title: The use of psychiatric services by young adults who came to Sweden as teenage refugees: a national cohort study.
abstract: To investigate the patterns of use of different forms of psychiatric care in refugees who settled in Sweden as teenagers.
  
  
  
  Cox proportional hazards models were used to estimate the use of different forms of psychiatric care from 2009 to 2012 in a population of 35 457 refugees, aged from 20 to 36, who had settled in Sweden as teenagers between 1989 and 2004. These findings were compared with 1.26 million peers from the same birth cohorts in the general Swedish population.
  
  
  
  Unaccompanied and accompanied refugees were more likely to experience compulsory admission to a psychiatric hospital compared with the native Swedish population, with hazard ratios (HRs) of 2.76 (1.86-4.10) and 1.89 (1.53-2.34), respectively, as well as psychiatric inpatient care, with HRs of 1.62 (1.34-1.94) and 1.37 (1.25-1.50). Outpatient care visits by the young refugees were similar to the native Swedish population. The longer the refugees had residency in Sweden, the more they used outpatient psychiatric care. Refugees born in the Horn of Africa and Iran were most likely to undergo compulsory admission, with HRs of 3.98 (2.12-7.46) and 3.07 (1.52-6.19), respectively. They were also the groups who were most likely to receive inpatient care, with HRs of 1.55 (1.17-2.06) and 1.84 (1.37-2.47), respectively. Our results also indicated that the use of psychiatric care services increased with the level of education in the refugee population, while the opposite was true for the native Swedish population. In fact, the risks of compulsory admissions were particularly higher among refugees who had received a secondary education, compared with native Swedish residents, with HRs of 4.72 (3.06-7.29) for unaccompanied refugees and 2.04 (1.51-2.73) for accompanied refugees.
  
  
  
  Young refugees received more psychiatric inpatient care than the native Swedish population, with the highest rates seen in refugees who were not accompanied by their parents. The discrepancy between the use of inpatient and outpatient care by young refugees suggests that there are barriers to outpatient care, but we did note that living in Sweden longer increased the use of outpatient services. Further research is needed to clarify the role that education levels among Sweden's refugee populations have on their mental health and health-seeking behaviour.
authors.affiliation: CHESS Centre for Health Equity Studies,Centre for Health Equity Studies (CHESS),Stockholm University/Karolinska,Sveaplan,Sveavägen 160,Floor 5,Stockholm,Stockholm,Sweden.
authors.forename: H
authors.initials: H
authors.lastname: Manhica
authors.affiliation: Centre for Health Equity Studies (CHESS),Stockholm University/Karolinska Institute,Stockholm,Sweden.
authors.forename: Y
authors.initials: Y
authors.lastname: Almquist
authors.affiliation: Centre for Health Equity Studies (CHESS),Stockholm University/Karolinska Institute,Stockholm,Sweden.
authors.forename: M
authors.initials: M
authors.lastname: Rostila
authors.affiliation: Department of Medicine,Karolinska Institute and Centre for Health Equity Studies,Stockholm,Sweden.
authors.forename: A
authors.initials: A
authors.lastname: Hjern
mesh_terms: D000293:Adolescent; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000208:ethnology* / Q000523:psychology; D008605:Mental Health Services / Q000706:statistics & numerical data*; D012036:Refugees / Q000523:psychology*; D012307:Risk Factors; D012959:Socioeconomic Factors; D013548:Sweden / Q000453:epidemiology; D055815:Young Adult
keywords: Adolescents; discrimination; mental health; primary care; psychiatric services