|Year : 2021 | Volume
| Issue : 2 | Page : 215-223
Waiting for Life to Begin, Wishing it Would End: Suicidal Ideation among Newly Arrived Refugees
Anna Leiler, Elisabet Wasteson, Ingrid Zakrisson, Anna Bjärtå
Institution of Psychology and Social Work, Mid Sweden University, Sweden
|Date of Submission||26-Nov-2020|
|Date of Decision||14-May-2021|
|Date of Acceptance||12-Aug-2021|
|Date of Web Publication||09-Sep-2021|
PhD Anna Leiler
Kunskapens väg 1, 83125 Östersund
Source of Support: None, Conflict of Interest: None
Research indicates that subgroups of refugees may be at increased risk for suicidal ideation, but further knowledge on this topic is needed. This study aimed to assess both prevalence and factors associated with suicidal ideation among newly arrived refugees in Sweden. Assessing suicidal ideation was part of a larger project, aiming to develop a model for assessment and treatment of mental health problems among refugees. The included data were based on a cross-sectional survey among 510 asylum seekers and refugees, all under the care of the Swedish Migration Agency. The project group visited 12 asylum accommodations and 9 other locations, asking potential participants to answer a survey with questions on mental health, suicidal ideation and quality of life. Data were analysed using logistic regression. Symptoms of depression, anxiety and posttraumatic stress disorder, low physical and psychological quality of life, and being of young age were all independently associated with suicidal ideation. This study points to the importance of identifying refugees with mental health problems and of providing them with adequate care. It also indicates the importance of assuring a decent quality of life at asylum accommodations, and it shows that the young may constitute an especially vulnerable group.
Keywords: asylum seekers, mental health, quality of life, refugees, suicidal ideation
|How to cite this article:|
Leiler A, Wasteson E, Zakrisson I, Bjärtå A. Waiting for Life to Begin, Wishing it Would End: Suicidal Ideation among Newly Arrived Refugees. Intervention 2021;19:215-23
Key implications for practice
- The association between mental health problems and suicidal ideation is as pertinent among refugees as in the general population.
- The association between quality of life and increased suicidal ideation points to the importance of decent housing standards for individuals seeking asylum in western countries.
- Refugees of young age may constitute an especially vulnerable group, and particular attention needs to be given to these individuals.
| Introduction|| |
In 2012, suicide accounted for 1.4% of all deaths worldwide. For individuals aged 15–29, suicide accounted for 8.5% of all deaths, making it the second most common reason for death in this age group (World Health Organisation (WHO), 2014). Immigrants generally do not seem to be at higher risk than native populations (Amiri, 2020). However, this will depend on which country the person comes from and arrives in. Cultural factors tend to influence suicidal behaviours (Colucci & Too, 2015), in that factors affecting the decision to end one’s life may reflect collective values. Suicide can, for example, be regarded as an unforgiveable sin, a human right or as a ritual obligation. The different meanings ascribed to it may in turn influence suicide rates. Individuals with strong survivalist values and who find religion important, generally show less acceptance of suicidal acts, as well as individuals from countries with large percentages of Catholics, Hindus and Muslims, compared to individuals from countries with large proportions of Buddhists, Orthodox Christians and Protestants (Boyd & Chung, 2012).
The risk of death by suicide among immigrants thus resembles the risk seen in the immigrant’s country of origin (Spallek et al., 2015). In 2016, the crude suicide rate in Sweden (14.8 per 100,000 population for both sexes; WHO, 2018) was significantly higher than in all the most common countries of origin of the arriving refugees (ranging from 1.9 per 100,000 population in Syria to 7.9 per 100,000 in Eritrea). This may thus explain the finding in epidemiological research that in Sweden, refugees are not at increased risk compared either to the host population or to labour immigrants (see, for example, Hollander et al., 2020), although most studies tend to find refugees an especially vulnerable group (Haroz et al., 2020). Few studies focus explicitly on the refugee subgroup of asylum seekers, but according to those that do, male asylum seekers seem to be at increased risk of ending their lives by suicide (Goosen et al., 2011; Kalt et al., 2013; Staehr & Munk-Andersen, 2006).
Suicidal ideation is among the most prominent risk factors for death by suicide (Beck et al., 1999; Brown et al., 2000; Simon et al., 2013), and the cross national lifetime prevalence has been estimated to 9.2% (Nock et al., 2008). Although reported rates of death by suicide vary between countries (from 0.4 to 44.2 per 100,000 population; WHO, 2014), similar rates have been found between developing and developed countries (Nock et al., 2008). However, among refugee groups, point prevalence of suicidal ideation has been estimated to approximately 30% (e.g. to 27% by Akinyemi et al., 2015 and to 31% by Ferrada-Noli et al., 1998a,b).
In the general population, having mental health problems is the most prominent factor associated with death by suicide (Cavanagh et al., 2003), and depression is the most common mental disorder among individuals who end their lives (Hawton et al., 2013). Mental health problems also constitute a risk factor for suicidal ideation, plans and attempts (Nock et al., 2008). Apart from poor mental health, low quality of life (QOL; Goldney et al., 2001) has also been associated with increased risk of suicidal thoughts and behaviours in the general population.
High levels of mental health problems are often found in refugee populations (Blackmore et al., 2020). Higher levels are found among resettled refugees than among nonrefugee migrants, and yet again higher among asylum seekers (Heeren et al., 2014; Posselt et al., 2020). However, little is known regarding the association between mental disorder and suicidality among refugees and asylum seekers. Ferrada-Noli et al. (1998a,b) found an association between posttraumatic stress disorder (PTSD) and suicidal behaviour among refugees in Sweden, and Leiler et al. (2019b) found an association between severity of distress and suicidal ideation among individuals at asylum accommodations, but the link between mental health problems and suicidality in these groups warrants further investigation.
Some risk factors for suicidal thoughts and behaviours are the same for refugees as in the general population (Nock et al., 2008; Vijayakumar & Jotheeswaran, 2010), for example, being of younger age, having less education, and being single. Men generally seem to be at increased risk for death by suicide compared to women, although women normally have higher rates of suicidal ideation. However, one risk factors is specific for refugees: the increased risk associated with an insecure residence status (Lerner et al., 2016; Sundvall et al., 2015; Yilmaz & Riecher-Rössler, 2012).
In 2015, Sweden received almost 163,000 asylum seekers (The Swedish Migration Agency (SMA), 2019). Sweden does not practice detention of asylum seekers, but during this time, large housing facilities, often far from the surrounding societies, were established. While waiting for an asylum decision, refugees are under the care of the SMA, but they are supposed to be relocated to a municipality after receiving a residence permit. In 2016 and 2017, many individuals remained in these facilities, and thus under the care of the SMA, even after receiving a residence permit. Asylum seekers in Sweden are free to leave their dwellings, to work and to attend school (SMA, 2021). However, as many housing facilities were far from the surrounding society, leaving them to visit the city was not always easy. Asylum seekers in Sweden have the right to treatments that cannot be deferred (Socialstyrelsen (The National Board on Health and Welfare), 2019). Although this should be interpreted generously, utilisation of psychiatric care remained sparse (Brendler-Lindqvist et al., 2014). In our previous study (Leiler et al., 2019a), we found high levels of mental health problems among individuals in refugee housing facilities. Mittendorfer-Rutz et al. (2020) reported an alarmingly high suicide rate among unaccompanied refugee minors (URMs), indicating a need for suicide prevention interventions. In the light of this finding, as well as the known association between mental health problems and suicide, we wanted to assess suicidal ideation in our sample. Further on, although the suicide risk clearly seemed elevated among URMs, this is not generally the case among refugees in Sweden (Hollander et al., 2020). Thus, there is a need for a better understanding of which individuals are at increased risk. The present study aims to assess prevalence and factors associated with suicidal ideation among refugees under the care of the SMA. This includes both asylum seekers and individuals with a residence permit, residing in asylum accommodation while waiting to be relocated to a municipality. Both groups will herein be referred to as “refugees under the care of the SMA”.
| Subjects and Methods|| |
Context and Design
The study was a cross-sectional survey conducted at or nearby asylum accommodations in Sweden. Individuals seeking asylum in Sweden normally submit their asylum application directly upon arrival, and are then offered temporary housing provided by the SMA. The present study was performed in the region of Jämtland-Härjedalen, a large and sparsely populated region about 600 km northwest of the Swedish capital. Assessing suicidal ideation among refugees under the care of the SMA was part of a larger project, aiming to develop a model for assessment and treatment of mental health problems among refugees. Data from the present study have been reported elsewhere (Bjärtå et al., 2018; Leiler et al., 2019a,b), however not focusing on factors associated with suicidal ideation.
Asking about suicidal ideation is sensitive and warrants careful consideration. However, research assessing research participants’ reactions to answering questions on suicidal ideation indicate that neither psychological distress, nor suicidal ideation, seems to increase in response to these questions (Blades et al., 2018). Furthermore, the question about suicidal ideation was extracted from a scale measuring depressive symptoms (the Patient Health Questionnaire-9 (PHQ-9), see below), the primary focus of the full project was not to investigate suicidal ideation.
Another ethical dilemma concerns the risk that asylum seekers may feel obliged to participate in proposed research if they are to receive a residence permit. To counter this, it was emphasised in both the written and the oral information that participation could not, in any direction, affect their asylum decisions. Taken together, we judged that the possible benefits associated with conducting this study outweighed possible risks. The full project was approved by the Regional Ethics Board (reference number 2016/364-31).
The sample was a convenience sample of refugees under the care of the SMA, from the age of 18, in Jämtland-Härjedalen, Sweden, between November 2016 and April 2017. In total, this sample consisted of 1332 individuals. Of these, 577 (43%) individuals participated in the study. Due to incomplete answers, 67 individuals were excluded, resulting in a total sample of 510 (38% of 1332) participants. Fifteen individuals completed the survey online (see [Table 1] for demographic characteristics of the sample).
|Table 1 Prevalence of Suicidal Ideation (SI) and Unadjusted Odds Ratios (OR)|
Click here to view
Using an iterative back and forth procedure, all materials were translated into the five, at the time, most common refugee languages (Arabic, Dari, Farsi, Somali and Tigrinya). A letter was sent to all refugees under the care of the SMA, speaking any of these languages (N = 1265). In this letter, they were invited to participate in the study either by using a link or by coming to a screening meeting that was conducted at an asylum accommodation, or in areas where most refugees were accommodated in apartments, in nongovernmental organisation (NGO) centres. The project screening group subsequently visited 12 asylum accommodations and 9 NGO centres. At screening meetings, potential participants received oral information regarding the study and were given the opportunity to ask questions. After giving an active digital consent, they were asked to answer the survey on-site using a tablet personal computer. For participants with low reading proficiency to be able to participate, all instructions and questions were recorded in Arabic, Dari, Farsi and Tigrinya.
As the survey was answered anonymously, individual follow up or direct referrals were not possible. However, in Sweden, it is possible for individuals (including newly arrived refugees) to, by themselves, seek mental health care. Information on how to do so was provided both by bilingual project personnel, most of whom had worked in health care in their home countries, and in translated leaflets. Contact information to a member of the project was provided, and participants could always turn to us with questions or for guidance. During the initial data collection, we learned that many individuals spoke several languages. We therefore wanted to offer individuals speaking other languages the possibility to participate, albeit not in their mother tongue. A new letter was thus sent out to all refugees under the care of the SMA regardless of mother tongue (n = 1332). This letter invited them to answer the survey online in any language version (including Swedish and English). In this letter, it was made clear that those who had already answered the survey should not take it again.
As an adjustment to possible reading deficiencies among the participants, brevity was prioritised while choosing instruments. All instruments had previously been used in refugee populations, which were thought to indicate that the instrument had at least some levels of transcultural validity.
The PHQ-9 is a self-report questionnaire originally designed for depression screening in primary care. It consists of a general question: “Over the last 2 weeks, how often have you been bothered by any of the following problems?” which is followed by nine items consistent with the diagnostic criteria for major depression. Each item is scored from 0 to 3. A score of 0 equals “not at all”, 1 equals “several days”, 2 equals “more than half the days” and 3 equals “nearly every day”. For the purpose of this study, the PHQ-9 was split in two parts, screening for depressive symptoms and suicidal ideation, respectively.
The first eight items were used to assess depressive symptoms. The version using only the first eight items of the scale is referred to as the PHQ-8 (Kroenke et al., 2009; Kroenke & Spitzer, 2002). In this version, the ninth item, asking about suicidal ideation, is omitted. The same cut-offs that are recommended for the PHQ-9 are also recommended for the PHQ-8 (Kroenke & Spitzer, 2002): A score of 10 or above represents clinically significant depression. When assessing corrected item-total correlations on the PHQ-9 (Lee et al., 2007), no single item detracted from overall scale functioning; however, the ninth item correlated the least with the total. Deleting it did not significantly change the alpha value. Cronbach’s α for PHQ-8 was 0.87 in the present sample, the same as when using the nine-item version (Leiler et al., 2019a).
The ninth item of the PHQ-9 was used to assess suicidal ideation. Item 9 asks, “Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?”. Any answer above 0 is considered as positive (Kroenke et al., 2001). Uebelacker et al. (2011) compared this single item to the use of a structured interview to assess suicidal ideation and found the sensitivity of the PHQ-9 item to be 0.69 and specificity 0.84. It has been shown that a positive response to item 9 is a predictor of suicide attempt or suicide death over the following year (Simon et al., 2013, 2016).
Symptoms of anxiety were measured by the General Anxiety Disorder 7 (GAD-7; Kroenke et al., 2007), an instrument frequently used to assess severity of anxiety symptoms in primary care settings. It consists of seven items scored 0–3, total score maximum 21. A score of 8 or above is used to detect anxiety disorders. The instrument has good psychometric properties; in the present sample, Cronbach’s α was 0.91.
Risk for PTSD was measured by the Primary Care PTSD Screen (PC-PTSD; Prins et al., 2004) which is a 4-item screener for posttraumatic stress. It consists of four questions regarding avoidance, intrusions, arousal and emotional numbing. Each question is answered either yes (1) or no (0) and a score of 3 or above is used to detect PTSD. The scale has acceptable psychometric properties (Kimerling et al., 2006) and Cronbach’s α in the present sample was 0.69.
The QOL was measured by the World Health Organisation Quality of Life − brief version WHOQOL-BREF (WHOQOL Group, 1998), a transcultural measure of QOL and health. It is scored from 1 to 5 and shows good psychometric properties (Skevington et al., 2004). The WHOQOL-BREF assesses physical, psychological, social and environmental health and QOL. Raw scores are transformed to domain scores ranging from 4 to 20. In a sample consisting of 11,830 adults from 23 countries (Skevington et al., 2004), mean domain scores ranged from 13.5 to 16.2 (standard deviation: 2.6–3.2). The authors defined a mean domain score of 12 as a scale midpoint, where QOL is judged as neither good nor bad. Cronbach’s α in the present sample was 0.92.
Gender (male, female or other), age (age groups 18–25, 26–35, 36–45 and 46 or older), marital status (married, divorced or single) and country of origin (Afghanistan, Syria, Iraq, Eritrea, Somalia or “other”) and residence status (having received a residence permit in Sweden or not) were included as sociodemographic factors.
Data Treatment and Statistical Analysis
Small categories were collapsed into larger. The age groups 46–55 (n = 45), 56–65 (n = 12) and 66+ (n = 3) were collapsed into one category (n = 60). Nationalities with less than five individuals (altogether n = 21) and the group of unknown nationalities (n = 51) were collapsed into one category (n = 72). Divorced (n = 24) and widowed (n = 9) participants were collapsed into one category (n = 33). The psychiatric variables were dichotomised in accordance with previously validated cut-offs: an answer of 1 or above on item 9 of the PHQ-9 was coded as 1 (Kroenke et al., 2001), thus indicating the presence of suicidal ideation. On the PHQ-8, scoring 10 or above was coded as 1 (Kroenke et al., 2009). On GAD-7, the cut-off was set at 8 or above (Kroenke et al., 2007). For PC-PTSD, the cut-off was set at 3 or above (Prins et al., 2004). For QOL, the cut-off was set at 12, with scores below 12 coded as 1 (Skevington et al., 2004). The psychological variables, as well as the domains of QOL, were investigated for multicollinearity. As could be expected all variables were intercorrelated (r ranging from 0.17 to 0.62); however, the variable inflated factors and tolerance levels were well within any risk cut-offs.
Binary logistic regression was used to identify the factors associated with suicidal ideation. As a first step, all variables were assessed at the univariate level. To identify factors independently associated with suicidal ideation, all factors statistically significant at the univariate level were then assessed in a multivariate logistic regression analysis.
As the dependent variable was assessed with an item from the PHQ-9, which also is the scale used for assessing depressive symptoms, depressive symptoms could be expected to correlate with suicidal ideation. Due to this possible bias, a hierarchical variable selection procedure was used. Depressive symptoms were first entered separately. In the next block, all other factors, statistically significant at the univariate level, were entered. Purposeful variable selection, as proposed by Hosmer et al. (2013) was used: the variables that were not significant in the multivariate model were removed one by one, starting with the variable with lowest Wald value. At the removal of each nonsignificant variable, the value of each remaining estimate was assessed to make sure that the removal did not change the odds ratios (ORs) of the remaining variables with more than 20%. When only significant variables and confounders remained, variables not entered in the initial multivariate model were added one at a time and removed if not contributing to the overall model or the included factors.
| Results|| |
When assessed separately, residence status, nationality, age and marital status were all significantly associated with suicidal ideation, as well as all psychiatric factors and the four domains of QOL (see [Table 1]). Prevalence of suicidal ideation was 33.9% in the total sample, and prevalence divided by subgroups is shown in [Table 1].
The first block of the multivariate analysis, including only depressive symptoms explained between 16% (Cox & Snell) and 22% (Nagelkerke R2) of the variance in suicidal ideation. This step increased the percentage correctly classified to 66.5%, from the 66.1% in the constant only model. The next step, the addition of the other univariate significant factors, was in itself significant and improved the overall model (see [Table 2]). The percentage of explained variance increased to between 27.3% (Cox & Snell) and 37.7% (Nagelkerke R2). The percentage of correctly classified cases increased to 75.0%.
|Table 2 Initial Multivariate Analysis Including All Factors Univariately Showing an Association with Suicidal Ideation|
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The variables not significant in the multivariate model were then removed one by one. Removing these variables did not change the estimates of the remaining variables. To further assess the effect of depressive symptoms, this variable was now removed. This operation did change the OR of anxiety symptoms from 2.03 to 3.59 (an increase of 77%), the depression variable was thus re-entered. As a final operation, the variable not included in the first model; sex was now entered. This did not affect the ORs of the other variables, nor did it in itself contribute to the model, and was thus removed. These procedures resulted in a model including symptoms of anxiety, depression, PTSD, age and, finally, physical and psychological QOL (see [Table 3]). These factors together explained between 26.1% (Cox & Snell) and 36.1% (Nagelkerke R2) of the variance in suicidal ideation and 76.0% of the cases were correctly classified.
|Table 3 Final Model: Factors Independently Associated with Suicidal Ideation|
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| Discussion|| |
The results of this study point to an association between poor QOL and increased risk for suicidal ideation among asylum seekers and newly arrived refugees. They also suggest an increased risk among the young. Further on, this study serves to establish the link between mental health problems and suicidal ideation among refugees.
As Akinyemi et al. (2012) point out, the association between low QOL and suicidal ideation warrants attention to the overall welfare of refugees, for example, in terms of housing conditions. But how should QOL among refugees of various cultures be interpreted? WHO’s QOL group states that QOL is “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals” (WHOQOL Group, 1995, p. 1405), indicating that both cultural and individual values influence perceived QOL. In the current study, the association was particularly strong between physical QOL and suicidal ideation, independent of other mental health problems. It is possible that participants with physical health problems have chronic pain or have been victims of violence, explaining the association between physical QOL and suicidal ideation, and it has previously been suggested that somatic symptoms play an important role in the QOL of refugees (Kounou et al., 2017). In our previous study (Leiler et al., 2019a), a correlation was found between physical QOL and depressive symptoms, and given the interplay between physical and somatic symptoms (see, for example, Bhugra & Mastrogianni, 2004, for a discussion on depression and somatisation), it is also possible that the association between physical QOL and suicidal ideation is via depressive symptoms.
Being young of age was the last factor independently associated with suicidal ideation. The WHO (2014) reports that suicide is the second most common reason for death in the age group 15–29. Mittendorfer-Rutz et al. (2020) found a particularly high prevalence of death by suicide among URMs. Nock et al. (2008) found suicidal ideation to be associated with young age. The results of this study are in line with previous research, and strengthen the notion of the young as especially vulnerable. Many young individuals flee their home countries alone, and may lack social support in their host country, and lack of social support has shown to be an important predictor of distress (see, for example, Carlsson et al., 2006). Refugee youths also seem to receive more compulsory in-patient psychiatric care than their in-born peers, indicating that they do not receive care in the mild or early stages of mental ill-health (Manhica et al., 2017). There is clearly a need for mental health screening and interventions to be more readily accessible for this group.
Previous reports have found an increased prevalence of suicidal behaviour among asylum seekers (Goosen et al., 2011; Staehr & Munk-Andersen, 2006). However, in the present study, residence status did not contribute significantly to the model. One explanation could be that the effect of residence permit was obscured by the high levels of mental health problems found in the sample. However, another reason could be that undetermined residence status, although in itself a risk factor for mental health problems (Gerritsen et al., 2006; Posselt et al., 2020) is not decisive of suicidal ideation; it is more likely the presence of mental health problems that is related to suicidal ideation.
At the univariate level, several other demographic factors were significant; however, when entered into a model with psychiatric variables and QOL, the significance of all demographic factors but age diminished. Previous findings of specific sociodemographic risk factors for suicidal ideation were thus not replicated. However, these results are in line with previous results by for example Cavanagh et al. (2003), showing that mental disorders had a stronger association with suicidal behaviour than other factors.
One-third of the participants reported suicidal ideation, similar to the numbers found by Ferrada-Noli et al. (1998a,b) and Akinyemi et al. (2015) in refugee populations. This is three times higher than the 9.2% found in the cross national, general population (Nock et al., 2008) and twice as high as the rates reported by Simon et al. (2016) when using the PHQ-9. These numbers are alarmingly high and indicate that the mental health of asylum seekers and newly arrived refugees needs to be tended to.
In interpreting the results from this study, some limitations ought to be considered. One regards the lack of a referral pathway for those needing it. We initially planned to conduct the study in conjunction to the health examination that all asylum seekers are offered, which would have enabled the possibility of directly referring those in need of care. However, when the study was initiated, most individuals under the care of the SMA had already received their health examination, which is why the study was conducted separately, and instead of referrals, information on how to seek care was provided. Methodologically, a convenience sampling method was used which limits the generalisability of the results, and only 38% of the total sample participated, which might have affected the results. Although the sample resembled the population regarding sex and age groups (SMA, 2019), it is possible that a higher proportion of young individuals with suicidal ideation chose to participate. Another limitation concerns the instrument used to assess suicidal ideation. Although Simon et al. (2013, 2016) showed response to item 9 on the PHQ-9 to be predictive of suicide attempts or death by suicide, some studies question the usefulness of this item for assessing suicidal ideation (see, for example, Razykov et al., 2012). In the present study, the suicidal ideation measure and the measure of depressive symptoms were derived from the same instrument, which further complicates the use of this item to assess suicidal ideation. Although the included instruments were partly chosen because they had previously been used in refugee populations, the matter of transcultural validity is complicated and there are studies pointing to the need for differentiated cut-offs for asylum seekers (Grupp et al., 2020). The present study further left a lot variance unexplained, indicating that the full range of factors affecting suicidal ideation was not captured.
| Conclusions|| |
The high prevalence of suicidal ideation in present study should not be interpreted as bearing the meaning that all individuals expressing suicidal ideation will end their lives by suicide. It is, however, reasonable to interpret the results as another sign of the high levels of suffering among asylum seekers and newly arrived refugees. It further points to the importance of detecting individuals with mental health problems and to assure a decent QOL for refugees under the care of the SMA. It also indicates that young refugees may constitute an especially vulnerable group.
Financial support and sponsorship
The research was funded by AMIF (the Asylum, Migration, and Integration Fund − European Commission), project number I2119.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]