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Refugee migration and risk of schizophrenia and other non-affective psychoses: cohort study of 1.3 million people in Sweden

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Hollander, Anna-Clara, Dal, Henrik, Lewis, Glyn, Magnusson, Cecilia, Kirkbride, James B, Dalman, Christina·2016·BMJ

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Abstract

OBJECTIVE: To determine whether refugees are at elevated risk of schizophrenia and other non-affective psychotic disorders, relative to non-refugee migrants from similar regions of origin and the Swedish-born population. DESIGN: Cohort study of people living in Sweden, born after 1 January 1984 and followed from their 14th birthday or arrival in Sweden, if later, until diagnosis of a non-affective psychotic disorder, emigration, death, or 31 December 2011. SETTING: Linked Swedish national register data. PARTICIPANTS: 1,347,790 people, including people born in Sweden to two Swedish-born parents (1,191,004; 88.4%), refugees (24,123; 1.8%), and non-refugee migrants (132,663; 9.8%) from four major refugee generating regions: the Middle East and north Africa, sub-Saharan Africa, Asia, and Eastern Europe and Russia. MAIN OUTCOME MEASURES: Cox regression analysis was used to estimate adjusted hazard ratios for non-affective psychotic disorders by refugee status and region of origin, controlling for age at risk, sex, disposable income, and population density. RESULTS: 3704 cases of non-affective psychotic disorder were identified during 8.9 million person years of follow-up. The crude incidence rate was 38.5 (95% confidence interval 37.2 to 39.9) per 100,000 person years in the Swedish-born population, 80.4 (72.7 to 88.9) per 100,000 person years in non-refugee migrants, and 126.4 (103.1 to 154.8) per 100,000 person years in refugees. Refugees were at increased risk of psychosis compared with both the Swedish-born population (adjusted hazard ratio 2.9, 95% confidence interval 2.3 to 3.6) and non-refugee migrants (1.7, 1.3 to 2.1) after adjustment for confounders. The increased rate in refugees compared with non-refugee migrants was more pronounced in men (likelihood ratio test for interaction χ(2) (df=2) z=13.5; P=0.001) and was present for refugees from all regions except sub-Saharan Africa. Both refugees and non-refugee migrants from sub-Saharan Africa had similarly high rates relative to the Swedish-born population. CONCLUSIONS: Refugees face an increased risk of schizophrenia and other non-affective psychotic disorders compared with non-refugee migrants from similar regions of origin and the native-born Swedish population. Clinicians and health service planners in refugee receiving countries should be aware of a raised risk of psychosis in addition to other mental and physical health inequalities experienced by refugees.

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Authors: Hollander, A.-C., Dal, H., Lewis, G., Magnusson, C., Kirkbride, J. B., & Dalman, C.
Affiliations: Karolinska Institutet (SE)
Region Stockholm (SE)
University College London (GB)
Corresponding author: Hollander, Anna-Clara
ORCID: Hollander, Anna-Clara
Dal, Henrik
Lewis, Glyn
Magnusson, Cecilia
Kirkbride, James B
Dalman, Christina
Venue: BMJ
Publisher: BMJ
Published: 2016-03-15
Volume: 352
Pages: i1030
ISSN: 1756-1833 (ISSN-L)
DOI: 10.1136/bmj.i1030
PMC: PMC4793153
OpenAlex: W2298599425
Cited by: 240
References: 38
Citations by year: 2026: 5 · 2025: 12 · 2024: 16 · 2023: 16 · 2022: 21 · 2021: 32 · 2020: 34 · 2019: 41 · 2018: 31 · 2017: 26 · 2016: 6
FWCI: 46.41
Type: journal article
Language: en
Update notices: correction (2016-05-27)
Open access: hybrid
doi.org
Licence: cc-by
www.bmj.org/licenses/tdm/1.0/terms-and-conditions.html (tdm)
Locations: BMJ (publishedVersion, cc-by)
Europe PMC (PubMed Central) (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
UCL Discovery (University College London) (submittedVersion)
HighWire Press Open Archive (submittedVersion)
Funders: Wellcome Trust (101272, 101272/Z/13/Z)
Vetenskapsrådet
Forskningsrådet om Hälsa, Arbetsliv och Välfärd
Topics: Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
Keywords: refugees, schizophrenia, non-affective psychosis, psychosis risk, immigrant mental health, region of origin, sex differences, psychosis incidence, migration and mental health, Sweden, Middle East and North Africa, sub-Saharan Africa, Asia, population density, disposable income
MeSH terms: Adolescent, Adult, Aged, Europe, Eastern, Female, Humans, Male, Middle Aged, Psychotic Disorders, Refugees, Russia, Schizophrenia, Socioeconomic Factors, Sweden, Transients and Migrants, Proportional Hazards Models, Age Distribution, Sex Distribution, Africa South of the Sahara

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Refugee migration and risk of schizophrenia and other non-affective psychoses: cohort study of 1.3 million people in Sweden

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