Compared to Swedish natives, migrant groups without suicide attempt received more specialised mental healthcare, but migrants from outside the Western countries with attempt received less such care than Swedish natives with suicide attempt. The risk of labour market marginalization varied with regard to previous suicide attempt, region of birth country, and specific labour market marginalisation outcome. For individuals without suicide attempt, all migrant groups had higher risks for long-term unemployment and most had similar risks for long-term sickness absence and lower risks for disability pension as compared to natives. A suicide attempt was associated with higher estimates for all three outcome measures in all groups. For individuals with suicide attempt, all migrant groups had higher risk estimates than natives for subsequent unemployment, and lower estimates for sickness absence and disability pension, as compared to natives. No consistent pattern between different migrant groups with regard to the three outcome measures was observed.
Compared to natives without suicide attempt, the risk for long-term unemployment was higher for migrant subgroups without suicide attempt. The more distant the culture of the country of birth of the respective migrant group was, the higher were the risk estimates. This is in line with previous research suggesting that non-European migrants have a higher risk of unemployment than other migrants and natives . Underlying mechanisms might be both related to post-migration difficulties including psychosocial acculturation problems and ethnical discrimination, but also differences in educational level . In turn, these socio-economic disadvantages of migrants in the host country compared to the native population might be associated with access to lower paid jobs characterised by worse psychosocial environment and higher job insecurity .
Presence of a suicide attempt generally resulted in even higher risk estimates for subsequent unemployment, with generally similar patterns across migrant subgroups as seen in groups without suicide attempt. These findings contribute to the current literature on suicide attempt being a risk factor for subsequent unemployment . The results suggest that the health selection due to a suicide attempt, i.e. the consequences of the deficits in social and occupational functioning associated with the mental disorder underlying the suicide attempt and/or the physical injuries associated with the suicidal act, may act similarly regardless of migration status . We found one exception to this general pattern: migrants from other world regions had similar risk estimates for subsequent long-term unemployment regardless of a suicide attempt. An explanation for this is that migrants from other world regions without a suicide attempt already had a high risk of unemployment, i.e. most prominent difficulties to establish themselves on the labour market. A suicide attempt did not seem to contribute to exacerbate this risk.
Risk patterns for subsequent sickness absence and disability pension differed from those with regard to long-term unemployment. For individuals without suicide attempt, there were similar or only slightly increased risk estimates for the different migrant groups with regard to subsequent sickness absence, and there were even lower risk estimates for most migrant subgroups with regard to subsequent disability pension. To the best of our knowledge, this has not been reported to date. In those individuals with previous suicide attempt, all migrant groups had higher risks for subsequent sickness absence and disability pension compared to natives without suicide attempt. However, in contrast to the patterns observed for unemployment, risk estimates were highest for natives with suicide attempt for both sickness absence and disability pension. Here, estimates were significantly lower for migrants from other world regions with regard to both outcome measures. This is in line with previous findings which show that young individuals with suicide attempt born outside Europe had a higher risk of unemployment but a lower risk of disability pension, as compared to the Swedish-born population . However, findings are inconsistent with other results indicating that adults with a depressive disorder had higher risk estimates for subsequent disability pension if their country of birth was outside Europe . Discrepancies might stem from differences in the study populations, i.e. differences between suicide attempters and patients with depressive disorders, or from differences in age groups. More research is warranted to elucidate these discrepancies in findings.
Earlier studies on suicide attempt have shown cultural differences in the prevalence and severity of suicide attempts [1, 31]. Despite common aetiological features of suicidal behaviour across cultures, risk factors may also differ . For example, lower rates of mental ill-health and a higher likelihood to respond impulsively to stressful life events have been reported for suicidal behaviour of Asian women than what is known from the literature based on women in Western countries . It is possible that if suicide attempts are less related to mental disorders in some migrant groups, some migrant groups might, therefore, be less likely to need a disability pension or a prolonged sickness absence. Another explanation might be connected to higher levels of stigma among some migrant groups with regard to accessing the disability pension and/or taking an extended sickness absence [34, 35].
In addition, some migrant groups may be less informed about the Swedish welfare system and the accessibility of sickness absence and disability pension. Moreover, formal requirements for receiving sickness absence include a minimum level of salary which might not be reached among some migrant groups. Disability pension, in turn, does not have this requirement, but is often preceded by sickness absence, which means that the pathway to disability pension among some migrant groups may deviate from those in natives.
Experiences of discrimination may play a role in the identified associations. Discrimination is likely to be more prevalent against migrants , and may also be associated with an increased risk of suicide attempt. Additionally, discrimination may be at play in terms of greater risk for unemployment, reduced access to the disability pension and a reduced capacity to take a prolonged absence from work.
Moreover, discrimination in the health care setting, as well as with regard to access of care, and adequate treatment, likely plays a role in the identified associations. Here, potential discrepancies can be discussed in the framework of differences in access to care, in clinical manifestation and symptomatology of the underlying disease and consequently in its diagnostics as well as differences in care after a suicide attempt . Adequate care following suicidal behaviour in immigrants/refugees might be hampered by language barriers, as well as the lack of competence in transcultural psychiatry and psychology in the health care settings of the host country .
In this context, it is interesting that natives and EU25 and other Western countries-born individuals showed a strong reduction of risk estimates for disability pension when adjusting for their healthcare characteristics, which was less pronounced in respective analyses for migrant populations from European countries outside the EU and other world regions. This finding may again indicate that a suicide attempt is more strongly related to mental and somatic disease in natives and individuals from Western countries, and/or it may indicate that migrants from birth countries in Europe outside the EU and from other world regions are less frequently seeking healthcare before their suicide attempt. This is supported by our findings that specialised mental healthcare was lower in suicide attempters with birth countries outside EU25 and other world regions than in natives, while such care was higher in these migrants without suicide attempt.
Strengths and limitations
Strengths of the present study are the prospective design based on national register data. These registers have practically no dropouts. Several registers have been evaluated and have shown high data quality, with, e.g. 1.2 and 0.8% missing main diagnoses reported for the National Patient Register and the Causes of Death Register, respectively . Registers of the Social Insurance Agency with data on sickness absence and disability pension indicate received benefits and have generally been considered to be of good quality .
The present study has also limitations. First, due to data availability on national level, only individuals hospitalized for suicide attempt were included. Around a quarter of suicide attempters have been estimated to receive inpatient care, therefore, the present findings can only be generalised to more severe cases of suicide attempts .
Another limitation is that the occurrence of unemployment, sickness absence, and disability pension is affected by regional and temporal changes in social insurance policies and in fluctuations in economic development [38, 39]. Therefore, studies from different birth cohorts and from different countries are needed to assess potential differences in patterns. Finally, heterogeneous groups of migrants were collapsed into categories. This was partly to guarantee sufficient power for the respective analyses and partly due to data availability. This particularly applies to the group “other world regions”. Heterogeneous patterns within this collapsed group seem likely and future studies are warranted to elucidate differences in patterns of labour market marginalisation in this group.