Anna-Clara Hollander

Research idea and purposeAutism spectrum disorder (from now on autism) with intellectual disability (ID) is a severe and long-lasting disorder. Repeated systematic reviews show that migrant children have an increased risk of it, but the use of available care is lower in the group. Based on this we have two, separate but interlinked, general research ideas. The first is to elucidate the complex reasons why children of migrants have an increased risk of autism with ID and go from evidence to action to prevent it.The second is to co-design, evaluate and implement interventions to promote a better understanding of the disorder in high-risk migrant groups to decrease stigma and increase the use of available evidence-based care.The focus of the planning grant is to start together with the most affected population, the Somali population. Estimates from Sweden show that children with a Somali descent have about a four times higher prevalence as compared with non-Somali children, and this is in line with international studies. The purpose of this planning grant is to, together with parents of children with autism and ID and trusted Somali community leaders and health care staff, co-create a roadmap for research on the general research ideas.Work plan, methods and project realisationWe have a broad network of stakeholder contacts in Järva outside Stockholm and there we will adopt a community-based participatory research approach. Together with three Somali speaking research assistants we will do focus group interviews with Somali parents of children who have autism with ID and locally trusted community leaders throughout the summer 2025. The results of the focus group interviews will be published in a report in plain and accessible language that will be translated to Somali. The report will be the base for a workshop followed by activities to co-create a viable way forward.Societal relevance and utilisationAutism with ID is a highly disabling disorder with large human and economic costs. Children of Somali descent in high-income countries have a severely increased prevalence and the parents wonder why their children are so disproportionally affected. Research of causes, and interventions to make affected children thrive must include and enlist the help of those affected not to overlook risk factors and to increase the likelihood that the research findings can be applied in real life.

Research problem and specific questionsThe proportion individuals admitted to compulsory psychiatric care is higher amongst migrants (defined here as a person born abroad and settled in Sweden) when compared with the majority Swedish population. The purpose of this project is to study compulsory psychiatric care use within different migrant groups as compared with the Swedish majority population, and to explore possible reasons for any differences. This will be achieved by answering the following questions: What are the differences in likelihood of compulsory psychiatric care use in the total population by migrant status (i.e. by migrants, descendants of migrants, and the majority Swedish population) and amongst migrants by migration related factors such as country-of-origin, reason for migration, duration of stay in Sweden and age of migration? Are there differences regarding age, gender, socioeconomic factors and/or geographical regions in Sweden?What could explain the differences? The following possible explanations will be studied: Variations in prevalence of psychiatric disorders and suicide attemptsLower use of voluntary psychiatric care amongst those with higher use of compulsory psychiatric careFactors in the health care setting that increase the risk of a patient being perceived as a risk to themselves or others Data and methodWe will use a mixed methods approach. For the longitudinal epidemiological studies, we plan to use our register-linkage to create a total population cohort of all individuals born 1944-1988 with a follow-up during 2006-2020. In the qualitative study, we will use focus groups and results will be analysed using Thematic analysis.Societal relevance and utilisationIn cases of immediate danger to a patient or others, physicians have a difficult dual mandate when deciding if compulsory psychiatric care is needed

requiring them to balance the patient’s right to autonomy with the protection of the patient’s and others’ lives. The project will highlight inequities in the use of compulsory psychiatric care and explore potential factors influencing these patterns, paving the way for more equitable psychiatric care.Plan for project realisationThe project will be carried out by a team with extensive research experience in psychiatric epidemiology, and in clinical and transcultural psychiatry. The total budget for the three years will be 4,9 million SEK, including salaries and social security contributions of 3,9 million SEK.

Mental and alcohol use disorders in Africa are seriously understudied and underfinanced but have a huge impact on the burden of disease, human suffering and progress towards goals of leaving no-one behind and Agenda 2030. During COVID-related lockdowns, mental distress has increased in high-income settings but primary data from Africa and appropriate interventions are lacking. However mental health is closely interlinked with school closures, lost life opportunities, poverty, food insecurity. This large population-based study in Uganda aims to analyse the occurrence of the most common mental disorders (depression, anxiety) and alcohol abuse, and interactions with poverty, age, gender, reproductive health (HIV), urbanicity, food insecurity and partner violence. We will validate tools on stigma against mental illness and care seeking, and, assess the influence of the pandemic on access to care and prevention for mental and alcohol use disorders. This 3-year project will use longitudinal data from a cohort of 11,000 individuals aged 13-80 years before, during and after the pandemic. Based on our results we will suggest new policy guidelines for health care and community interventions to mitigate the impact of mental disorders and change prevailing discriminatory views of mental health in general. We build on a strong collaboration between Karolinska and AMBSO research organisation in Uganda overall aiming to optimize capacity for operational research in low-income contexts.

The discussion on how to support the possibly increasing group of adolescents with mental health problems sometimes becomes polarized due to our fragmentary knowledge of the actual needs and numbers. This project will, for the first time, systematically assess:the proportions of adolescents in Sweden with different levels of mental health problems, ranging from emotional distress (which does not fulfill diagnostic criteria) to mental disorders (fulfilling criteria, for, e.g., depression or anxiety), andtheir need and utilization of support and care, taking a broad view of potential support structures beyond, but including, the health care system.The study is based on computer assisted assessments of 6,000 eligible 14- and 17-year-olds in schools and their parents online. Emotional distress will be measured with validated symptom scales (GAD-7 and PHQ-A) and mental disorders using a well-established diagnostic instrument (DAWBA). Information on the frequency, severity, and duration of symptoms and their impact on function will be integrated into Children’s Global Assessment Scale (CGAS) ratings. All together these measures form a solid ground for experienced psychiatrists to appraise  levels of emotional distress and diagnosed mental disorders as well as need of support. Information on self-reported need of a wide range of support functions will be compared with professionals’ assessments of need. Health care data from registers in combination with self-reported utilization of support and care will be compared with professionals’ judgement of need, to estimate hidden proportions of those who are not in contact with care despite an existing need or identify potential “overutilization”. Key demographic and socioeconomic information will be linked from registers to understand how the prevalence of emotional distress and mental disorders varies among different populations, as well as the degree to which needs for support are met in different groups.  The main applicant is responsible for the project, supported by a senior researcher as academic coordinator and a fulltime project leader for practical tasks. Questions on self-reported needs and utilization will be developed in collaboration with e.g. adolescents, NGOs, school health care. The budget is estimated to total 6.9 million over four years.Not until we have the facts can we appropriately act and lay the ground for a broader perspective on support for mental health for adolescents in Sweden.