children: a register-based study.

AIMS: Underutilisation of mental health services among migrant youth has been demonstrated repeatedly, but little is known about potential discrepancies in terms of treatment receipt for those who do reach services. This study examines the type and level of care received among migrant children and descendants of migrants, particularly investigating disparities in treatment receipt given a specific diagnosis. METHODS: We used register data of the total population aged 6-17 years in Stockholm, followed from 2006 to 2015, comprising 444 196 individuals, categorised as refugees, non-refugee migrants, descendants of migrants and Swedish-born. To identify recommended treatments for specific diagnoses we used official clinical guidelines. We report logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) of diagnosis receipt, treatment provision and level of care where a diagnosis was first registered. RESULTS: Migrant children had a lower likelihood of receiving a wide range of psychiatric diagnoses, including mood disorder (OR 0.58; 95% CI 0.52-0.64), anxiety disorder (OR 0.62; 95% CI 0.57-69) and neurodevelopmental disorder (OR 0.59; 95% CI 0.55-0.63). Moreover, when these diagnoses were set, migrant children had a lower likelihood of receiving the recommended treatments for these conditions compared to the majority individuals with the same diagnosis (OR of receiving psychotherapy for anxiety disorder and depression: 0.71; 95% CI 0.62-0.95 and 0.50; 95% CI 0.33-0.75, respectively; OR for receiving ADHD-medication: 0.49; 95% CI 0.43-0.54). CONCLUSIONS: Migrant children risk underdiagnosis of various mental health conditions, and, when reaching mental health services, risk not receiving the optimal care available.

The relationship between motherhood and use of mental health care services among married migrant and non-migrant women: a national register study.

BACKGROUND: Giving birth to one's first child is a life changing event. Beyond the post-partum period, little is known about the association between becoming a mother and mental disorder among migrant women. This study investigates outpatient mental health (OPMH) service use, a proxy for mental disorder, among married migrant and non-migrant women who become mothers and those who do not. METHODS: Using Norwegian register data, we followed 90,195 married women, aged 18-40 years, with no children at baseline between 2008-2013 to see if becoming a mother was associated with OPMH service use. Data were analysed using discrete time analyses. RESULTS: We found an interaction between motherhood and migrant category. Married non-migrant mothers, both in the perinatal period and beyond, had lower odds of OPMH use than married non-mothers. There was no association between motherhood and OPMH service use for migrants. However, there was no significant interaction between motherhood and migrant category when we excluded women who had been in Norway less than five years. Among women aged 25-40 years, a stable labour market attachment was associated with lower odds of OPMH use for non-migrants but not migrants, regardless of motherhood status. CONCLUSIONS: The perinatal period is not associated with increased odds of OPMH use and appears to be associated with lower odds for married non-migrant women. Selection effects and barriers to care may explain the lack of difference in OPMH service use that we found across motherhood status and labour market attachment for married migrant women. Married migrant women in general have a lower level of OPMH use than married non-migrants. Married migrant women with less than five years in Norway and those with no/weak labour market attachment may experience the greatest barriers to care. Further research to bridge the gap between need for, and use of, mental health care among migrant women is required.

Association between migration status and subsequent labour market marginalisation among individuals with posttraumatic stress disorder: a Swedish nationwide register-based cohort study.

PURPOSE: The high prevalence of posttraumatic stress disorder (PTSD) among migrants in Europe is widely reported. Our research aimed to investigate the association between migration status and subsequent labour market marginalisation (LMM) events, i.e., long-term unemployment (LTU), long-term sickness absence (LTSA), and disability pension (DP) among individuals with PTSD, and to elucidate how the sociodemographic factors and the pre-existing health conditions influence such association. METHODS: We established a cohort of 36,714 individuals born between 1960 and 1995, living in Sweden during 2004-2009, aged 19 years or above, with PTSD diagnosis during 2006-2009. Migration status, categorized as refugees, non-refugees, second-generation migrants, and Swedish-born with Swedish-born parents (reference group) was considered as exposure and LMM events as outcome. The cohort was followed from 01-Jan-2010 until LMM, death, or end of follow-up (31-Dec-2016). Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by Cox regression with a seven-year follow-up. RESULTS: Refugees (HR 2.07, 95% CI 1.86-2.30), and non-refugees (HR 1.96, 95% CI 1.85-2.07) had almost doubled relative risk of long-term unemployment, compared with the Swedish-born. The hazards of long-term sickness absence were similar across the groups. Refugees (HR 1.49, 95% CI 1.24-1.77), and non-refugees (HR 1.42, 95% CI 1.30-1.56) also had elevated relative risk of disability pension, whereas second-generation migrants had moderately increased relative risks for all three labour market marginalisation events compared with the Swedish-born. CONCLUSION: Among the individuals with PTSD, being a migrant increases the risk of LMM, refugees being the foremost among migrants. Further research may benefit from including more recent migrant population, pre-migration information and measuring PTSD clinical severity.

The association between persistent low parental income during preschool age and mental disorder in adolescence and early adulthood: a Norwegian register-based study of migrants and non-migrants.

BACKGROUND: Low socioeconomic status during childhood is associated with increased risk of mental disorders later in life. Yet, there is limited research on whether this association varies by migrant background, despite an overrepresentation of migrants among the economically disadvantaged. METHODS: Using national register data on a study population of 577,072 individuals, we investigated the association between persistent low parental income during preschool, measured at age 3-5 years and mental disorder during adolescence and early adulthood, measured between ages 16-25. Outpatient mental healthcare (OPMH) service use was a proxy for mental disorder and was measured between 2006 and 2015. We applied discrete-time logistic regression analyses with interaction terms to study differences in the relationship between persistent low parental income and OPMH service use by migrant background and gender. RESULTS: Persistent low parental income during preschool age was associated with increased odds of OPMH service use in adolescence and early adulthood (aOR = 1.99, 95% CI 1.90-2.08), even after adjusting for gender, migrant background, parental education and persistent lower income at later ages (aOR = 1.33, 95% CI 1.27-1.40). Statistically significant interactions between migrant background and persistent low parental income were recalculated and presented as marginal yearly probabilities. These results showed that the association was in the opposite direction for migrants; those in the higher income group had higher probability of OPMH service use, although the differences were non-significant for some groups. The relationship did not vary by gender. CONCLUSIONS: Social inequalities in mental health, as measured by OPMH service use, may have an onset already in childhood. Interventions to reduce inequalities should therefore start early in the life course. Since the association differed for migrants, future research should aim to investigate the mechanisms behind these disparities.

Outpatient mental health service use following contact with primary health care among migrants in Norway: A national register study.

Majority of mental health problems are treated in primary care, while a minority require specialised treatment. This study aims to identify factors that predict contact with outpatient mental healthcare services (OPMH) among individuals who have been diagnosed with a mental health problem in primary healthcare services (PHC), with a special focus on migrants. Using linked national Norwegian registry data, we followed 1,002,456 individuals who had been diagnosed with a mental health problem in PHC for a period of two years. Using Cox regression, we applied Andersen's Model of Healthcare Utilisation to assess differences in risk of OPMH use between the majority population and eight migrant groups. We also conducted interaction analyses to see if the relationship between OPMH use and predisposing factors (gender, age, migrant status, civil status, education) differed across migrant groups. Migrants from Nordic countries, Western Europe and the Middle-East/North Africa had a higher risk of using OPMH services compared to the majority, while migrants from EU Eastern Europe, Sub-Saharan Africa and South Asia had a lower risk after controlling for all factors. Hazard ratios for non-EU Eastern Europeans and East/South East Asian's did not differ. Men had a higher risk than women. Additionally, the relationship between predisposing factors and OPMH use differed for some migrant groups. Education was not related to OPMH contact among five migrant groups. While lack of help-seeking at the primary care level may explain some of the lower rates of specialist service use observed for migrants compared to non-migrants in previous studies, there appear to be barriers for some migrant groups at the secondary level too. This warrants further investigation. Future research should look at differences between referrals and actual uptake of services among different migrant groups.

Mental health service use among migrant and Swedish-born children and youth: a register-based cohort study of 472,129 individuals in Stockholm.

PURPOSE: Migrant children underutilize mental health services (MHS), but differences according to age, reason for migration, type of problem, and time have not been thoroughly analyzed. We aimed to explore utilization of MHS among migrant children and youth and to study if the hypothesized lower utilization could be explained by fewer neurodevelopmental assessments. METHODS: A cohort of the population aged 0-24 years in Stockholm, comprising 472,129 individuals were followed for maximum 10 years, between January 1, 2006 and December 31, 2015. We categorized individuals as accompanied refugee migrants, unaccompanied refugee migrants and non-refugee migrants, or Swedish-born. We used survival and logistic analyses to estimate rates of utilization of MHS. RESULTS: Migrant children and youth utilized less MHS than the majority population, with hazard ratios ranging from 0.62 (95% CI: 0.57; 0.67) to 0.72 (95% CI: 0.69; 0.76). Refugee and non-refugee children utilized less mental health care than their Swedish peers, apart from the youngest refugees (0-10 years) who had similar utilization as Swedish-born. The lower rates were partly explained by all migrant youths' lower risk of being diagnosed with a neurodevelopmental condition. Time in Sweden had a major impact, such that unaccompanied refugee minors had a higher utilization in their first 2 years in Sweden (OR: 3.39, 95% CI: 2.96; 3.85). CONCLUSION: Migrant youth use less MHS compared with native-born peers, and this is partly explained by fewer neurodevelopmental diagnoses. Strengthening the awareness about unmet needs, and the referring capacity by professionals in contact with migrant children could help reduce barriers to care.

Differential impact of the COVID-19 pandemic on primary care utilization related to common mental disorders in four European countries: A retrospective observational study.

Background: The COVID-19 pandemic is commonly believed to have increased common mental disorders (CMD, i.e., depression and anxiety), either directly due to COVID-19 contractions (death of near ones or residual conditions), or indirectly by increasing stress, economic uncertainty, and disruptions in daily life resulting from containment measure. Whereas studies reporting on initial changes in self-reported data frequently have reported increases in CMD, pandemic related changes in CMD related to primary care utilization are less well known. Analyzing time series of routinely and continuously sampled primary healthcare data from Sweden, Norway, Netherlands, and Latvia, we aimed to characterize the impact of the pandemic on CMD recorded prevalence in primary care. Furthermore, by relating these changes to country specific time-trajectories of two classes of containment measures, we evaluated the differential impact of containment strategies on CMD rates. Specifically, we wanted to test whether school restrictions would preferentially affect age groups corresponding to those of school children or their parents. Methods: For the four investigated countries, we collected time-series of monthly counts of unique CMD patients in primary healthcare from the year 2015 (or 2017) until 2021. Using pre-pandemic timepoints to train seasonal Auto Regressive Integrated Moving Average (ARIMA) models, we predicted healthcare utilization during the pandemic. Discrepancies between observed and expected time series were quantified to infer pandemic related changes. To evaluate the effects of COVID-19 measures on CMD related primary care utilization, the predicted time series were related to country specific time series of levels of social distancing and school restrictions. Results: In all countries except Latvia there was an initial (April 2020) decrease in CMD care prevalence, where largest drops were found in Sweden (Prevalence Ratio, PR = 0.85; 95% CI 0.81-0.90), followed by Netherlands (0.86; 95% CI 0.76-1.02) and Norway (0.90; 95% CI 0.83-0.98). Latvia on the other hand experienced increased rates (1.25; 95% CI 1.08-1.49). Whereas PRs in Norway and Netherlands normalized during the latter half of 2020, PRs stayed low in Sweden and elevated in Latvia. The overall changes in PR during the pandemic year 2020 was significantly changed only for Sweden (0.91; 95% CI 0.90-0.93) and Latvia (1.20; 95% CI 1.14-1.26). Overall, the relationship between containment measures and CMD care prevalence were weak and non-significant. In particular, we could not observe any relationship of school restriction to CMD care prevalence for the age groups best corresponding to school children or their parents. Conclusion: Common mental disorders prevalence in primary care decreased during the initial phase of the COVID-19 pandemic in all countries except from Latvia, but normalized in Norway and Netherlands by the latter half of 2020. The onset of the pandemic and the containment strategies were highly correlated within each country, limiting strong conclusions on whether restriction policy had any effects on mental health. Specifically, we found no evidence of associations between school restrictions and CMD care prevalence. Overall, current results lend no support to the common belief that the pandemic severely impacted the mental health of the general population as indicated by healthcare utilization, apart from in Latvia. However, since healthcare utilization is affected by multiple factors in addition to actual need, future studies should combine complementary types of data to better understand the mental health impacts of the pandemic.

Perceived barriers to care for migrant children and young people with mental health problems and/or neurodevelopmental differences in high-income countries: a meta-ethnography.

OBJECTIVES: To develop conceptual understanding of perceived barriers to seeking care for migrant children and young people (aged 0-25 years) with mental health problems and/or neurodevelopmental differences in high-income countries. DESIGN: Qualitative evidence synthesis using meta-ethnography methodology. We searched four electronic databases (Medline, PsycINFO, Global Health and Web of Science) from inception to July 2019 for qualitative studies exploring barriers to care (as perceived by migrant communities and service providers) for migrant children and young people in high-income countries with neurodevelopmental differences and/or mental health problems. The quality of included studies was explored systematically using a quality assessment tool. RESULTS: We screened 753 unique citations and 101 full texts, and 30 studies met our inclusion criteria. We developed 16 themes representing perceived barriers to care on the supply and demand side of the care-seeking process. Barriers included: stigma; fear and mistrust of services; lack of information on mental health and service providers lacking cultural responsiveness. Themes were incorporated into Levesque et al's conceptual framework of patient-centred access to healthcare, creating a version of the framework specific to migrant children and young people's mental health and neurodevelopmental differences. CONCLUSIONS: This is the first qualitative evidence synthesis on barriers to care for mental health problems and/or neurodevelopmental differences in migrant children and young people in high-income countries. We present an adapted conceptual framework that will help professionals and policy-makers to visualise the complex nature of barriers to care, and assist in improving practice and designing interventions to overcome them. Similar barriers were identified across study participants and migrant populations. While many barriers were also similar to those for children and young people in general populations, migrant families faced further, specific barriers to care. Interventions targeting multiple barriers may be required to ensure migrant families reach care.