Suicide and Self-Harm in Recent Immigrants in Ontario, Canada: A Population-Based Study

Abstract

Objective: To estimate the rates of suicide and self-harm among recent immigrants and to determine which immigrant-specific risk factors are associated with these outcomes. Methods: Population-based cohort study using linked health administrative data sets (2003 to 2017) in Ontario, Canada which included adults ≥18 years, living in Ontario ( N = 9,055,079). The main exposure was immigrant status (long-term resident vs. recent immigrant). Immigrant-specific exposures included visa class and country of origin. Outcome measures were death by suicide or emergency department visit for self-harm. Cox proportional hazards estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). Results: We included 590,289 recent immigrants and 8,464,790 long-term residents. Suicide rates were lower among immigrants ( n = 130 suicides, 3.3/100,000) than long-term residents ( n = 6,354 suicides, 11.8/100,000) with aHR 0.3, 95% CI, 0.2 to 0.3. Male–female ratios in suicide rates were attenuated in immigrants. Refugees had 2.1 (95% CI, 1.3 to 3.6; rate 6.1/100,000) and 2.8 (95% CI, 2.5 to 3.2) times the likelihood of suicide and self-harm, respectively, compared with nonrefugee immigrants. Self-harm rate was lower among immigrants ( n = 2,256 events, 4.4/10,000) than long-term residents ( n = 68,039 events, 9.7/10,000 person-years; aHR 0.3; 95% CI, 0.3 to 0.3). Unlike long-term residents, where low income was associated with high suicide rates, income was not associated with suicide among immigrants and there was an attenuated income gradient for self-harm. Country of origin-specific analyses showed wide ranges in suicide rates (1.4 to 9.9/100,000) and self-harm (1.8 to 14.9/10,000). Conclusion: Recent immigrants have lower rates of suicide and self-harm and different sociodemographic predictors compared with long-term residents. Analysis of contextual factors including immigrant class, origin, and destination should be considered for all immigrant suicide risk assessment.

Characterising risk of homicide in a population-based cohort

“…Detailed information including immigration class and landing date with systematic and uniform data collection distinguishes this study from other small homicide registry studies28 or other population-based immigrant homicide studies that lacked detailed immigration data 27 28. Results of our study are likely generalisable to other countries with a similarly large and heterogeneous immigrant population (eg, UK, Australia) 3139. Given that there is evidence to suggest deaths of undetermined intent may include a proportion of homicides,25 26 a sensitivity analysis was undertaken and found that the socioeconomic gradient of deaths of unknown intent were similar to homicide.…”

“…This research also highlights the need to recognise contextual factors such as immigration characteristics (ie, refugee status, time since immigration) as important for understanding the heterogeneity of immigrants as a whole and their risk for homicide victimisation more broadly. 31 Despite the immigrant health advantage, research shows that immigrant populations are over-represented in low-income groups, relative to non-immigrants 32 with many facing barriers in access to health services, unemployment and housing instability. 33…”

“…27 28 Results of our study are likely generalisable to other countries with a similarly large and heterogeneous immigrant population (eg, UK, Australia). 31 39 Given that there is evidence to suggest deaths of undetermined intent may include a proportion of homicides, 25 26 a sensitivity analysis was undertaken and found that the socioeconomic gradient of deaths of unknown intent were similar to homicide. Our team has previously shown that at least a proportion of undetermined intent deaths may be misclassified suicides, which likely contributes to the discrepancies identified (ie, different high-risk age groups) in the analysis.…”

Segmenting or Summing the Parts? A Scoping Review of Male Suicide Research in Canada

“…50 Long-term male residents, those middle-aged or older and/or living in neighborhoods with low income levels had increased risk of suicide. 51 Targeted suicide prevention strategies were recommended for established immigrants. 46…”

“…Across these marginalized men, suicidality was linked to social isolation (immigration, homelessness, incarceration experiences) compounded by complex personal histories comprising traumas, 47,49,53 psychological despair, 54 and lack of access to resources. 50 –52,54…”