This study is among the first to examine a broad range of social risk and protective factors and factors related to previous and current mental health problems as well as characteristics of care in a population of asylum seekers. When comparing the asylum seekers and the control group we found several differences: different patterns of risk and protective factors, different clinical pictures and diagnoses and different treatment and follow-up.

One result that differed from most earlier studies on attempted suicide was that a majority of the attempters were men. This reflects the fact that a majority of the asylum seekers in Sweden during this period were men [38–40].

Our results suggest that the decision on the asylum application was an important risk factor, whereas some other studies have failed to find a relationship [2, 5]. The fact that almost a quarter of the studied sample of asylum seekers made a suicide attempt early in the process does not exclude stress related to the insecurity of the asylum process. Other studies have reported the asylum process as an important stressor irrespective of time of rejection [2, 7, 19, 21–26]. Combined with the fact that many of the asylum seekers had earlier mental health problems, the early suicide attempts could also indicate a more longstanding illness process and effects of premigration stress.

We found contrasting patterns of risk factors such as trauma and stressful situations in the two groups. The fact that 23 % of the asylum seekers had been exposed to torture is in line with demographic data from the UK [4] and with other studies on asylum-seeking suicide attempters [3, 6]. One circumstantial indicator of suicidal intent, carrying out the suicide attempt without anyone else present, was lower for the asylum seekers. On the other hand, two subjective indicators of intent - expressing the seriousness of the attempt and that its purpose was death - were higher for the asylum seekers. Discrepancies between these two sections are known in literature. The subjective section consistently generates higher intent scores. Freedenthal [31] discusses the possibility that suicide attempters exaggerate their intent in order to justify their actions, win attention or otherwise give socially desirable responses. In our study it may be thought that, in the case of asylum seekers being assessed within a special legal framework, there are incentives to exaggerate the suicidal intent. Freedenthal’s conclusion is that there may be other explanations, for instance that the objective section is less internally consistent, and that more qualitative research is needed to clarify these discrepancies.

There were significant differences in the diagnoses of stress reactions, PTSD, adjustment and personality disorders as well as alcohol and substance abuse. The levels of diagnoses of PTSD and stress reactions vary in studies of asylum seekers. Our group placed themselves in between the extremes of other studies [3, 4]. The observed low level of alcohol and substance abuse coincides with findings in a UK study [4].

Our data could not clarify how traumatic experiences were taken into account and influenced diagnostic procedures. Other studies have shown that an assessment using a cultural formulation has led to changes in diagnoses, particularly regarding PTSD and psychosis [43, 44]. Our aim is to deepen our understanding of the process of assessing trauma through a qualitative study of the same material.

Our study showed differences between the male and female asylum seekers that have not been demonstrated previously: The asylum - seeking men appeared more anonymous than the women and significantly more so than the male controls, since there was less documentation on their social context, on previous suicidal behaviour and on suicide in the family and close environment. This lack of exploration may affect the assessment of suicide risk. Further, exploring the individual’s social network is a way to approach the subjective world of the patient, which is essential in learning about the determinants of suicide. In this context, it is noteworthy that information on suicidal intention was lacking in a majority of the subjects in both groups.

The female asylum seekers more often made the suicide attempt closer in time to the asylum decision and they were more traumatized than the asylum-seeking men. Compared to the female controls they significantly more often used a suicide method classified as self-injury, regarded as reflecting higher suicide intent than self-poisoning [42]. They also received different diagnoses and more intense and prolonged treatment in hospital.

In spite of this, and in spite of the similarities in the previous history of mental health problems and suicide attempts, the asylum seekers as a group were referred to less specialized mental health care for follow-up than the controls. Staff within the mental health services might not find this surprising, since asylum seekers only had access to “treatment that cannot wait”. In official guidelines, however, suicidal ideation and behaviour are considered serious conditions that require attention by a specialist. Further, as early as 1995 official guidelines emphasized that intense anxiety or depression and torture-related problems should be thoroughly considered when the clinician makes a decision about whether care can wait or not [45].

The fact that the documented clinical picture, the diagnoses and the treatment interventions varied could have different interpretations: there could be a real difference in clinical problems; there could be differences in the assessment of the patient based on the clinician’s assumptions and understanding of cultural factors; more days in hospital could indicate a more serious condition or a lack of outpatient resources for this group of patients. Was trauma more often recorded in the asylum seekers simply because they more often disclosed trauma, given the importance that getting recognition for trauma may have in the asylum process? Or was it because the clinician asked them more often about trauma?

An additional finding is that the Bangladeshi asylum seekers had a higher representation in our study than among asylum seekers in general in Sweden in these years [46]. However, as there are no regional statistics of asylum seekers, we cannot be certain that they were overrepresented in our (Stockholm County) sample during the study period. If there is an overrepresentation, it is improbable that this reflects the suicide pattern of the home country [47]. Other possible explanations could be that Bangladeshi asylum seekers had a higher rate of rejection of their asylum claims and longer waiting time than the average applicant during the study period [48], that the Bangladeshi asylum seekers had different background trauma, and possibly greater difficulties than others in making themselves understood in the Swedish health care system.

Strengths and limitations

The strength of the study is that we were able to access all registered suicide attempts during the research period. During this period, suicide risk identification routines that involved the systematic and mandatory registration of all suicide attempts were implemented. Given the paucity of data on asylum seekers our material is unique.

A limitation is that in spite of the guidelines we cannot know to what degree attempted suicide in the population was in fact registered.

Another strength is that using the medical records as a source made it possible for us to map a broad range of risk factors as they were perceived by the clinician and link them to the actions of the clinician. The obvious corresponding limitation is that we could not find information in medical records on some of the initially formulated items, reducing the number of variables that could be analysed. It was especially difficult interpreting absence of information, since medical records are not written systematically denying absent phenomena. Did the absence of a criterion indicate it not being present in the medical history, not being explored or not being documented?

Also we did not register a number of known risk factors for suicide in our protocol, including socioeconomic status and sexual orientation, since it was unlikely that such data would be documented in the medical records.

Another limitation is that the sample was too small to reach statistical power in some subgroup analyses, for instance the analysis of differences in suicide methods.