Our analyses indicate that Swedish adolescents born to immigrant women have a lower use of psychotropic medication in adolescence than do the offspring of native Swedish women. This observation was evident in both sexes but was especially pronounced in girls. Moreover, the relative use of psychotropic medication decreased linearly with the income (ie, GNI per capita) of the mother's country of birth and was lowest for girls with mothers born in low-income countries.
Several mechanisms could explain our findings. Adolescents born to immigrant women might have better psychological health and therefore lower needs for psychotropic drug treatment than the offspring of native Swedish women. If this were true, adjusting for needs would make any difference disappear or at least decrease. To create a RS, we adopted a life-course approach28
and observed that a number of maternal and offspring characteristics during pregnancy, delivery, infancy, childhood and adolescence predicted psychotropic drug use during adolescence. Nevertheless, after adjusting for needs using the RS, the influence of mother's country of birth (ie, lower use of psychotropic medication among adolescents with mothers from low-income countries) remained independent and even increased. This finding suggests that differences in psychotropic drug use may reflect divergences in access to healthcare resources rather than lower needs. However, we cannot exclude the possibility that we missed other relevant factors that condition needs, such as childhood adversities, which affect psychological health later in life (eg, neglect and verbal or physical abuse).29
Because we were restricted to the available information, our adjustment for needs is inherently incomplete.
Since the National Prescription Register contains only prescriptions that were handled by the pharmacies, information on medication prescribed but never picked up at the pharmacy is not available. Therefore, the observed differences in psychotropic drug use might reflect disparities in primary compliance rather than in prescription behaviour (ie, medication could be prescribed but the individual could never pick it up from the pharmacy). In Sweden, at the time of our study, the total yearly cost that a particular individual needed to pay for prescribed medications was 4300 SEK (ie, about 500 EU). Beyond this ceiling, medication was free of charge.30
Therefore, individuals with a low socioeconomic position may be less prone to pick up prescribed medication. We adjusted for socioeconomic factors in the RS for psychotropic drug use but this procedure might be insufficient.
One explanation for the observed underutilisation of psychotropic medication by descendants of immigrants may be that the cultural context in which one grows up influences healthcare-seeking behaviour. Examples of these cultural influences are different conceptions of disease and taboos.31
Another factor affecting the lower use of psychotropic medication by descendants of immigrants may be so-called health illiteracy (ie, unfamiliarity with the country's healthcare system).32
These cultural and health illiteracy-related aspects may explain the underutilisation of healthcare by mothers. However, the children in our study grew up and attended school in Sweden. Thus, they had the opportunity to become familiar with the Swedish system. Nevertheless, it is likely that the effects of cultural influences and health illiteracy on mothers’ healthcare-seeking behaviours are transmitted to the next generation because it is often mothers who regulate healthcare contacts for children.
Another circumstance behind the observed patterns of use of medication could be the communication between the patient and the healthcare provider. In this sense, insufficient intercultural competence among the healthcare staff might affect the interpretation of the patient's symptoms and hence, the prescription of medication.
The process of incorporating the host culture into an individual's behaviour, such as healthcare behaviour, is known as acculturation.33
From this perspective, the number of years spent in Sweden might condition the degree of acculturation. Indeed, we found a high correlation between time spent in Sweden before delivery and mothers’ country of birth, the lowest percentage of mothers with more than 18 years in Sweden being the group of mothers from low-income countries.
Interestingly, our results suggesting a relative underutilisation of psychotropic medication in 18-year-old descendants of immigrants contrast with previous findings that observed a higher rate of psychotropic drug use in first-generation immigrants.34
In addition, a study in the Netherlands35
found that in comparison with the native population, first- and descendants of Turkish and Moroccan immigrants had an increased rate of antidepressant and antipsychotic drug prescriptions and a decreased rate of attention-deficit/hyperactivity disorder (ADHD) medication and lithium prescriptions. However, in our earlier investigations in the county of Scania, we observed that overall utilisation of psychiatric healthcare resources in 18-year-old to 80-year-old immigrants was considerably less than expected according to self-reported needs.32
In this analysis, we only considered prescribed medication. Therefore, the results may be biased by the sale of over-the-counter (OTC) medication. In Sweden, the only available OTC psychotropic drug is Propiomazine. Nevertheless, we believe it is improbable that our results would be affected by the inclusion of Propiomazine in the analyses because this assumption would imply that descendants of immigrants use this OTC drug as a substitute for all other psychotropic medication.
Strength of our study is that we had information from registries covering the entire Swedish population. Furthermore, 98.6% of all births are registered in the Swedish Medical Birth Registry. Therefore, we do not believe that giving birth at home is an important source of bias in our estimations. It could be possible that some mothers give birth at home because they are illegally residing in Sweden or because the Swedish healthcare is very different to their original traditions as is the case for Somali women.36
However, we do not have information on the country of origin of the 1.4% of the women giving birth at home in Sweden. Furthermore, all women in Sweden with a PIN have the right to attend antenatal care and the majority of them do indeed use this service. However, a minor percentage do not attend all visits that they have the right to, and immigrated women tend to come later in the pregnancy then native Swedish women.37
Also, even if information was quite complete overall, data on some variables were more frequently missing in children with an immigrant mother than in children with a native mother which may originate information bias. Besides, since smoking is a self-reported variable, there might be a bias due to linguistic barriers or cultural differences in the attitude towards reporting smoking.
The information recorded in the Medical Birth Register, the National Patient Register and the National Cause of Death Register is mandatorily reported by law, and the quality of the registries is regularly evaluated by the National Board of Health and Welfare and Statistics Sweden.
Measurement of psychotropic drug use using administrative registries reflects both access to healthcare and the presence of psychological disorders. From the perspective of community medicine, the identification of an imbalance between needs and utilisation of psychotropic medication raises questions about equity in access to healthcare resources. However, our findings also identify the existence of information bias when using a register-based measurement of psychotropic drug use as a proxy for impaired psychological health if descendants of immigrants are included in the analyses.
We performed analyses investigating specific groups of psychotropic medication (results available on request), but the results were similar to those found when analysing the entire medication group. Moreover, because the therapeutic profiles of the studied medication groups overlap each other (ie, different psychiatric disorders can be treated with the same drug group), we cannot create a direct link between specific medications and diagnoses.
The suitability of treating young people with psychotropic medication is polemic. Side effects can be severe and, certainly, there are risks when these medications are used in children and adolescents.38
Also, it is not clear as to whether adolescents in Sweden and other high-income countries are prescribed these medication in excess (ie, overutilisation).40
However, underuse may engender avoidable suffering41
and therefore it is important to ensure that all people in need are granted access to medication.
If underutilisation of psychotropic medication by adolescent descendants of immigrants occurs, policy makers in the Swedish healthcare system should take this situation into account. Swedish healthcare policy is based on the principle of equity that supports the distribution of healthcare resources on equal terms and according to needs, regardless of any other determinants. This aspect is particularly relevant because one of the main goals stated by the Swedish National Institute of Public Health is to achieve ‘secure and favourable conditions during childhood and adolescence’ and, specifically, ‘improved mental health among children and young people’.39
we need further research to clarify whether patients of different ethnic backgrounds with the same symptoms receive similar diagnoses and adequate treatment.