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Suicide in Immigrants: An Overview

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Suicide in Immigrants: An Overview

Abstract

Globalization in the Internet era has rendered job mobility and migration frequent and important social phenomena, with implications at several different levels of societies. In addition, migration, either voluntary or forced, is accompanied by significant changes in suicide ideation, frequency of suicide attempts and rates of suicide of people that migrate compared to the host country. However, several different peculiarities render the interpretation of the interaction of migration-suicidality as quite complex. This article provides an overview of the most significant aspects that contribute to this complexity, in order to provide the reader with a road map for better orientation in a world of rapidly changing landscapes.
Open Journal of Medical Psychology, 2013, 2, 124-133
http://dx.doi.org/10.4236/ojmp.2013.23019 Published Online July 2013 (http://www.scirp.org/journal/ojmp)
Suicide in Immigrants: An Overview
Katarzyna Anna Ratkowska1, Diego De Leo1,2,3*
1De Leo Fund, Padua, Italy
2Australian Institute for Suicide Research and Prevention, Griffith University, Mt Gravatt Campus, Mt Gravatt, Australia
3Slovene Centre for Suicide Research, University of Primorska, Koper, Slovenia
Email: *d.deleo@griffith.edu.au
Received April 15, 2013; revised May 27, 2013; accepted June 8, 2013
Copyright © 2013 Katarzyna Anna Ratkowska, Diego De Leo. This is an open access article distributed under the Creative Com-
mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
ABSTRACT
Globalization in the Internet era has rendered job mobility and migration frequent and important social phenomena,
with implications at several different levels of societies. In addition, migration, either voluntary or forced, is accompa-
nied by significant changes in suicide ideation, frequency of suicide attempts and rates of suicide of people that migrate
compared to the host country. However, several different peculiarities render the interpretation of the interaction of mi-
gration-suicidality as quite complex. This article provides an overview of the most significant aspects that contribute to
this complexity, in order to provide the reader with a road map for better orientation in a world of rapidly changing
landscapes.
Keywords: Globalization; Migration; Acculturation Stress; Inter-Generational Conflicts; Asylum Seekers
1. Globalization and Suicide
Already in 1897, Durkheim [1] stated that the changes
associated with modernization were related to higher
rates of suicide in European countries. After the Second
World War and the collapse of the Soviet empire, a phe-
nomenon somewhat similar to what reported by Durk-
heim, defined as “globalization” has expanded. Global-
ization is a process of creating networks between indi-
viduals from different continents, through flows of peo-
ple, information, ideas, capital and goods. It manifests
itself in the increase of economic and political connec-
tions between countries, faster transportation, more effi-
cient forms of instant communication, use of new tech-
nologies such as the Internet, and changes in jobs type
and location [2]. Globalization is breaking down natural
boundaries: it makes it possible to travel from one culture
to another, either physically or through television, Inter-
net, movies and books.
Global migration and rapid changes in the social fabric
and context and in the labour market could contribute to
further isolate people, increasing their risk of suicide.
Globalization may also increase suicide probability
through increased accessibility of alcohol and drugs,
while decreasing protective factors specific to each cul-
ture through the process of homogenization or “cultural
hybridization” [2,3].
2. Emigration and Suicidal Behaviour
Emigration is defined as the process by which an indi-
vidual moves from one cultural context to another, in
order to settle for a long period of time or lifelong [4].
Emigration can occur en masse or individually. For ex-
ample, people who emigrate for economic or academic
reasons can move initially alone and then be followed by
families. Instead, people who emigrate for political
causes move more often in mass, with or without fami-
lies [5].
The process of migration (human movement in general)
has been divided into three phases: the pre-migration,
which includes the decision to migrate and the prepara-
tion for it; the step of emigration, i.e., the physical trans-
fer of the person from one place to another, and the
post-migration, defined as the process of integration of
immigrants in the new social and cultural context of the
hosting country, where new rules and roles have to be
learned [5]. Quite clearly, this process might vary sig-
nificantly from person to person [4].
Immigrants might have higher rates of psychopa-
thology and suicidal behaviour than the host populations,
due to exposure to the stress of the migrating process.
The ending of the links with their country of origin, the
*Corresponding author.
C
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K. A. RATKOWSKA, D. DE LEO 125
loss of status and social network, a sense of inadequacy
because of language barriers, unemployment, financial
problems, a sense of not belonging, and feelings of ex-
clusion can cause loss of interest in entering into a rela-
tionship with others, and cause a variety of psychiatric
disorders such as depression, anxiety, post-traumatic
stress disorder, addiction to alcohol and drugs, and lead
to loneliness and hopelessness, and suicidal behaviours
[4,6,7].
The person might live a condition similar to bereave-
ment, caused by the loss of their previous social structure
and culture. The most missed aspects are the language
(especially colloquial language and dialect), attitudes,
values and social support networks. The pain for these
losses is a natural consequence of emigration. However,
if the suffering causes significant distress or impairment
and lasts for a long period of time, professional support
may be necessary [5].
Migration poses a risk not only for immigrants but also
for the families remained in the country of origin. For
example, it has been observed that the next of kin of
Mexican immigrants in the United States were at greater
risk of suicidal ideation and suicide attempts that Mexi-
cans without a family history of emigration [8]. Emigra-
tion could weaken family ties, lead to feelings of loneli-
ness and insecurity, and thus increase the risk of suicide
among family members who remained at home [8].
3. Acculturation and Acculturation Stress
“Acculturation” refers to the changes that groups and
individuals undergo when they come into contact with a
different culture. Acculturation stress is instead a more
specific concept and refers to the psychological reactions
that result directly from the process of acculturation. The
latter can be a risk factor for suicidal behaviour [6].
Acculturation is a two-way process, where members of
both cultures (the migrant and the host) do change. In
order to witness a successful acculturation process, the
person or the group of individuals should retain their own
cultural identity but in the meantime establish a good
relationship with the host society: there should be then
integration between the two cultures or “biculturalism”.
In some cases, however, the immigrant encounter with
the dominant culture may produce different outcomes,
such as assimilation, rejection or “deculturation”. “As-
similation” indicates the loss of the cultural identity of
origin, replaced by identification with the dominant
group. It is therefore a unidirectional adaptation process,
where the migrants adopt the language, laws, religion,
norms and behaviours of the dominant culture.
“Rejection” refers to the maintenance of the cultural
identity of origin without establishing a positive attitude
towards the host community. “Deculturation” is instead
the loss of own cultural identity in the absence of a posi-
tive relationship with the dominant culture [5,9]. Ac-
cording to some researchers, the highest degree of social
assimilation corresponds also to the highest risk of sui-
cide; for acculturation, instead, there would be the op-
posed trend [10]. One possible explanation is that as-
similation, in addition to leading to more probable im-
provements in own economic position, could reduce the
protective factors, such as religion, cultural identity and
integration among immigrants in the same area [11].
Acculturation stress may be composed of a mixture of
emotions and behaviours, including anxiety and depres-
sion, and feelings of marginality and alienation, psycho-
somatic symptoms and identity confusion [10]. Some
studies have reported the existence of a significant corre-
lation with suicide ideation [9].
Individuals who migrate from predominantly collec-
tivist societies to individualistic societies may face seri-
ous problems of adaptation. This could result in a real or
perceived lack of adequate social support system, dispar-
ity between expectations and reality, and low self-esteem
[5]. Many immigrants undergo radical changes in their
social status and may also be subject to discrimination.
This could be an additional risk factor for suicide, as
evidenced by one of the US studies where immigrant’s
suicide rates were positively correlated with the negative
valence of the words used by the majority to describe
their ethnic group [12].
The main variables that can reduce the stress of accul-
turation, and therefore lower the levels of depression and
suicidal ideation, are social support within the family and
the new community, a good socio-economic status, self-
esteem, coping skills, knowledge of the new language
and culture, the voluntary choice to emigrate, hope for
the future, strong religious beliefs, and high degree of
tolerance towards other cultures [5,6,10]. Immigrants
who experience a sense of loss for their culture and feel a
sense of guilt for having left their homeland may dis-
cover, with the progress of the acculturation process, to
be able to feel more part of the new country. When the
individual becomes more linguistically and socially ex-
pert in the dominant culture, the latter may appear less
threatening and more inviting, and social support can
come in the form of new friendships, job opportunities,
and medical care, thus reducing the feelings of loss and
grief related to the process of emigrating [5]. Usually,
immigrants who perceive the changes embedded to the
acculturation as an opportunity experience less stress and
present less suicide ideation [6].
4. Cultural Differences and Suicide Rates
among Immigrants
Often there is confusion in the definition of culture, eth-
nicity and race of the immigrant. “Culture” is the set of
shared ideas, meanings and roles, in other words, the lens
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K. A. RATKOWSKA, D. DE LEO
126
through which each person perceives and understands the
world. The ethnic group usually shares the same geo-
graphical origin, the same culture, language and religious
traditions. The race involves instead the genetic homo-
geneity, and is characterized by physical appearance—
especially skin colour—but provides in itself little infor-
mation on the ethnic group to which the immigrant be-
longs [13].
Several studies show that suicide rates vary from
country to country, and that the rates among immigrants
tend to follow those of the country of origin, showing a
significant and positive correlation (from moderate to
strong) between the two values [14-18]. Most of the re-
search originated in the United States, but the same type
of evidence has been obtained in other host countries,
such as Austria, Australia, Canada, Sweden and the
United Kingdom. The similarity of the rates with those of
the country of origin was also found among immigrants
of second generation [19,20]. In a study conducted in
Austria lowest rates were found among Turkish immi-
grants and the highest among the Japanese [20]. This
result was in line with the rates of both countries of ori-
gin and with those observed in other host countries:
lower for Turks in Germany, high for the Japanese in the
United States [20]. A similar trend was found in a study
involving ten European countries: Turkey, Switzerland,
Belgium, Finland, Israel, the Netherlands, Italy, Sweden,
Estonia and Germany [21]. In this survey, the highest
rates of suicide attempts among immigrants generally
corresponded to higher rates of suicide in the country of
origin, and there was also an analogy between the rates
of suicide attempts of the same ethnic group in different
host countries [21]. Similarly, in 33 studies that reported
rates of suicide among immigrants from almost 50 na-
tionalities in seven host countries (Australia, Austria,
Canada, England, the Netherlands, Sweden and the USA),
the rates of suicide among immigrants and those of the
countries of origin were strongly correlated [18].
In most studies conducted in Europe, America and
Australia, the highest risk of suicide was found in immi-
grants from northern Europe (including the UK, Ireland
and Finland), and Eastern Europe (especially from Rus-
sia and Hungary). The lowest risk was instead found in
immigrants from southern Europe and the Middle East.
With regard to immigrants from Asian countries, the risk
of suicide seems generally low for men but appreciably
higher for women. The rates vary, therefore, not only in
relation to the country of origin but also for sex of the
immigrant [5,19,21-24]. For example, in a study con-
ducted in the United States, Asian, black and Hispanic
men had the lowest risk of suicide, while non-Hispanic
white and Asian women had higher risk than the host
population [14]. The apparently difficult cultural transi-
tion of Asian women will be discussed in the next sec-
tion.
The high suicide rates among immigrants from North-
ern and Eastern Europe might be partly explained by the
high alcohol consumption typical of these countries. For
example, there is a significant correlation between alco-
hol consumption and suicide in Finland; Finnish immi-
grants who died by undetermined causes of death in
Sweden also tend to have high alcohol levels in their
blood [26]. A similar trend was found in Russia, where
suicide rates related to alcohol abuse are very high, and
among Russian immigrants who died by suicide in Esto-
nia [27].
The low rates of suicide among immigrants from
southern Europe, the Middle East and Asia may be due to
some protective factors, such as the strong influence of
traditional values, family and religious beliefs. These
countries are more collectivist, have strong family ties
and a strong group identity outside their country of origin.
Both in Catholic and Muslim countries religion may be a
strong deterrent to suicide, which is considered as a sin in
the Catholic religion and as haram, or forbidden, by the
Islamic law (sharia) [14,28]. The protective role of re-
ligion could also depend on the ties with the religious
community, which might represent a strong source of
social support [6,10].
5. Suicide in South Asian Women
The stress of acculturation and intergenerational conflicts
related to acculturation appear to contribute to suicidal
behaviour in young South Asian immigrant women in
various countries around the world. For example, in
Great Britain, Asian women attempt suicide three times
more than their white race peers, while young Asian
males are less likely to die by suicide than their white
race peers [29]. Even young Hindustani women immi-
grant in the Netherlands attempt suicide four times more
often than young Dutch women [30]. The rates are high-
est among women aged 18 - 25 years, but not in adoles-
cents. This seems to suggest that when women start to
find their way in life, they may experience more cultural
conflicts with parents and other family members [5].
In many cases, migrant women follow their primary
provider, this being husband or father. They often have
low level of education, do not know the language and
culture of the host country, live isolated and without
friends. Their experience of migration and response to
stress can be so very different from that of men. Women
can experience the cultural conflict and the transition
from the traditional cultural identity in the West. In some
cases, husbands and in-laws want the woman to reach
good levels of education and establish a career, but at the
same time remaining true to their traditional female role
[31]. The changes and role expectations that women live
cause them family conflicts that their male counterparts
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K. A. RATKOWSKA, D. DE LEO 127
do not experience [32]. For example, they may have
family disputes on marriage (often combined), the style
of life, and submission to husband or parents [31].
Suicidal ideation and behaviour in Asian women seem
to be associated with poor communication with parents
and the lack of affection from them, in the presence of
high levels of control of cultural values [33]. According
to Durkheim’s “fatalistic suicide” hypothesis, in many
cases these values are imposed by the family and are no
longer seen as their own. The traditional rules concerning
the most important situations in life, such as marriage,
divorce and sexuality then begin to be experienced as
oppressive, and suicide becomes the only possible way to
influence the course of their lives. It is clear that, in this
case, strong links with the community of origin bring
more risk factors than protective factors [34].
6. Immigrants in Italy
In recent decades, Italy has undergone major socio-po-
litical changes that have profoundly influenced the life of
the country and its inhabitants. Like Ireland, Spain and
Portugal, Italy has transformed itself from a country of
emigrants to a desirable destination for immigrants.
These often come as refugees in poor health conditions,
and with the hope of finding “heaven” [35,36].
The data published on March 12, 2012 by the Italian
National Institute of Statistics show that there were over
4.5 million foreigners living legally in the country in
2011, an increase of 7.9% from 2010 to 2011. These data
covered all foreigners in possession of a valid residence
permit, which represent approximately 7.5% of the resi-
dent population. Almost half (46.3%) of the citizens le-
gally residing in Italy obtained a residence permit for an
indefinite period. In 2010, approximately 60% of the
permits were issued for work, 30% for family reasons,
and 10% for other causes. In addition, it has been esti-
mated that there are about 700,000 illegal immigrants in
Italy [4].
Following the increased flow of immigration, there has
also been a significant increase in the number of foreign-
ers who have attempted suicide. For example, in Padua,
comparing the periods 1992-1996 and 2002-2006, in the
first period only 2.1% of people who have attempted
suicide were not of Italian origin, in the second period
instead foreigners accounted for 18.2% of the examined
sample [36]. In this study, migrants of Romanian origin,
Moldova and North Africa were most at risk. This might
depend on the poor socio-economic conditions of these
immigrants. For example, with regard to the Romanian
immigrants in Veneto Region, even though the majority
of them arrive for business reasons, they often perform
less qualified tasks, and in less favourable working con-
ditions [36].
It is possible that there is a strong political and ideo-
logical bias towards immigrants [36]. Italians, in general,
show two main attitudes: on the one hand they are con-
vinced that immigrants are necessary for the economy;
on the other, they have also developed the conviction that
illegal immigration and crime are deeply correlated [4].
In a study involving only immigrants resident in Italy
for at least 5 years, the risk of suicidal behaviours was
similar between Italians and immigrants. This finding
suggests the positive mediation of certain factors, such as
acculturation, cultural proximity and improved socio-
economic conditions [4].
7. Genetic and Environmental Factors
Immigrants bring with them both a specific genetic pro-
file (containing predisposition to physical and mental
illness and perhaps to certain conducts, such as tendency
to dyscontrol and suicidal behaviour) and environmental
factors, such as the culture of the country of origin and
personal experiences.
According to some initial research on the role of ge-
netics in suicidal behaviour in Slovenia, individuals with
different surnames would also present different risk of
suicide, regardless of the area of the country in which
they live [37]. The correspondence between suicide rates
of immigrants and their country of origin described in the
section on cultural differences is consistent with the hy-
pothesis of genetic risk factors. The genetic makeup re-
mains largely intact despite the environmental changes,
and also tends to be transmitted from one generation of
immigrants to the other because of the tendency to en-
dogamy, or marriage within the same ethnic group, that
exists in many communities. In this way, suicide rates in
various groups remain almost unchanged [20].
Unlike genetic factors, the influence of the culture of
the country of origin may decrease over time. Many im-
migrants—to be possibly considered as less rooted in
their culture of origin, given the decision to emigrate—
are constantly exposed to the host culture, and this may
influence their suicide rates, making them farer from
those of the country of origin and converge with those of
the native population. This hypothesis has been con-
firmed by many studies. For example, in research on
immigrants of the former Soviet Union in Israel, a much
higher rate of suicide than that of the local population
was noted, although the rate was considerably lower than
that characterizing Russia [38]. In the same research it
was evident that suicide rates varied according to the
time of permanence in Israel. Even suicidal ideation,
presence of a suicide plan or previous suicide attempts
were particularly frequent among recent immigrants,
compared to those residing in the country for longer [36].
Over time, therefore, suicidal behaviours among immi-
grants tended to decrease in frequency and converge with
those of the host country.
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K. A. RATKOWSKA, D. DE LEO
128
A tendency to converge was also observed among
immigrants coming form countries with low rates of sui-
cide, such as those from the Middle East, migrating to
California. Among them, suicide rates tended to be posi-
tively associated with length of residence, and then
gradually increase in frequency with the time, to con-
verge with the rates of autochthonous population [39]. A
trend towards convergence has also been found among
immigrants in Slovenia: the suicide rate of Hungarian
immigrants in Slovenia was in fact lower than that re-
corded in Hungary and more similar to the Slovene rate
[19]. In contrast, Croatian immigrants in Slovenia had
higher suicide rates that in the home country, while
Croatian immigrants in Australia had rates lower than
those detected in Croatia, presenting then in both cases
rates very close to those of the two host countries [19]. It
would seem plausible to conclude that rates tend to con-
verge, and often express intermediate values between the
country of origin and destination, contributing in some
cases to a decrease in the overall rate of suicide in the
host population [14,15,40,41].
The importance of both genetic and environmental
factors is confirmed by the “paradigm of interaction”.
According to this paradigm, health is the result of inter-
acting processes, including genetic predisposition, life
experiences, and stressors during the migration process,
and the individual and social resources to cope with them
[42].
8. Urbanization and Ethnic Density
There are two contextual factors of post-settlement that
seem related to suicidal behaviour among immigrants:
urbanization and ethno-racial density. The importance of
these factors seems to depend mainly from the accessi-
bility to social support.
Contrary to what suggested by Durkheim [1], to reside
in urban areas does not seem to be a risk factor for suici-
dal behaviour and could, in fact, constitute a protective
factor, especially for males. For example, in a study car-
ried out in Australia, the risk of suicide in men from
Europe, the Middle East and New Zealand was signifi-
cantly higher in rural areas than in urban areas, while
there was no difference in the risk between rural and ur-
ban areas for Australians [24]. Isolation, rigors of coun-
try life, easy access to means for suicide, lack of em-
ployment and recreational opportunities and mental
health services could explain this result. The geographic
isolation, even if offset by the cohesion typical of small
communities (for the autochthonous population), could
lead to real feelings of isolation among immigrants, as
they are not considered part of those communities and
then easily excluded [24].
Generally, since the immigrant population is concen-
trated in metropolitan areas, it may be that it is the largest
ethnic density and therefore greater social support avail-
ability to justify the lower rates of suicide in those areas
[43]. This may be especially true for immigrants belong-
ing to racial minorities. In Canada, for example, the
prevalence of suicidal ideation was noted to be higher
among immigrants of racial minorities living in rural
areas than in urban areas compared to white immigrants
and residents in both rural and urban. A possible expla-
nation may lie in greater access to mental health services
in urban areas, which could represent an opportunity for
timely treatment and at the same time be a source of so-
cial support. Also, it may be that racism is more deeply
rooted and difficult to control in rural communities [44].
The increase in density of hosted ethnicity can im-
prove social support and adaptation of certain immigrants,
but also increase the discomfort of others, especially if
there is any conflict between the individual immigrant
and his culture of origin. For some people, the culture of
the host country may be more suited to their beliefs than
the original one. In this case, an increase in density can
cause a ethnic cultural conflict and become a risk factor,
instead of a protective one [5].
9. The “Healthy Immigrant Effect”
Some North-American research evidenced lower rates of
suicidal behaviour among immigrants relative to the
population of the host countries. It was then proposed the
hypothesis of the healthy immigrant (healthy immigrant
effect), according to which immigrants should be less
likely to commit suicide being generally above average
in terms of mental an physical health [45]. According to
some studies, poor health would prevent emigration; as a
result, immigrants would in fact be represented by
strongest individuals [23]. The exception to this rule is
represented by countries with unrestricted emigration, as
in the case of the Irish within the United Kingdom or the
Finns in Sweden: they can all migrate regardless their
health condition [23].
However, several researches done in the United States,
England, Canada and Sweden showed overall higher
suicide rates among immigrants, and this when compared
to both the country of origin and the host one [22,27,46].
These observations suggest that the low suicide rates
presented in other studies could be due to having consid-
ered immigrants as a large homogeneous group, without
distinguishing between countries of origin. As we have
seen, there are instead rather large differences [46].
10. Immigrants of First and Second
Generation
Research has noticed the existence of remarkable differ-
ences in rates of suicide among first-generation immi-
grants, or born abroad, and second-generation immi-
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K. A. RATKOWSKA, D. DE LEO 129
grants, i.e., children of first-generation immigrants, usu-
ally born in the host country. Second-generation immi-
grants generally show a higher risk of suicidal behaviour
compared to those of the first generation [45,47,48]. For
example, among Mexican adolescents in the United
States, those born in Mexico showed lower rates of sui-
cidal ideation and less use of illicit drugs than those born
in the United States [10]. In the study by Pena and asso-
ciates [49], the second-generation Hispanic immigrants
in the United States were twice more likely to present
higher frequency of suicide attempt and abuse of alcohol
and drugs than the first generation of teenagers. The third
generation had a three times higher probability of pre-
senting these behaviours compared to first-generation
immigrants [49]. Even in Sweden suicide rates of the
second-generation immigrants were reported to be higher
than those of the first generation [47]. Unfortunately,
many studies have included second- and third-generation
immigrants in the group of the host population, and
therefore there are not many other available data to con-
firm this hypothesis [49].
To explain the better health of first-generation immi-
grants at least three main hypotheses have been proposed
[49]. The first is known as the Protective Culture Model,
which suggests the presence of some protective factors
against suicide in the culture of origin, such as religious
beliefs and good family and social support, able to re-
duce the stress of acculturation. The protective effect of
these values would decrease with time of residence, and
therefore suicide rates would become progressively higher
[48,49]. The second model, the Intergenerational Accul-
turation Conflict Model, considers the role of intergen-
erational conflict due to acculturation. The latter, in fact,
can progress with different speed between parents and
children and lead to misunderstandings, conflicts or role
reversal, and then to suicidal behaviours in young second
generation individuals. The third model, the Resilient
Immigrant Model, is in line with the healthy immigrant
paradigm, and suggests a selective effect of migration,
which would involve only individuals in good health and
with high resilience. In the second generation, this selec-
tivity would no longer be present [45,47,49].
The first-generation immigrants are often characterised
by a low socio-economic level, which, however, could be
offset by a sense of privilege rather than deprivation. The
first-generation immigrants tend, in fact, to compare their
situation with that of the country of origin rather than
with that of the host country. In contrast, second-genera-
tion immigrants tend to compare with the host population,
and therefore in them may prevail feelings of disadvan-
tage and deprivation [11].
11. Adolescents
Adolescence is a period of life in which people may be
very vulnerable and likely to present self-harm behaviour
and suicidal ideation. This risk appears to increase in the
case of adolescent immigrants [10]. Along with the nor-
mal developmental challenges of construction of per-
sonal identity, young people are facing the stress of ac-
culturation in the host country, and at the same time try-
ing to remain faithful to their culture of origin. In addi-
tion, because adolescents and their parents go through the
process of acculturation with different rhythms, family
conflicts may arise, which represent an additional source
of stress [26]. The most relevant aspects characteristic of
suicidal behaviour in adolescent immigrants seem to be
the low socio-economic status, substance abuse and fam-
ily conflicts. With regard to the low socio-economic
status, it could lead to discrimination and fatalism, thus
increasing the risk of suicidal behaviour [33].
Alcohol abuse and drug use seem important in medi-
ating suicidal behaviour in adolescent immigrants. For
example, in a study of cases of suicide among young
Hispanics in the United States, more than 40% of them
had alcohol in their blood [50]. Canadian immigrant
adolescents in the United States show suicide rates lower
than their US peers, with appreciably lower consumption
of drugs during the suicidal crisis in Canadian immi-
grants [51].
The risk of suicidal ideation appears to be higher
among adolescents who have family problems, difficul-
ties in relationships with parents or see their peers as
hostile [52]. Children of immigrants often reach levels of
acculturation and education much higher than those of
their parents, contributing to intergenerational conflict
and decreasing the understanding and closeness between
parents and children [33]. In several studies related to
suicide among young immigrants, intergenerational con-
flicts with parents were reported as particularly present.
For example, a study of young people of Asian origin in
the United States showed that intergenerational conflict
did increase the risk of suicide even by thirty times, es-
pecially in less educated young people. More educated
adolescents, even though they could experience higher
levels of conflict with their parents, had anyway lower
rates of suicide. It is possible that as a result of intergen-
erational conflicts and loss of family support, more edu-
cated young people rely on peer support to mitigate their
stress [29]. Also separation from one or both parents
could lead to suicidal behaviour. It has been seen, for
example, that adolescent Korean immigrants in the
United States without parents (both) reported almost
double levels of suicidal ideation compared to other im-
migrants, high levels of depressive symptoms and risk of
suicide. Living with both parents was instead a strong
protective factor, probably because, in addition to pro-
viding family support, it gives a sense of stability and
security [52].
Copyright © 2013 SciRes. OJMP
K. A. RATKOWSKA, D. DE LEO
130
12. Refugees and Asylum Seekers
According to the Geneva Convention (1951), a refugee is
a person who has a “well-founded fear of being perse-
cuted for reasons of race, religion, nationality, member-
ship of a particular social group or a particular political
opinion, is outside the country of his nationality and can
not, or will not, because of such fear, benefit of the pro-
tection of that country”. The asylum seeker is someone
who has left his/her country of origin, has applied for
recognition as a refugee and is awaiting a decision by the
new state [5].
In general, risk factors for suicide in this particular
group of people are the young age, male gender, low
income, past traumatic experiences and lack of social
support. Refugees and asylum seekers often have several
of these risk factors [53]. Refugees are perhaps the most
vulnerable group of all immigrants: they are often fleeing
war, torture and persecution, with Post-Traumatic Stress
Disorder (PTSD), depressive and anxiety symptoms [42].
Lack of adequate preparation, the way in which they are
received in the destination country, poor living condi-
tions, and lack of social support and isolation usually add
to these vulnerabilities [5]. Refugees may also feel guilty
for leaving the loved ones at home or for their death. The
sense of guilt, together with isolation and pathological
symptoms consequent to trauma, may be a strong risk
factor for suicide [54].
To investigate the influence of Post-Traumatic Stress
Disorder and depression on suicidal ideation and behav-
iour, a study of 149 refugees from various countries was
carried out in Sweden. Of the refugees, 79% had PTSD.
The rate of suicide attempts was higher among refugees
with diagnosis of PTSD but not of depression; suicidal
ideation, however, was more frequent in the presence of
PTSD co-morbid with depression [54]. A recent review
of the literature has also shown a moderate association
between PTSD and suicidal ideation but no evidence of
correlation between PTSD and death by suicide [55].
Immigrants describe the asylum procedure as the most
important source of stress; therefore this would also in-
crease the risk of suicide. The pending of a decision by
the authorities could mainly affect suicidal behaviour of
men. For example, people seeking asylum in the Nether-
lands in the years 2002-2007 had higher rates of suicide
than native Dutch; women instead had rates similar to the
Dutch women. It may be that men are more likely to be
affected by unpleasant consequences if forced to return
to their homeland; in addition, they may see the return as
a failure, and are more likely to use substances [55].
Some asylum seekers slip slowly into depression,
while others act impulsively in the face of a negative
decision by the authorities; someone else loses hope and
decides to die by suicide even before knowing the out-
come of asylum request [53]. This is in line with the the-
ory of entrapment, which states that suicide occurs when
people perceive occurring events as a defeat or a hu-
miliation from which they do not feel able to escape, or
see no possible alternatives [56].
13. Prevention
Immigration not only affects suicide rates of the host
country but also the effectiveness of its prevention
strategies. For example, in one of the US studies it was
found that immigrants residing in the United States for
less than 15 years were more likely to call the emergency
number 911 and less likely to call a helpline at the time
of suicidal crisis [57]. Differences were also found be-
tween US citizens of different ethnic groups: 66% of
those who called the helpline were Caucasian, whilst
African-Americans and Hispanics more frequently sought
help by calling 911 and going to the emergency room,
but not using the helpline. Unfortunately, in this study it
was not possible to distinguish between second- and
third-generation immigrants and ethnic minorities [57].
The study of Goldston and associates [58] confirmed
the hypothesis of a different way to handle crises of peo-
ple of different racial and ethnic backgrounds. In this
study, African-Americans were less likely to seek pro-
fessional resources, and more likely to seek help in in-
formal settings such as parishes. Hispanic Americans
instead tended to ask for help from family members or
primary care physician, rather than professionals of
mental health [58]. Korean immigrants in the United
States, despite high levels of depression, used very little
local services and sought the support of parishes, friends
and relatives [59].
In some cases, psychological problems can be seen as
a punishment, as a thing to be ashamed of, or condition
not serious enough to require the intervention of special-
ists. Immigrants may also be afraid of being stigmatised
[60,61]. On the other hand, specialists might not always
find easy to diagnose a mental disorder and determine the
risk of suicide because immigrants may have symptoms
other than those usually reported by patients of the
dominant culture. For example, Chinese citizens do not
report feeling depressed or sad, but rather describe as-
pects of boredom, discomfort, pain, dizziness and fatigue,
and this may confound the diagnosis [61]. In young
Asian immigrants, impulsive, antisocial and poorly con-
trolled behaviours are negatively correlated to suicidal
behaviour, and may actually constitute protective factors
[29].
Education on mental health for immigrants, and edu-
cation about cultural differences for specialists are there-
fore of fundamental importance for the advancement of
suicide prevention [60].
Copyright © 2013 SciRes. OJMP
K. A. RATKOWSKA, D. DE LEO 131
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... Most suicide deaths among young people occur within the age of 15-24 years [17]. Migrants may be at a higher risk of suicidal ideation, suicide attempts, self-harm, and death by suicide compared to the general population [18][19][20]. Suicide risk may vary among ethnic minorities, and they may experience different risk factors for suicidal behaviour compared to the native population of a country [21][22][23]. Some evidence indicates that acculturation, a process by which individuals acquire the attitudes, values, customs, beliefs, and behaviours of a different culture, may in fact increase the risk of suicidal behaviour among some migrants [24]. ...
... Res. Public Health 2022,19, 8329 ...
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Young people experience high rates of suicidal ideation, self-harm, suicide attempt and death due to suicide. As a result of increasing globalisation, young people are increasingly mobile and can migrate from one country to another seeking educational and employment opportunities. With a growing number of young migrants, it is important to understand the prevalence of suicidal behaviour among this population group. We systematically searched Medline, Embase, and PsycINFO from inception until 31 March 2022. Eligible studies were those providing data on suicidal ideation, self-harm, suicide attempt, and death due to suicide. Seventeen studies were included in the review, some of which provided data on multiple outcomes of interest. Twelve studies provided data on suicidal ideation, five provided data on self-harm, eight provided data on suicide attempt, and one study had data on suicide death among young migrants. The quality of the included studies was varied and limited. The studies included in this review commonly reported that young migrants experience higher rates of self-harm and suicide attempt, but no major differences in suicidal ideation and suicide death compared to non-migrant young people. However, the limited number of studies focused on suicidal behaviour among young migrants highlights the need for further high-quality studies to capture accurate information. This will enable the development of policies and interventions that reduce the risk of suicidal behaviour among young migrants.
... [3] [4,5] [1] [6][7][8] [9] ...
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Objectives: To investigate the influences of demographic, socioeconomic, and geographic factors on nonresident suicides. Methods: In this cross-sectional study, data on demographics, geographical locations of residence, and places of death for 2011–2013 were retrieved from the Taiwanese National Cause-of-Death Register. The odds ratios for nonresident suicides associated with each risk factor were calculated. The correlations of county-level socioeconomic indicators with nonresident suicide data obtained from public government databases were analyzed. Multilevel modeling was used to examine the cross-level interaction effects between individual level and county-level variables. Results: A total of 10,474 suicide deaths occurred during 2011–2013, of which 1,538 (14.7%) deaths occurred away from the area of residence. The most common suicide methods used were hanging and asphyxiation (32.1%). Among the regions of Taiwan, the offshore islands (33.3%), Taipei and the surrounding area (20.4%), and the Hualien–Taitung area (15.8%) had the highest proportions of nonresident suicides. Age of <25 years (OR = 1.31, p < .05), single and divorced marital status (single: OR = 1.83, p < .001; divorced: OR = 1.55, p < .001), and a lower labor force participation rate (OR = .87, p < .05) and higher dependency ratio (OR = 1.10, p < .05) in the resident area were associated with increased odds of nonresident suicides. Gender, age, and marital status interacted with most of the socioeconomic indicators. Conclusions: Nonresident suicides highlight the effects of employment opportunities, elderly care, and housing issues on public mental health.
... However, this protection decreases with time spent in the host country, resulting in increased suicidal ideation and attempts in the second generation. Factors influencing suicidality among immigrants are acculturation stress, experiences of discrimination, cultural differences, and environmental factors, among others (for an overview, see [46]). Also worth considering are post-migration stressors such as socioeconomic factors, social and interpersonal circumstances, and stressors related to the asylum process and immigration policies [15,47], which can be burdensome. ...
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Background Suicidal ideation and attempts are one of the most serious mental health problems affecting refugees. Risk factors such as mental disorders, low socio-economic status, and stressful life events all contribute to making refugees a high-risk group. For this reason, this meta-analysis aims to investigate the prevalence of suicidal ideation and attempts among refugees in non-clinical populations. Method We searched PubMed, Web of Science, PubPsych , and PsycInfo for articles reporting (period) prevalence rates of suicidal ideation and attempts. Inclusion criteria were the population of refugees or asylum seekers (aged 16 years and older), assessment of the prevalence of suicidal ideation and attempts in empirical studies in cross-sectional or longitudinal settings, written in English, and published by August 2020. Exclusion criteria were defined as a population of immigrants who have lived in the host country for a long time, studies that examined children and adolescents younger than 16 years, and research in clinical samples. Overall prevalence rates were calculated using Rstudio. Results Of 294 matches, 11 publications met the inclusion criteria. The overall period prevalence of suicidal ideation was 20.5% (CI: 0.11–0.32, I ² = 98%, n = 8), 22.3% (CI: 0.10–0.38, I ² = 97%, n = 5) for women, and 27.7% for men (CI: 0.14–0.45, I ² = 93%, n = 3). Suicide attempts had an overall prevalence of 0.57% (CI: 0.00–0.02, I ² = 81%, n = 4). Conclusion There is a great lack of epidemiological studies on suicidal ideation and attempts among refugees. The high prevalence of suicidal ideation indicates the existence of heavy psychological burden among this population. The prevalence of suicide attempts is similar to that in non-refugee populations. Because of the large heterogeneity between studies, the pooled prevalence estimates must be interpreted with caution. The results underline the need for systematic and standardized assessment and treatment of suicidal ideation and attempts.
... Life experiences and stress in the course of their adjustment in South Korea put NKRW in great danger of suicidal behaviors (Noh et al., 2017). Empirical studies on refugees or immigrants have consistently suggested that females generally show higher suicide risks both in ideation and attempts, compared to residents of the host country (Burger et al., 2009;Burvill, 1998;Kosidou et al., 2012;Ratkowska & Leo, 2013;Yilmaz & Riecher-Rössler, 2012). Previous studies on suicidality of NKRW have found that major factors associated with suicidal risk include depression (Im et al., 2017;An et al., 2018;Um et al., 2015), social isolation (Ryu & Park, 2018), alcohol misuse , and life stress Noh et al., 2017). ...
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Background: North Korean Refugee Women (NKRW) are at a high risk for suicide. However, few studies have examined risk factors for suicide among NKRW in South Korea. This study aimed to examine factors increasing risk for suicidal ideation and to identify factors differentiating suicide attempt from ideation among NKRW in South Korea. Methods: A sample of 140 NKRW was analyzed; multinomial logistic regression was conducted to identify factors distinguishing respondents with (1) no suicidal ideation, (2) isolated suicidal ideation (without attempts), and (3) ideation with attempts. Results: About 46% of the sample reported suicidal ideation, and about 18% attempted suicide during the past year. NKRW without any suicidal risk had significantly lower levels of social isolation (OR = 0.86, p = 0.02) and less exposure to traumatic events (OR = 0.89, p = 0.02) than those with suicidal ideation. NKRW who attempted suicide were more likely to have higher levels of stress than those with only suicidal ideation (OR = 1.40, p = 0.03). Conclusion: This study provides insights into suicide prevention among refugees and emphasized that post-migration life stress significantly differentiates suicidal ideation from attempt among NKRW. Intervening to address current life stress, traumatic experiences, and social isolation may help prevent refugee suicidal ideation and further attempt.
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Background Suicide rate in Hungary was nearly the highest in the world in the decades preceding the transition of the social system. Shortly after the transition in 1989, a radical decrease in fatal suicides occurred, parallel with a marked increase in emigration. Methods We analyzed the data published by the Hungarian Central Statistical Office to detect if there was an association between the remarkable drop in suicide rates and the changes in emigration rates from 1995 to 2019. Results The results of a brief statistical analysis on the correlation between suicide rate and emigration confirmed a strong negative relationship ( r = −.855, p = .00). For more precise results, we applied linear regression analysis, which showed that the emigration rate predicted 73.2% of suicide rate variances with a high predictive value (β = −.983). Conclusion The study provides a possible explanation through a phenomenological analysis on major life transformations. Relating the arrested flight/cry of pain theory, the theory of rites of passage and double-bind communication resulted a comprehensive and coherent, but not exhaustive explanation on the relationship between suicide and emigration.
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Depression and anxiety specifically in migrants is an emerging topic, since about 272 million people are migrating worldwide. The prevalence of depression seems to be similar in first generation migrants and the native population, but increases in the second and further generations. However, it is often reported that the rate of depression is significantly higher in migrants, especially in refugees. People, who are moving to another country with a specific culture are subject to risk factors, which need special attention. Treatment of depression and anxiety and suicide prevention should be seen under cultural aspects and would need the professionals’ “cultural competency” and their awareness of being in a specific cultural context themselves. About 800,000 people commit suicide every year worldwide and it is assumed that the rate is higher among migrants because of the higher prevalence rate of depression. It is important to be aware that suicide has different meanings in societies of different cultures and therefore suicide prevention and treatment need cultural sensitivity. The WHO has developed the Mental health Action Plan (2013–2020) and the Mental Health Gap action Plan (mhGAP) to improve mental health and well-being worldwide and to improve treatment and care in Low and Middle Income Countries.
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Background: Suicidal ideation and attempts are one of the most serious mental health problems affecting refugees. Risk factors such as mental disorders, low socio-economic status, and stressful life events all contribute to making refugees a high-risk group. For this reason, this meta-analysis aims to investigate the prevalence of suicidal ideation and attempts among refugees in non-clinical populations. Method: All studies published in English up through August 2020 were considered for the analysis. We searched four databases for articles reporting (period) prevalence rates of suicidal ideation and attempts. Results: Of 294 hits, 11 publications met the inclusion criteria. Overall prevalence rates were calculated using Rstudio. The overall period prevalence of suicidal ideation was 20.5% (CI: 0.11-0.32, I²=98%, n=8), 22.3% (CI: 0.10-0.38, I²=97%, n=5) for women, and 23.3% for men (CI: 0.13-0.35, I²=87%, n=3). Suicide attempts had an overall prevalence of 0.57% (CI: 0.00-0.02, I²=81%, n=4). Conclusion: There is a great lack of epidemiological studies on suicidal ideation and attempts among refugees. The high prevalence of suicidal ideation indicates the existence of heavy psychological burden among this population. The prevalence of suicide attempts is similar to that in non-refugee populations. In addition, the results underline the need for systematic and standardized assessment and treatment of suicidal ideation and attempts.
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Background: Immigrants may experience several negative consequences as a result of their migration including discrimination, unsatisfactory economic conditions, and rejection from the host countries, which may contribute to psychiatric illness and vulnerability to suicidal behaviors. The purpose of the current study was to determine whether or not the theorized components of measured dimensions of suicide risk and psychopathology vary across samples of Italians and immigrants. Methods: We investigated 237 Italians and 234 immigrants, who were administered self-report questionnaires to assess temperament (TEMPS-A), hopelessness (BHS), personality (EPQ-R), and self-other perception (9AP). Results: Multi-group confirmatory factor analyses were conducted, which yielded a final model with an excellent fit to the data (χ (53) (2) = 57.56; CFI = 0.994; RMSEA = 0.014). This final model fits significantly better than the previously tested models and indicated that the same pattern of relationships was found between suicide risk and psychopathology across both groups. Conclusions: Although immigrants represent a unique population and may experience specific stressors contributing to psychopathology and suicide risk, our findings suggest that the samples of Italians and immigrants may be more similar on the study variables under investigation than previously thought. Implications are offered for the improved identification and treatment of immigrants and resident citizens in Europe in general and in Italy in particular.
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This paper reports results of a national community survey of self-reported suicide ideation and attempts and their relation to psychological distress, depression, social support, and adjustment difficulties in a sample of recent immigrants from the former Soviet Union (FSU) to Israel. Using a door-to-door sampling procedure, a sample of 788 Russian-born Jewish immigrants, ages 18–74 years, was selected to match the age and sex structure of the total immigrant population. An indigenous sample of Jews in Russia (n = 411) was matched with the immigrants for comparison. Parameters of interest were measured with the Demographic Inventory, Talbieh Brief Distress Inventory, Beck Depression Inventory, and Multidimensional Scale of Perceived Social Support. The 1-month prevalence rate of suicide ideation in the immigrant sample (15.1%) was found to be significantly higher than that in Russian controls (6.6%). A total of 5.5% of immigrants but only 0.5% of controls had made a suicide attempt at some time in their lives. Risk factors for suicide ideation included younger age, living without a spouse, low level of social support, being a physician or teacher, a history of immigration from the Baltic countries or Moscow, or duration of stay in Israel from 2 to 3 years. The strongest risk factors were higher level of psychological distress and symptoms such as depression, hostility, and paranoid ideation. These findings can be used as a point of departure for the development of community-based suicide prevention programs for recent immigrants.
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Immigrants represent a substantial proportion of suicides in Canada. This study assesses the hypothesis that high immigrant density fosters personal sense of community belonging among immigrants, and in turn, protects against suicide risk. This multilevel cross-sectional study is based on individual-level data from the 2007 Canadian Community Health Survey (n = 12,951 participants) merged with area-level data from the 2006 Canadian census (n = 57 health regions). Prevalence of suicidal ideation was 1.3 %. Among rural racial minority immigrants, each 10 % increase in immigrant density associated with 67 % lower odds of suicidal ideation (adjusted odds ratio (AOR) = 0.33, 95 % CI: 0.14-0.77); sense of community belonging did not mediate this association, but was independently associated with suicidal ideation (AOR = 0.44, 95 % CI: 0.28-0.69). Immigrant density was not associated with suicidal ideation among white immigrants or urban settings. Immigrant density and sense of community belonging may correlate with suicidal ideation through distinct mechanisms of association.
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Purpose This study analysed suicide rates among first-generation immigrants in Australia from 1974 to 2006, and compared their suicide risks against the Australian-born population. It also examined the associations between the suicide rates of immigrants from 23 selected countries of birth during 2001–2006, and in their home countries. Method Age-standardised suicide rates (15+ years) and rate ratios, with a 95 % confidence interval, during 1974–2006 were calculated for country of birth (COB) groups. Spearman’s rank correlation coefficient was calculated between COB-specific immigrant suicide rates during 2001–2006 in Australia and in their homelands. Results Suicide rates showed a decreasing time-trend among all COB groups for both genders in Australia. The lowest suicide rates were found during 2004–2006, compared to other year groups. Throughout the study period, males born in Eastern, Northern and Western Europe and New Zealand had the highest suicide rates in Australia. For females, the highest rates were among those born in Western Europe and the UK (including Ireland). Male and female migrants born in North Africa and the Middle East, Southern and Central Asia and South East Asia showed the lowest suicide rates. There was a significant correlation between male immigrant suicide rates by COB and the rates of their home countries. Conclusion The patterns of suicide rates in immigrants were influenced by the social and cultural norms of their COB. The overall decrease in suicide risk among immigrants was particularly evident in males.
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Several suicide and suicidal behaviour risk factors are highly prevalent in asylum seekers, but there is little insight into the suicide death rate and the suicidal behaviour incidence in this population. The main objective of this study is to assess the burden of suicide and hospital-treated non-fatal suicidal behaviour in asylum seekers in the Netherlands and to identify factors that could guide prevention. We obtained data on cases of suicide and suicidal behaviour from all asylum seeker reception centres in the Netherlands (period 2002-2007, age 15+). The suicide death rates in this population and in subgroups by sex, age and region of origin were compared with the rate in the Dutch population; the rates of hospital-treated suicidal behaviour were compared with that in the population of The Hague using indirect age group standardization. The study included 35 suicide deaths and 290 cases of hospital-treated suicidal behaviour. The suicide death rate and the incidence of hospital-treated suicidal behaviour differed between subgroups by sex and region of origin. For male asylum seekers, the suicide death rate was higher than that of the Dutch population (N = 32; RR = 2.0, 95%CI 1.37-2.83). No difference was found between suicide mortality in female asylum seekers and in the female general population of the Netherlands (N = 3; RR = 0.73; 95%CI 0.15-2.07). The incidence of hospital-treated suicidal behaviour was high in comparison with the population of The Hague for males and females from Europe and the Middle East/South West Asia, and low for males and females from Africa. Health professionals knew about mental health problems prior to the suicidal behaviour for 80% of the hospital-treated suicidal behaviour cases in asylum seekers. In this study the suicide death rate was higher in male asylum seekers than in males in the reference population. The incidence of hospital-treated suicidal behaviour was higher in several subgroups of asylum seekers than that in the reference population. We conclude that measures to prevent suicide and suicidal behaviour among asylum seekers in the Netherlands are indicated.
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The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outlined, as well as the specific problems of groups such as women, children and adolescents, the elderly, refugees and asylum seekers, and lesbian, gay, bisexual and transgender individuals. The concepts of cultural bereavement, cultural identity and cultural congruity are discussed. The epidemiology of mental disorders in migrants is described. A series of recommendations to policy makers, service providers and clinicians aimed to improve mental health care in migrants are provided, covering the special needs of migrants concerning pharmacotherapies and psychotherapies.
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This study compares the frequencies of attempted suicide among immigrants and their hosts, between different immigrant groups, and between immigrants and their countries of origin. The material, 27,048 persons, including 4,160 immigrants, was obtained from the WHO/EURO Multicentre Study on Suicidal Behaviour, the largest available European database, and was collected in a standardised manner from 11 European centres in 1989-2003. Person-based suicide-attempt rates (SARs) were calculated for each group. The larger immigrant groups were studied at each centre and compared across centres. Completed-suicide rates of their countries of origin were compared to the SARs of the immigrant groups using rank correlations. 27 of 56 immigrant groups studied showed significantly higher, and only four groups significantly lower SARs than their hosts. Immigrant groups tended to have similar rates across different centres. Moreover, positive correlation between the immigrant SAR and the country-of-origin suicide rate was found. However, Chileans, Iranians, Moroccans, and Turks displayed high SARs as immigrants despite low suicide rates in the home countries. The similarity of most immigrant groups' SARs across centres, and the correlation with suicidality in the countries of origin suggest a strong continuity that can be interpreted in either cultural or genetic terms. However, the generally higher rates among immigrants compared to host populations and the similarity of the rates of foreign-born and those immigrants who retained the citizenship of their country of origin point to difficulties in the acculturation and integration process. The positive correlation found between attempted and completed suicide rates suggests that the two are related, a fact with strong implications for suicide prevention.
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