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Aims: Scientific knowledge about risk factors for work disability in terms of long-term sickness absence and disability pension following lumbar spine decompression surgery remains insufficient. This study aimed to investigate the associations between socio-demographic, work-related, and medical characteristics with subsequent long-term sickness absence (>90 days) and disability pension for individuals who underwent lumbar spine decompression surgery. Methods: A prospective cohort study of all individuals aged 19–60 years with diagnosed dorsopathies, who underwent lumbar spine decompression surgery 2008–10 in Sweden ( n=7373) was performed. Univariate and multivariate hazard ratios with 95% confidence intervals regarding long-term sickness absence and disability pension with a 3-year follow-up period were estimated by Cox proportional regression. Results: Low educational level, being a non-European immigrant and preoperative sickness absence were risk factors for both long-term sickness absence and disability pension (hazard ratios: 1.2–3.8). Female sex was a risk factor for long-term sickness absence (hazard ratios: 1.3) whereas age >44 years and being a Nordic immigrant were risk factors for disability pension (hazard ratios: 1.9–2.6). Medical factors as common mental disorders, other mental disorders, prescribed psychiatric medication and somatic comorbidity were risk factors for both long-term sickness absence and disability pension (hazard ratios: 1.2–3.4). A simultaneous lumbar fusion surgery and high preoperative pain severity were risk factors for long-term sickness absence (hazard ratios 1.2–1.8). Conclusions: To prevent long-term work disability after lumbar spine decompression surgery, specific focus is required on older and female patients, those with mental or somatic comorbidities, high levels of preoperative pain or sickness absence, with a simultaneous lumbar fusion surgery, a low educational level or a non-European immigrant background.

BackgroundThe impact of obsessive–compulsive disorder (OCD) on objective indicators of labour market marginalisation has not been quantified.MethodsLinking various Swedish national registers, we estimated the risk of three labour market marginalisation outcomes (receipt of newly granted disability pension, long-term sickness absence and long-term unemployment) in individuals diagnosed with OCD between 2001 and 2013 who were between 16 and 64 years old at the date of the first OCD diagnosis (n = 16 267), compared with matched general population controls (n = 157 176). Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using Cox regression models, adjusting for a number of covariates (e.g. somatic disorders) and stratifying by sex. To adjust for potential familial confounders, we further analysed data from 7905 families that included full siblings discordant for OCD.ResultsPatients were more likely to receive at least one outcome of interest [adjusted HR = 3.63 (95% CI 3.53–3.74)], including disability pension [adjusted HR = 16.36 (95% CI 15.34–17.45)], being on long-term sickness absence [adjusted HR = 3.07 (95% CI 2.95–3.19)] and being on long-term unemployment [adjusted HR = 1.72 (95% CI 1.63–1.82)]. Results remained similar in the adjusted sibling comparison models. Exclusion of comorbid psychiatric disorders had a minimal impact on the results.ConclusionsHelp-seeking individuals with OCD diagnosed in specialist care experience marked difficulties to participate in the labour market. The findings emphasise the need for cooperation between policy-makers, vocational rehabilitation and mental health services in order to design and implement specific strategies aimed at improving the patients’ participation in the labour market.

Background There is limited knowledge regarding psychiatric healthcare utilization around the time of granting disability pension (DP) due to common mental disorders (CMD) among immigrants and if this is related to social insurance regulations. The aim was to evaluate patterns of psychiatric healthcare utilization before and after DP due to CMD among immigrants and natives. A second aim was to evaluate if such patterns differed before and after changes in social insurance regulations in Sweden in 2008. Methods All 28 354 individuals living in Sweden with incident DP due to CMD, before (2005-06; n = 24 298) or after (2009-10; n = 4056) changes in regulations of granting DP, were included. Patterns of psychiatric in- and specialized outpatient healthcare utilization during a 7-year window around DP granting were assessed by Generalized Estimating Equations estimating multivariate adjusted odds ratios (OR) and 95% confidence intervals (CI). Results Prevalence rates of psychiatric inpatient care were comparable among immigrants and natives, lower in non-Western immigrants (Africa, Asia and South-America). Three years after DP, non-Western immigrants in comparison to natives and Western immigrants had a stronger decrease in inpatient psychiatric healthcare: OR 0.48 (CI 0.38-0.62), 0.76 (0.70-0.83) and 1.01 (0.76-1.34), respectively. After 2008, a strong reduction in outpatient psychiatric healthcare after DP granting was observed, similarly in immigrants and natives. Conclusions Non-Western immigrants showed a different pattern of inpatient specialized healthcare after DP granting in comparison to natives. After changes in social insurance regulations, the decline in outpatient psychiatric healthcare following DP granting was comparable in immigrants and natives.

Background Suicide attempt in young age is associated with subsequent labour market marginalisation, but little is known about how marginalisation is affected by changes in suicide attempt rates and social insurance legislation and by age differences. Methods Prospective cohort study based on register linkage of > 2.4 million Swedish residents per birth cohort, aged 19-40 years in 1999; 2004 and 2009, respectively, and followed up for 4 years. Suicide attempters treated in inpatient care in the three years preceding study entry (n > 7000 per cohort) were compared with the general population of the same age without attempt (1987 to end of follow-up). Hazard ratios (HR) and 95% confidence intervals for long-term unemployment (>180 days), sickness absence (>90 days) and disability pension were calculated with Cox regression, adjusted for several risk markers. Additional analyses were stratified by age (below/above 30 years). Results Across all cohorts, suicide attempt was associated with subsequent labour market marginalisation. Estimates were generally highest for disability pension [e.g. 2009 cohort: adjusted (a) HR = 2.7], followed by sickness absence (2009 cohort: aHR = 2.3) and unemployment (2009 cohort: aHR = 1.5). aHRs were higher in the 2004 and 2009 cohorts compared with the 1999 cohort. For disability pension, for example, aHRs were 2.39, 3.90 and 2.68 for the 1999, 2004 and 2009 cohorts, respectively. Stratification revealed marginal age differences. Conclusion It seems to have become more difficult for suicide attempters to establish themselves on the labour market in later cohorts, which might result from changes in social insurance regulations. There were no considerable age differences.

ObjectivesThe aims of the study were to trace the patterns of work environment factors and compensated sickness absence (SA) among nurses and care assistants compared with other occupations and to compare SA among exposed and non-exposed nurses and care assistants.DesignA cross-sectional survey on work environment factors based on the biennial Swedish Work Environment Surveys 1991–2013, linked to longitudinal register data on SA 1993–2014.ParticipantsThe study included 98 249 individuals, stratified into nurses and care assistants (n=16 179) and a reference population including all other occupations (n=82 070).Outcome measureAnnual days of compensated SA (>14 days) 3 years after exposure years.ResultsNurses and care assistants had higher SA in 1993–2014 compared with all other occupations, and differences in background factors only partly explained this relationship. For both groups, exposure to physical work factors remained steady, but the number of exposed were 10%–30% higher among nurses and care assistants. Those exposed to heavy physical work and strenuous working postures had in most years significantly higher SA when compared with non-exposed (rate ratio range: 1.4–1.9). Exposure to high job demands increased 10%–25% in 1991–1999 among nurses and care assistants but became more stable in 2001–2013 and high proportions of high job demands coincided with the increase in SA in 1995–1999. Nurses and care assistants exposed to high job demands had for most years significantly higher SA than non-exposed (rate ratio range: 1.5–2.1). Low job control and low support from supervisors elevated SA significantly only for a few years.ConclusionsExposure to negative work factors among nurses and care assistants was weakly associated with variations in SA, but may be related to their higher level of SA when compared with other occupations. Improved physical and psychosocial working conditions may reduce the elevated SA level in these occupations.

This study investigated the extent to which work disability patterns including sickness absence and disability pension (SA/DP) before and after acute myocardial infarction (AMI) were associated with subsequent common mental disorders (CMDs) such as depression and anxiety in AMI patients without previous CMD. Total 11,493 patients 26–64 years with incident AMI during 2008–10 were followed up for CMD (measured as antidepressant prescription) through 2013. Four SA/DP trajectory groups during the 3-years pre-AMI and 1-year post-AMI were identified. Hazard ratios (HRs) with 95% confidence intervals for subsequent CMD were estimated in Cox models. Higher pre-AMI SA/DP annual levels (>1–12 months/year) were associated with 40–60% increased CMD rate than the majority (78%) with low increasing levels (increasing up to 1 month/year). Regarding post-AMI findings, constant high (~25–30 days/month) SA/DP levels within the first 3 months was associated with a 76% higher CMD rate, compared to constant low (0 days/month). A gradually decreasing post-AMI SA/DP pattern over a 12-month period suggested protective influences for CMD (HR = 0.80). This is the first study to demonstrate that pre- and post-AMI work disability patterns are associated with subsequent CMD risk in AMI patients. Work disability patterns should be considered as an indicator of AMI prognosis in terms of CMD risk.

Background This study investigated the extent to which work-disability patterns including sickness absence and disability pension (SA/DP) before and after acute myocardial infarction (AMI) were associated with subsequent common mental disorders (CMDs) such as depression and anxiety in AMI patients without previous CMD. Methods A cohort of 11,493 patients aged 26-64 years without previous CMD with incident AMI during 2008-2010 were followed up for CMD measured as antidepressant prescription through 2013. Four SA/DP trajectory groups during the 3 years pre-AMI and 1 year post-AMI were identified. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated in Cox models. Results Higher pre-AMI SA/DP levels (>1-12 months/year), compared to the majority of patients (78%) following low increasing annual levels (increasing up to 1 month/year) of pre-AMI SA/DP, were associated with a 40-60% increased CMD rate. Regarding post-AMI findings, constant high (∼25-30 days/month) and steeply decreasing SA/DP levels within the first 3 months were associated with a 76% and 35% higher CMD rate, respectively, compared to constant low ( Conclusions This is the first study to demonstrate that pre- and post-AMI work disability patterns are associated with subsequent CMD risk in AMI patients. Work disability patterns should be considered in clinical practice as an indicator of AMI prognosis in terms of CMD risk. Key messages Increasing and high persistent levels of pre-AMI work disability are associated with higher risk of subsequent CMD, while gradually decreasing post-AMI work disability has a favourable CMD prognosis. Pre- and post-AMI patterns of work disability (sickness absence and disability pension) can be a useful marker in terms of CMD prognosis.

BackgroundMental disorders are associated with an elevated risk for suicide attempt and suicide. Whether the strength of the associations also holds for refugees is unclear.AimsTo examine the relationship between specific mental disorders and suicide attempt and suicide in refugees and Swedish-born individuals.MethodThis longitudinal cohort study included 5 083 447 individuals aged 16–64 years, residing in Sweden in 2004, where 196 757 were refugees. Mental disorders were defined as having a diagnosis in psychiatric care during 2000–2004. Estimates of risk of suicide attempt and suicide were calculated as hazard ratios with 95% confidence intervals. Adjustments were made for important confounding factors, including history of attempt. The reference group comprised Swedish-born individuals without mental disorders.ResultsRates for suicide attempt in individuals with a mental disorder were lower in refugees compared with Swedish-born individuals (480 v. 850 per 100 000 person-years, respectively). This pattern was true for most specific disorders: compared with the reference group, among refugees, multivariable-adjusted hazard ratios for suicide attempt ranged from 3.0 (anxiety) to 7.4 (substance misuse), and among Swedish-born individuals, from 4.9 (stress-related disorder) to 9.3 (substance misuse). For schizophrenia, bipolar disorder and personality disorder, estimates for suicide attempt were comparable between refugees and Swedish-born individuals. Similar patterns were seen for suicide.ConclusionsFor most mental disorders, refugees were less likely to be admitted to hospital for suicide attempt or die by suicide compared with Swedish-born individuals. Further research on risk and protective factors for suicide attempt and suicide among refugees with mental disorders is warranted.Declaration of interestNone.

Background: Future Expectation is important for motivation and wellbeing, however drastic life events such as in refugee situations may result in low expectations. This study aims to investigate the prevalence and determinants of low future expectations among Syrian refugees resettled in Sweden. Methods: A random sample of 1215 Syrian refugees resettled in Sweden responded to questionnaire. Weighted analyses and adjusted relative risks were conducted to determine the prevalences and predictors of low future expectations. Synergy index was calculated for low social support and depression in relation to low expectations. Results: The prevalences of low future expectations for labour market, social and economic intergration were 10.9%, 13.4% and 14.1% respectively. Longer stay in Sweden, being older, low social support and depression were associated with low future expectations. The simultaneous presence of depression and low social support had a synergistic effect on low social expectation. Discussions: Understanding and addressing factors related to low future expectations among refugees may be useful for facilitating their labour market, social and economic integration.

Background Among potential pathways to suicidal behavior in individuals with mental disorders (MD), work disability (WD) may play an important role. We examined the role of WD in the relationship between MD and suicidal behavior in Swedish-born individuals and refugees. Methods The study cohort consisted of 4,195,058 individuals aged 16–64, residing in Sweden in 2004–2005, whereof 163,160 refugees were followed during 2006–2013 with respect to suicidal behavior. Risk estimates were calculated as hazard ratios (HR) with 95% confidence intervals (CI). The reference groups comprised individuals with neither MD nor WD. WD factors (sickness absence (SA) and disability pension (DP)) were explored as potential modifiers and mediators. Results In both Swedish-born and refugees, SA and DP were associated with an elevated risk of suicide attempt regardless of MD. In refugees, HRs for suicide attempt in long-term SA ranged from 2.96 (95% CI: 2.14–4.09) (no MD) to 6.23 (95% CI: 3.21–12.08) (MD). Similar associations were observed in Swedish-born. Elevated suicide attempt risks were also observed in DP. In Swedish-born individuals, there was a synergy effect between MD, and SA and DP regarding suicidal behavior. Both SA and DP were found to mediate the studied associations in Swedish-born, but not in refugees. Conclusion There is an effect modification and a mediating effect between mental disorders and WD for subsequent suicidal behavior in Swedish-born individuals. Also for refugees without MD, WD is a risk factor for subsequent suicidal behavior. Particularly for Swedish-born individuals with MD, information on WD is vital in a clinical suicide risk assessment.

Background The aims were to elucidate if trajectories of labour market marginalization (LMM), measured as sickness absence (SA)/disability pension (DP) or unemployment, differed between young immigrants and natives before and after an incident diagnosis of a common mental disorder (CMD), and to investigate if educational level, psychiatric comorbidity and duration of residence in Sweden (in immigrants) had different associations with subsequent LMM in natives compared with immigrants. Methods A total of 28 971 young adults (19–30 years), with an incident CMD (inpatient or specialized outpatient healthcare due to CMDs or dispensed prescribed antidepressants during 2007) were included. Group-based trajectory models were utilized to identify trajectories of annual months of LMM 3 years before and 6 years after the diagnosis. The associations of risk factors with different trajectories were investigated by multinomial logistic regression, χ2-test and Nagelkerke R2 to measure the associations’ strength. Immigrants were categorized into Western and non-Western immigrants. Results Young natives and immigrants showed similar trajectories of SA/DP. A higher proportion of non-Western immigrants (20.5%) followed trajectories of high levels of unemployment (>2 annual months) compared with Western immigrants (15%) and natives (16.5%). Educational level and duration of residence in Sweden (in immigrants) discriminated trajectories of both SA/DP and unemployment, whereas psychiatric comorbidity only discriminated trajectories of SA/DP. Conclusions Differences in trajectories of unemployment between young natives and immigrants with an incident CMD were found. Educational level and psychiatric comorbidity provided information on differences between natives and immigrants and duration of residence gave information for subgroups of immigrants.

BACKGROUND The aims were to study the differences in work-disability in patients with low back pain (LBP) in relation to (i) treatment provided (non-surgical or lumber spine surgery (decompression or fusion), and (ii) two time points, i.e. before and after the social insurance regulation changes in the in 2008. METHODS All non-pensioned individuals, aged 19-60 years, living in Sweden, diagnosed with LBP in 2004-06 or 2008-10 were included (n = 153739). Hazard ratios (HRs) with 95% confidence intervals for long-term sickness absence (>90 days, LTSA) and disability pension (DP) for LBP-patients (non-surgical, decompression, fusion, both surgeries) were estimated by Cox regression compared with the matched references from the general population without LBP (n = 566008). RESULTS LBP-patients had a higher risk of subsequent work-disability compared with the references before and after insurance regulation changes. LBP-patients receiving decompression surgery had similar risk for later work-disability as those treated non-surgically. However, following regulation changes, LBP-patients undergoing fusion surgery had higher risk estimates of both LTSA (HR: 3.3) and DP (HR: 4.8) than patients treated non-surgically (HR: LTSA 2.1; DP 2.5) or with decompression (HR: LTSA 2.6; DP 2.1). In the adjusted models, risk estimates mainly attenuated after controlling for previous sickness absence. CONCLUSION Risk for subsequent work-disability among LBP-patients was higher compared with people without LBP and lumbar spine surgery. Discrepancies in risk were explained by the treatment provided previous sickness absence and changes in the social insurance regulations, specifically LBP-patients treated with fusion surgery had an increased risk of subsequent work-disability after changes in regulations.

Background Labour-market marginalisation (LMM) and common mental disorders (CMDs) are serious societal problems. The aims were to describe trajectories of LMM (both work disability and unemployment) among young adults with and without CMDs, and to elucidate the characteristics associated with these trajectories. Methods The study was based on Swedish registers and consisted of all individuals 19–30 years with an incident diagnosis of a CMD in year 2007 (n = 7245), and a matched comparison group of individuals without mental disorders during the years 2004–07 (n = 7245). Group-based trajectory models were used to describe patterns of LMM both before, and after the incident diagnosis of a CMD. Multinomial logistic regressions investigated the associations between sociodemographic and medical covariates and the identified trajectories. Results Twenty-six percent (n = 1859) of young adults with CMDs followed trajectories of increasing or constant high levels of work disability, and 32 % (n = 2302) followed trajectories of increasing or constant high unemployment. In the comparison group, just 9 % (n = 665) followed increasing or constant high levels of work disability and 21 % (n = 1528) followed trajectories of increasing or constant high levels of unemployment. A lower share of young adults with CMDs followed trajectories of constant low levels of work disability (n = 4546, 63%) or unemployment (n = 2745, 38%), compared to the level of constant low work disability (n = 6158, 85%) and unemployment (n = 3385, 50%) in the comparison group. Remaining trajectories were fluctuating or decreasing. Around 50% of young adults with CMDs had persistent levels of LMM at the end of follow-up. The multinomial logistic regression revealed that educational level and comorbid mental disorders discriminated trajectories of work disability, while educational level, living area and age determined differences in trajectories of unemployment (R2difference = 0.02–0.05, p

BackgroundThe aim was to elucidate if the risk of labour market marginalisation (LMM), measured as long-term unemployment, long-term sickness absence, disability pension and a combined measure of these three measures, differed between refugees and non-refugee migrants with different regions of birth compared with native Swedes.MethodsAll non-pensioned individuals aged 19–60 years who were resident in Sweden on 31 December 2009 were included (n=4 441 813, whereof 216 930 refugees). HRs with 95% CIs were computed by Cox regression models with competing risks and time-dependent covariates with a follow-up period of 2010–2013.ResultsRefugees had in general a doubled risk (HR: 2.0, 95% CI 1.9 to 2.0) and non-refugee migrants had 70% increased risk (HR: 1.7, 95% CI 1.7 to 1.7) of the combined measure of LMM compared with native Swedes. Refugees from Somalia (HR: 2.7, 95% CI 2.6 to 2.8) and Syria (HR: 2.5, 95% CI 2.5 to 2.6) had especially high risk estimates of LMM, mostly due to high risk estimates of long-term unemployment (HR: 3.4, 95% CI 3.3 to 3.5 and HR: 3.2, 95% CI 3.1 to 3.2). African (HR: 0.7, 95% CI 0.6 to 0.7) and Asian (HR: 1.0, 95% CI 1.0 to 1.1) refugees had relatively low risk estimates of long-term sickness absence compared with other refugee groups. Refugees from Europe had the highest risk estimates of disability pension (HR: 1.9, 95% CI 1.8 to 2.0) compared with native Swedes.ConclusionRefugees had in general a higher risk of all measures of LMM compared with native Swedes. There were, however, large differences in risk estimates of LMM between subgroups of refugees and with regard to type of LMM. Actions addressing differences between subgroups of refugees is therefore crucial in order to ensure that refugees can obtain as well as retain a position on the labour market.

Despite decompression surgery being a widespread intervention for patients with dorsopathies (i.e. back pain) affecting the lumbar spine, the scientific knowledge on patterns and characteristics of work disability before and after the surgery is limited. Sickness absence (SA) and disability pension (DP) were examined three years before and after surgery in 8558 patients aged 25–60 years who underwent lumbar spine decompression surgery in Sweden. They were compared to individuals with diagnosed dorsopathies but no surgery and individuals from the general population as matched comparison groups. According to Group Based Trajectory models, in patients with decompression surgery, 39% had low levels of SA/DP during the entire study period and 15% started with low levels of SA/DP, which increased in the year before, and declined to almost zero in the second year after surgery. Three trajectory groups (12%, 17%, and 18%) started at different levels of SA/DP, which increased in the years before, and declined in the third year after surgery. The trajectory groups in the comparison groups showed lower levels of work disability. Sex, education, and the use of antidepressants and analgesics the year before surgery played an important role to explain the variance of trajectory groups in patients with surgery.

Background Despite high rates of youth suicide attempt, little is known about patterns of functional impairment in terms of sickness absence and disability pension (SA/DP) before and after an attempt. The aim was to identify SA/DP trajectories among young adults with or without suicide attempt and to describe associations of socio-demographic and clinical factors with such trajectories. Methods This is a population-based cohort study of 5385 individuals aged 25–40 years with a first suicide attempt during 2007–2009. One control for each case without suicide attempt was matched by socio-demographic factors. Trajectories of annual SA/DP months over an eight-year period were analysed by group-based trajectory modelling. Associations between socio-demographic and clinical factors with trajectory groups were estimated by chi2-test and multinomial logistic regression. Results Two groups of suicide attempters had low SA/DP levels over time (62%). One group had constantly high SA/DP levels (16%). The remaining two groups had increased SA/DP initially, which then decreased at different time points. Socio-demographic and clinical factors were associated with different trajectories (R2 = 0.44). Suicide attempters with low levels of SA/DP were likely to be unemployed whereas a larger proportion of those with high levels of SA/DP had psychiatric health care before the suicide attempt, particularly due to schizophrenia and non-affective psychoses or personality disorders. Conclusions Young suicide attempters even with no/low levels of SA/DP were likely to be marginalised at the labour market. Schizophrenia/non-affective psychoses and personality disorders were important clinical factors for differentiating the levels of SA/DP among young suicide attempters.

Background In several countries, immigrants have higher disability pension (DP) rates than natives. Reasons for this are poorly understood. The aim of this study was to investigate if the risk of diagnosis-specific DP differed in first, second, and second/intermediate generation immigrants compared to natives, in general and across regions of birth, and stratified by age. Methods A population-based prospective cohort study of all 3,507,055 individuals aged 19–50 years and living in Sweden in 2004 with a 6-year follow-up period. Hazard ratios (HR) and 95% confidence intervals (CI) for mental and somatic DP were estimated by Cox regression for first, second, and second/intermediate generation immigrants compared to natives, across regions of birth and stratified by age. Results After multivariate adjustment, HRs for both mental and somatic DP were higher at follow-up in the first generation compared to natives: mental HR 1.17 (CI 1.12–1.22) and somatic 1.15 (1.09–1.22) for individuals, published version, peerReviewed

Background: Sickness absence with cash benefits from the sickness insurance gives an opportunity to be relieved from work without losing financial security. There are, however, downsides to taking sickness absence. Periods of sickness absence, even short ones, can increase the risk for future spells of sickness absence and unemployment. The sickness period may in itself have a detrimental effect on health. The aim of the study was to investigate if there is an association between exposure to sickness absence at a young age and later sickness absence, disability pension, death, unemployment and income from work. Methods: Our cohort consisted of all immigrants aged 21-25 years in Sweden in 1993 (N=38 207) and a control group of native Swedes in the same age group (N=225 977). We measured exposure to sickness absence in 1993 with a follow-up period of 15 years. We conducted separate analyses for men and women, and for immigrants and native Swedes. Results: Exposure to >= 60 days of sickness absence in 1993 increased the risk of sickness absence [hazard ratio (HR) 1.6-11.4], unemployment (HR 1.1-1.2), disability pension (HR 1.2-5.3) and death (HR 1.2-3.5). The income from work, during the follow-up period, among individuals with spells of sick leave for >= 60 days in 1993 was around two-thirds of that of the working population who did not take sick leave. Conclusions: Individuals on sickness absence had an increased risk for work absence, death and lower future income.

Objectives Immigrants with common mental disorders (CMDs) are reported to have a higher risk of disability pension (DP) compared with native residents; however, the reasons for this are not fully understood. This study aimed to investigate (1) differences in morbidity (3 measures) and socioeconomic status in native Swedes, ‘Western’ and ‘non-Western’ immigrants with CMDs and (2) interactions between morbidity and socioeconomic status and immigrant status regarding subsequent DP. Design The study was a prospective population-based cohort study using national register data. Crude and multivariate HRs with 95% CIs were calculated using the Cox regression (2007–2010). Participants All individuals aged 18–59 with an incident sick-leave spell due to CMDs during 2006 were included in the study (N=66 097). The study population was divided into 3 groups based on country of birth: (1) Sweden, (2) immigrants from ‘Western’ countries (EU25, Norway, Iceland, North America and Oceania) and (3) immigrants from ‘non-Western’ countries (east Europe, Africa, Asia and South America). Results Particularly, immigrants born in non-Western countries had higher levels of morbidity and lower socioeconomic status than natives (p>0.001). No significant differences in the associations between specialised psychiatric and somatic care with regard to subsequent DP were found between immigrants and native Swedes. Being prescribed more than 1 type of psychiatric medication was associated with higher HRs for DP in immigrants from Western (HR 3.34; CI 2.3 to 4.9) and non-Western countries (3.6; 1.9 to 6.4) than in native Swedes (2.55; 2.3 to 2.8) (p interaction =0.003). Low education was a marginally stronger predictor for DP in non-Western immigrants than in native Swedes and Western immigrants (p interaction =0.03). Conclusions Morbidity measured by medication, but not by specialised healthcare, was a stronger predictor for DP in immigrants than in native Swedes, warranting scrutiny of differences in care and treatment in immigrants and native Swedes with CMDs.

The youth unemployment rate is increasing in many countries and unemployment affects future work participation. Immigrants have more difficulties than natives in succeeding on the labour market. This study examined the long-term effect of unemployment on future unemployment in Sweden. All immigrants born during 1968-1972 and a random sample of native Swedes of the same age are included. The follow-up period was 15 years, 1993-2007. Unemployed individuals had an elevated risk of unemployment during follow-up. The risk of unemployment increased with the length of unemployment in 1992. Immigrants had a higher risk of unemployment both at baseline and follow-up compared with native Swedes, but followed the same pattern as native Swedes when exposed to unemployment. For individuals with ≥100 days of unemployment in 1992, participation in an Active Labour Market Program (ALMP) increased the risk of future unemployment, whereas both higher educational level at baseline and attainment of a higher educational level between 1993 and 1997 decreased the risk. In addition to the human suffering caused, this can result in increased welfare payments and loss of productivity and tax income to a society. Immigrants seem not to be more vulnerable to unemployment than native Swedes.

Background The aim was to investigate the associations between mental disorders and three different measures of labour-market marginalisation, and differences between native Swedes and immigrants. Methods The study comprised 1,753,544 individuals, aged 20–35 years, and resident in Sweden 2004. They were followed 2005–2011 with regard to disability pension, sickness absence (≥90 days) and unemployment (≥180 days). Immigrants were born in Western countries (Nordic countries, EU, Europe outside EU or North-America/Oceania), or in non-Western countries (Africa, Asia or South-America). Mental disorders were grouped into seven subgroups based on a record of in- or specialised outpatient health care 2001–2004. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed by Cox regression models with both fixed and time-dependent covariates and competing risks. We also performed stratified analyses with regard to labour-market attachment. Results Individuals with mental disorders had a seven times higher risk of disability pension, a two times higher risk of sickness absence, and a 20% higher risk of unemployment than individuals without mental disorders. Individuals with personality disorders and schizophrenia/non-affective psychoses had highest risk estimates for having disability pension and long-term sickness absence, while the risk estimates of long-term unemployment were similar among all subgroups of mental disorders. Among persons with mental disorders, native Swedes had higher risk estimates for disability pension (HR:6.6; 95%CI:6.4–6.8) than Western immigrants (4.8; 4.4–5.2) and non-Western immigrants (4.8; 4.4–5.1), slightly higher risk estimates for sickness absence (2.1;2.1–2.2) than Western (1.9;1.8–2.1), and non-Western (1.9;1.7–2.0) immigrants but lower risk estimates for unemployment (1.4;1.3–1.4) than Western (1.8;1.7–1.9) and non-Western immigrants (2.0;1.9–2.1). There were similar risk estimates among sub-regions within both Western and non-Western countries. Stratification by labour-market attachment showed that the risk estimates for immigrants were lower the more distant individuals were from gainful employment. Conclusions Mental disorders were associated with all three measures of labour-market marginalisation, strongest with subsequent disability pension. Native Swedes had higher risk estimates for both disability pension and sickness absence, but lower risk estimates for unemployment than immigrants. Previous labour-market attachment explained a great part of the association between immigrant status and subsequent labour-market marginalisation.

ObjectivesThe aim was to investigate differences in the prescription of antidepressants during the transition to disability pension (DP) comparing DP due to back pain with DP due to other musculoskeletal and DP due to other somatic diagnoses.DesignA population-based cohort study with follow-up 3 years before and after the event. Estimated prevalence and adjusted ORs with 95% CIs for antidepressant prescription were computed for the 7-year window (ie, t-3 to t+3) around the DP by generalised estimating equations for repeated measures.Setting and participantsThis Swedish population-based nationwide study with registry data included individuals aged 18–64 years, with DP due to back pain (n=2011), DP due to other musculoskeletal (n=3548) or DP due to other somatic diagnoses (n=11 809).Primary outcome measuresPrescription of antidepressants.ResultsBefore DP, the prevalence of prescription of antidepressants was stable in DP due to back pain, but increased for the other DP groups. Similarly, the likelihood of prescription increased only marginally before DP due to back pain (ORs from 0.86 at t-3 to 1.10 at t-1), but clearly in DP due to musculoskeletal (from 0.42 to 1.15) and somatic diagnoses (from 0.29 to 0.98). Both prevalence measures and risks remained at the elevated levels after DP.ConclusionsPathways to DP due to musculoskeletal and somatic diagnoses seem to be partly driven by adverse mental health, which remains at a higher level after DP. The increasing prescription of antidepressants prior to DP suggests that special attention should be paid to mental health for prevention of DP. The period after DP needs attention to avoid deterioration of mental health.

Labour-market marginalisation after a mental diagnosis among natives and immigrants living in Sweden

BACKGROUND: Youth unemployment is an increasing problem for societies around the world. Research has revealed negative health effects of unemployment, and this longitudinal register-based cohort study examined the relationship between unemployment and later sickness absence, disability pension and death among youth in Sweden. METHOD: The study group of 199 623 individuals comprised all immigrants born between 1968 and 1972 who immigrated before 1990 (25 607) and a random sample of native Swedes in the same age-range (174 016). The baseline year was 1992, and the follow-up period was from 1993 to 2007. Subjects with unemployment benefit in 1990-91, disability pension in 1990-92, severe disorders leading to hospitalization in 1990-92 and subjects who emigrated during follow-up were excluded. RESULTS: Those who were unemployed in 1992 had elevated risk of ≥60 days of sickness absence (OR 1.02-1.49), disability pension (HR 1.08-1.62) and all except native Swedish women had elevated risk of death (HR 1.01-1.65) during follow-up compared with non-unemployed individuals. The risk of future sickness absence increased with the length of unemployment in 1992 (OR 1.06-1.54), and the risk of sickness absence increased over time. A larger part of the immigrant cohort was unemployed at baseline than native Swedes. Selection to unemployment by less healthy subjects may explain part of the association between unemployment and the studied outcomes. CONCLUSION: Unemployment at an early age may influence the future health of the individual. To a society it may lead to increased burdens on the welfare system and productivity loss for many years.

The aim of this register-based longitudinal study was to explore the relationship between exposure to unemployment and sick leave at a young age and later health and work related outcomes. A comparison was also made between immigrants and native Swedes. The study population consisted of all immigrants, born between 1968 and 1972, and a random sample of native Swedes in the same age range. The follow-up period was 15 years, divided into three 5-year periods. Unemployment in 1992 was associated with later ≥60 days of sickness absence, disability pension and, for all subjects except native Swedish women, also mortality during follow-up. The risk of future sickness absence was about the same in all three follow-up periods. There was an increased risk of ≥100 days of unemployment in all three follow-up periods, but the risk declined, however, until the last follow-up period. Higher level of education at baseline as well as education attained between 1993 and 1997 decreased the risk of future unemployment. Participating in active labour market programmes was associated with higher risk of future unemployment. The risk of both future unemployment and future sickness absence increased with the length of unemployment in 1992. Immigrants had a higher risk of unemployment both at baseline and at follow-up compared with native Swedes, but matched the pattern of native Swedes during follow-up. Exposure to ≥60 days of sickness absence in 1993 was associated with increased risk for ≥60 days of sickness absence, ≥100 days of unemployment, disability pension and mortality during follow-up compared with no sick leave at baseline. The income from work, during the follow-up period, among individuals with spells of sick leave ≥60 days in 1993 was around two-thirds of that of individuals not on >60 days of sick leave. There was a rapid increase in future work absence for the first 1–7 days of sick leave claimed. Thereafter there was a lower, but steady increase in days of future work absence for every increase in sick leave. This of course affects the individual in the first place and to a society it means substantial costs in the form of increased welfare payments, and loss of productivity and tax income.

Background There are many immigrants in the Swedish workforce, but knowledge of their general and work-related health is limited. The aim of this register-based study was to explore whether documented migrant residents in Sweden have a different health status regarding receipt of a disability pension, mortality and hospitalization for lung, heart, psychiatric, and musculoskeletal disorders compared with the native population, and if there were variations in relation to sex, geographical origin, position on the labor market, and time since first immigration. Methods This study included migrants to Sweden since 1960 who were 28–47 years old in 1990, and included 243 860 individuals. The comparison group comprised a random sample of 859 653 native Swedes. These cohorts were followed from 1991 to 2008 in national registers. The immigrants were divided into four groups based on geographic origin. Hazard ratios for men and women from different geographic origins and with different employment status were analyzed separately for the six outcomes, with adjustment for age, education level, and income. The influence of length of residence in Sweden was analyzed separately. Results Nordic immigrants had increased risks for all investigated outcomes while most other groups had equal or lower risks for those outcomes than the Swedes. The lowest HRs were found in the EU 15+ group (from western Europe, North America, Australia and New Zealand). All groups, except Nordic immigrants, had lower risk of mortality, but all had higher risk of disability pension receipt compared with native Swedes. Unemployed non-Nordic men displayed equal or lower HRs for most outcomes, except disability pension receipt, compared with unemployed Swedish men. A longer time since first immigration improved the health status of men, while women showed opposite results. Conclusions Employment status and length of residence are important factors for health. The contradictory results of low mortality and high disability pension risks need more attention. There is great potential to increase the knowledge in this field in Sweden, because of the high quality registers.

Objectives This study examined the relationship between long term unemployment (>100 days) during a recession among young men and women, both immigrants and native Swedes, and future unemployment, sickness absence, disability pension and death. Methods A register-based cohort study with data from national databases. The study population comprised all foreign-born individuals 20–24 years 1992 (N=32 808) and a random sample of Swedish-born individuals of the same age (n=186 352). The cohort was followed 1993–2007. The results were adjusted for age, income and geographical origin and analysed separately for men and women and educational background in three classes. Results Unemployed individuals at baseline (1992) had a higher risk (measured as OR) of future long-term unemployment, sickness absence and disability pension during follow-up compared to those employed. The length of the unemployment period 1992 was associated with the length of future unemployment periods and sickness absence periods. Unemployed also run an elevated risk of death compared to employed but the numbers were low in this young cohort. The higher the education level for the unemployed the lower the risk of future unemployment. There were no consistent differences between men and women or immigrants and native Swedes for the studied outcomes. Conclusions Unemployment in young ages led to increased OR for absence from work due to unemployment, sickness and disability pension during a 15-year follow-up period. To enrol young persons in working life seems to be very important both for the individual and the society.

Objectives The youth unemployment rate is increasing around the world due to recent recessions in the worldwide economy. Unemployment has been seen to affect future work participation. This register-based study examined the long-term effect of unemployment on future unemployment in Sweden. Methods The study group of 199,623 individuals included all immigrants born between 1968 and 1972 who immigrated to Sweden before 1990 (25,607) and a random sample of native Swedes of the same age (174,016). The follow-up period was 15 years, from 1993 to 2007. Results Individuals who were unemployed in 1992 had an elevated risk of ≥100 days of unemployment during the whole follow-up period. The risk of unemployment in the follow-up increased with the length of unemployment in 1992. Immigrants had a higher risk of unemployment both at baseline and follow-up compared with native Swedes, but followed the same pattern as native Swedes when exposed to unemployment. For individuals with ≥100 days of unemployment in 1992, participation in an Active Labour Market Programme (ALMP) increased the risk of future unemployment, whereas both higher educational level at baseline and attainment of a higher educational level between 1992 and 1997 decreased the risk of future unemployment. Conclusion Exposure to unemployment was associated with elevated risk of future unemployment 15 years after exposure. In addition to the human suffering caused, this can mean substantial costs in the form of increased welfare payments and loss of productivity and tax income to a society. ALMPs seem ineffective in promoting future work participation.

Work and health among native and foreign-born residents in Sweden 1990-2008 : a register-based study on hospitalization due to common potentially work-related disorders, disability pension and mortality

Purpose This study aimed to compare young individuals who differed in terms of birth region and history of suicide attempt regarding socio-demographic and healthcare factors, and with regard to their risks of subsequent unemployment, sickness absence and disability pension. Methods Prospective cohort study based on register linkage of 2,801,558 Swedish residents, aged 16–40 years in 2004, without disability pension and with known birth country, followed up 2005–2011. Suicide attempters treated in inpatient care during 2002–2004 (N = 9149) were compared to the general population of the same age without attempt 1987–2011 (N = 2,792,409). Hazard ratios (HR) and 95% confidence intervals (CIs) for long-term unemployment (>180 days), sickness absence (>90 days), and disability pension were calculated with Cox regression, adjusted for several risk markers. Results Compared to Swedish natives with suicide attempt, migrants of non-Western origin with attempt received less specialised mental healthcare. Distinct differences between native Swedes and migrants were present for the three labour market outcomes, but differences between migrant subgroups were inconsistent. As compared to native Swedes without attempts, non-European migrants with suicide attempt had adjusted HRs and CIs for subsequent unemployment 2.8 (2.5–3.1), sickness absence 2.0 (1.7–2.3) and disability pension 2.2 (1.8–2.6). Respective estimates for natives with suicide attempt were 2.0 (1.9–2.1); 2.7 (2.6–2.9) and 3.4 (3.2–3.6), respectively. Conclusions Migrant suicide attempters receive less specialised mental health care before their attempt than native Swedes, and their marginalzation patterns are different. Healthcare and policy makers need to take the differential risk profile for migrant and native populations into account.

Background: Sweden has a public and easily accessible sickness insurance. Research shows, however, downsides to taking sick leave. Both short and longer periods of sick leave have been seen to increase the risk for subsequent work absence. The aim of this study was to investigate whether there was an association between sick leave claimed in 1993 and work absence in the subsequent 15 years, i.e. up to 2008. A further aim was to explore differences in this relation with regard to gender, origin and educational level at baseline. Methods: Our cohort consisted of all immigrants aged 21-25 years in Sweden in 1993 and a control group of native Swedes in the same age group. Results: Subsequent work absence increased from 313 days among persons with no days of claimed sick leave in 1993 to 567 days among persons with 1-7 days of claimed sick leave in 1993. Thereafter there was a lower, but steady increase in days of future work absence, to 611 days among persons with 8-14 days of sick leave claimed in 1993. There was an interaction between sick leave and gender, education and origin respectively regarding later work absence. Conclusion: Periods of sick leave claimed were associated with subsequent work absence. Immigrants, women and persons with low education had the most risk of future work absence after a period of sick leave.