Initiation of antipsychotic medication among refugees, non-refugee migrants, second-generation migrants, and Swedish-born adults with incident non-affective psychotic disorders

TL;DR

The study found that migrants in Sweden with non-affective psychosis were more likely to start with long-acting antipsychotics, possibly due to concerns about medication adherence.

Contribution

This is the first study to compare antipsychotic initiation patterns across different migrant groups and Swedish-born individuals with non-affective psychosis.

Findings

Refugees had lower initial antipsychotic use compared to other groups, but this difference disappeared after adjusting for sociodemographic and clinical factors.

Migrants were more likely to start with long-acting injectable and first-generation antipsychotics compared to Swedish-born individuals.

Younger age, higher education, and inpatient care were associated with antipsychotic initiation in both refugees and Swedish-born individuals.

Abstract

It is not known if there are differences in antipsychotic initiation between migrants and native-born individuals diagnosed with non-affective psychotic disorder. This study aimed to determine (1) potential differences in initiation rate and type of first antipsychotic medication between refugees, non-refugee migrants, second-generation migrants, and Swedish-born young adults with incident non-affective psychosis and (2) which sociodemographic and clinical factors are associated with initiation.

This register-based cohort included 12,960 adults aged 18–35 years, residing in Sweden during 2007–2018, with an incident diagnosis of a non-affective psychotic disorder in inpatient or specialised outpatient care. Sociodemographic and clinical factors associated with antipsychotic initiation were determined using modified Poisson regression models yielding Relative Risk, RRs, and 95% Confidence Intervals, CI.

Initiation of antipsychotic use was slightly less common among refugees (65.6%) compared to non-refugee migrants (70.2%), second-generation migrants (71.0%), and Swedish-born individuals (71.1%). However, after adjustment for sociodemographic and clinical factors, there was no difference in initiation rates between refugees and Swedish-born individuals (adjusted RR 0.96; 95% CI 0.92-1.00). Olanzapine was most common initial antipsychotic in all groups. However, compared to the Swedish-born, refugees (1.47; 1.10–1.97), non-refugee migrants (1.70; 1.26–2.27) and second-generation migrants (1.43; 1.05–1.97) were more likely to initiate the use with long-acting injectable antipsychotics, and also with first-generation antipsychotics, particularly haloperidol. Sociodemographic factors associated with initiation were similar among refugees and Swedish-born individuals, including younger age, higher education and inpatient care.

Our finding that migrants were more likely to initiate long-acting antipsychotics suggests that clinical teams anticipate medication non-adherence among migrants.

The online version contains supplementary material available at 10.1007/s00127-025-02887-3.

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