Search

OBJECTIVE: This study aimed to investigate (i) the risk of work disability (>10-day sickness absence spell or disability pension) due to common mental disorders (CMD) among social workers compared with other health and social care, education, and non-human service professionals and (ii) whether the risk was mediated by job stress. METHODS: A cohort of 16 306 public sector professionals in Finland was followed using survey data from baseline (2004 or if not available, 2008) on job stress [job strain or effort-reward imbalance (ERI)] and register data on work disability due to CMD from baseline through 2011. A Cox proportional hazards model was used to analyze the risk of work disability due to CMD between three occupation-pairs in a counterfactual setting, controlling for age, sex, job contract, body mass index, alcohol risk use, smoking, and physical inactivity. RESULTS: Social workers’ job stress was at higher level only when compared to education professionals. Thus, the mediation hypothesis was analyzed comparing social workers to education professionals. Social workers had a higher risk of work disability due to CMD compared with education professionals [hazard ratio (HR) 2.08, 95% confidence interval (CI) 1.58–2.74]. This HR was partly mediated by job strain (24%) and ERI (12%). Social workers had a higher risk of work disability than non-human service professionals (HR 1.54, 95% CI 1.13–2.09), but not compared with other health and social care professionals. CONCLUSIONS: Job stress partly mediated the excess risk of work disability among social workers only in comparison with education professionals.

OBJECTIVES: This study aimed to compare the risk of labor market marginalization among refugees across different host countries of resettlement and examine the moderating role of birth country and length of stay on these associations. METHODS: Cohorts of refugees and native-born individuals aged 19–60 in Sweden (N=3 605 949, 3.5% refugees) and Norway (N=1 784 861, 1.7% refugees) were followed during 2010–2016. Rates (per 1000 person-years) of long-term unemployment, long-term sickness absence, and disability pension were estimated for refugees and the host populations. Cox regression models estimated crude and adjusted (for sex, age, educational level, and civil status) hazard ratio (HR_adj) for refugees compared to their respective host population, with 95% confidence intervals (CI). Analyses were also stratified by birth country and length of stay. RESULTS: Refugees in Norway and Sweden had a higher incidence of labor market marginalization compared to their host population. Refugees in Sweden had a comparatively lower relative risk of long-term unemployment but higher risk of disability pension (HR_adj 3.44, 95% CI, 3.38–3.50 and HR_adj 2.45, 2.35–2.56, respectively) than refugees in Norway (HR_adj 3.70, 3.58–3.82 and HR_adj 1.57, 1.49–1.66, respectively). These relative risks varied when stratifying by birth country. A shorter length of stay was associated with a higher risk of long-term unemployment and a lower risk of disability pension, with a stronger gradient in Sweden than in Norway. CONCLUSIONS: The relative risk of labor market marginalization varied by the refugees’ birth country but followed similar trends in Sweden and Norway. Although speculative, these findings may hint at non-structural factors related to the refugee experience playing a more important role than host country structural factors for the risk of labor market marginalization among refugees. Future research, including host countries with more variability in structural factors, is required to further investigate these associations. The higher risk of long-term unemployment among refugees with shorter length of stay indicates a need for more efficient labor market integration policies for newly-arrived refugees.

Abstract Background The COVID-19 pandemic as a public health crisis has led to a significant increase in mental health difficulties. Smoking is strongly associated with mental health conditions, which is why the pandemic might have influenced the otherwise decline in smoking rates. Persons belonging to socioeconomically disadvantaged groups may be particularly affected, both because the pandemic has exacerbated existing social inequalities and because this group was more likely to smoke before the pandemic. We examined smoking prevalence in a French cohort study, focusing on differences between educational attainment. In addition, we examined the association between interpersonal changes in tobacco consumption and educational level from 2018 to 2021. Methods Using four assessments of smoking status available from 2009 to 2021, we estimated smoking prevalence over time, stratified by highest educational level in the TEMPO cohort and the difference was tested using chi2 test. We studied the association between interpersonal change in smoking status between 2018 and 2021 and educational attainment among 148 smokers, using multinomial logistic regression. Results Smoking prevalence was higher among those with low education. The difference between the two groups increased from 2020 to 2021 (4.8–9.4%, p

Background Higher social support protects people from developing mental disorders. Limited evidence is available on the mechanism through which social support plays this protective role.Objective To investigate the stress-buffering process of social support on depressive symptoms using a novel longitudinal dynamic symptom network approach.Methods A total of 4242 adult participants who completed the first two waves (from May to October 2020) of the International Covid Mental Health Survey were included in the study. Cross-lagged panel network modelling was used to estimate a longitudinal network of self-reported social support, loneliness and depressive symptoms. Standardised regression coefficients from regularised cross-lagged regressions were estimated as edge weights of the network.Findings The results support a unidirectional protective effect of social support on key depressive symptoms, partly mediated through loneliness: A higher number of close confidants and accessible practical help was associated with decreased anhedonia (weight=−0.033) and negative self-appraisal symptoms (weight=−0.038). Support from others was also negatively associated with loneliness, which in turn associated with decreased depressed mood (weight=0.086) and negative self-appraisal (weight=0.077). We identified a greater number of direct relationships from social support to depressive symptoms among men compared with women. Also, the edge weights from social support to depression were generally stronger in the men’s network.Conclusions Reductions in negative self-appraisal might function as a bridge between social support and other depressive symptoms, and, thus, it may have amplified the protective effect of social support. Men appear to benefit more from social support than women.Clinical implications Building community-based support networks to deliver practical support, and loneliness reduction components are critical for depression prevention interventions after stressful experiences.

Background Evidence-based mental health interventions to support healthcare workers (HCWs) in crisis settings are scarce.Objective To evaluate the capacity of a mental health intervention in reducing anxiety and depression symptoms in HCWs, relative to enhanced care as usual (eCAU), amidst the COVID-19 pandemic.Methods We conducted an analyst-blind, parallel, multicentre, randomised controlled trial. We recruited HCWs with psychological distress from Madrid and Catalonia (Spain). The intervention arm received a stepped-care programme consisting of two WHO-developed interventions adapted for HCWs: Doing What Matters in Times of Stress (DWM) and Problem Management Plus (PM+). Each intervention lasted 5 weeks and was delivered remotely by non-specialist mental health providers. HCWs reporting psychological distress after DWM completion were invited to continue to PM+. The primary endpoint was self-reported anxiety/depression symptoms (Patient Health Questionnaire-Anxiety and Depression Scale) at week 21.Findings Between 3 November 2021 and 31 March 2022, 115 participants were randomised to stepped care and 117 to eCAU (86% women, mean age 37.5). The intervention showed a greater decrease in anxiety/depression symptoms compared with eCAU at the primary endpoint (baseline-adjusted difference 4.4, 95% CI 2.1 to 6.7; standardised effect size 0.8, 95% CI 0.4 to 1.2). No serious adverse events occurred.Conclusions Brief stepped-care psychological interventions reduce anxiety and depression during a period of stress among HCWs.Clinical implications Our results can inform policies and actions to protect the mental health of HCWs during major health crises and are potentially rapidly replicable in other settings where workers are affected by global emergencies.Trial registration number NCT04980326.

Background: The aims were to study the sustainability of labour-market participation five years after an incident diagnosis of attention-deficit/hyperactivity disorder (ADHD) among young adults with gainful employment, and to examine the impact of sociodemographic-, work- and health-related factors on these findings. Methods: Swedish registers identified 2517 individuals, 19–29 years old, with an incident diagnosis of ADHD and gainful employment during 2006–2011. Labour-market participation was measured by the core-peripheral model, a model that measures the connection to the labour market from a weak connection (peripheral) to a strong connection (core). Sequence analysis analysed clusters of labour-market participation, from one year before and up to five years after diagnosis. Odds ratios (OR) with 95% confidence intervals (CI) between sociodemographic factors, comorbid disorders, and the identified clusters were analysed by multinomial logistic regression. Results: Five clusters of labour-market participation were identified: 60% of individuals belonged to a cluster that maintained labour-market participation throughout the study period (core, close to core); 20% belonged to a cluster with a transition to a weak connection to the labour market (close to peripheral, peripheral); and 20% belonged to a cluster with “middle” labour-market participation, characterised by having long periods of sick leave and unemployment. Individuals with elementary school as highest attained education (OR:4.03;CI:2.35–6.93), comorbid mental disorders (OR:2.77;CI:2.10–3.66), or living in villages/small cities (OR:1.77;CI:1.25–2.51) were most likely to belong to a cluster transitioning towards a “peripheral” labour-market participation. Men were less likely to have peripheral labour-market participation than women (OR:0.55;CI:0.40–0.75). Conclusions: Over half of working individuals with ADHD maintain a strong attachment to the labour market several years after their first diagnosis of ADHD. Therefore, it is important to target those who have problems maintaining a position in the labour market, including women, those with low educational levels, and those living outside large cities.

Abstract Backgrounds Individuals with chronic medical conditions are considered highly exposed to COVID-19 pandemic stress, but emerging evidence is demonstrating that resilience is common even among them. We aimed at identifying sustained resilient outcomes and their predictors in chronically ill people during the first year of the pandemic. Methods This international 4-wave 1-year longitudinal online survey included items on socio-demographic characteristics, economic and living situation, lifestyle and habits, pandemic-related issues, and history of mental disorders. Adherence to and approval of imposed restrictions, trust in governments and in scientific community during the pandemic were also investigated. The following tools were administered: the Patient Health Questionnaire, the Generalized Anxiety Disorder scale, the PTSD Checklist DSM-5, the Oslo Social Support Scale, the Padua Inventory, and the Portrait Values Questionnaire. Results One thousand fifty-two individuals reporting a chronic condition out of 8011 total participants from 13 countries were included in the study, and 965 had data available for the final model. The estimated probability of being “sustained-resilient” was 34%. Older male individuals, participants employed before and during the pandemic or with perceived social support were more likely to belong to the sustained-resilience group. Loneliness, a previous mental disorder, high hedonism, fear of COVID-19 contamination, concern for the health of loved ones, and non-approving pandemic restrictions were predictors of not-resilient outcomes in our sample. Conclusions We found similarities and differences from established predictors of resilience and identified some new ones specific to pandemics. Further investigation is warranted and could inform the design of resilience-building interventions in people with chronic diseases.

Background Previous studies suggest that migrants tend to utilise antipsychotics less often than their native-born peers. However, studies examining antipsychotic use among refugees with psychosis are lacking. Aims To compare the prevalence of antipsychotic drug use during the first 5 years of illness among refugees and Swedish-born individuals with a newly diagnosed non-affective psychotic disorder, and to identify sociodemographic and clinical factors associated with antipsychotic use. Method The study population included refugees (n = 1656) and Swedish-born persons (n = 8908) aged 18–35 years during 2007–2018, with incident diagnosis of non-affective psychotic disorder recorded in the Swedish in-patient or specialised out-patient care register. Two-week point prevalence of antipsychotics use was assessed every 6 months in the 5 years following first diagnosis. Factors associated with antipsychotic use (versus non-use) at 1 year after diagnosis were examined with modified Poisson regression. Results Refugees were somewhat less likely to use antipsychotics at 1 year after first diagnosis compared with Swedish-born persons (37.1% v. 42.2%, age- and gender-adjusted risk ratio 0.88, 95% CI 0.82–0.95). However, at the 5-year follow-up, refugees and Swedish-born individuals showed similar patterns of antipsychotic use (41.1% v. 40.4%). Among refugees, higher educational level (>12 years), previous antidepressant use and being diagnosed with schizophrenia/schizoaffective disorder at baseline were associated with an increased risk of antipsychotics use, whereas being born in Afghanistan or Iraq (compared with former Yugoslavia) was associated with decreased risk. Conclusions Our findings suggest that refugees with non-affective psychotic disorders may need targeted interventions to ensure antipsychotic use during the early phase of illness.

IntroductionLong-term medication use is a recommended treatment for attention-deficit/hyperactivity disorder (ADHD), however, discontinuation is common. Non-medical factors which might influence initiation and discontinuation are understudied. Therefore, we investigated how different sociodemographic factors and comorbidities were associated with the initiation and discontinuation of ADHD medication use among young adults.Methods and resultsWe conducted a population-based prospective cohort study using individually linked administrative register data, in which we included all individuals residing in Sweden, between the age of 19 and 29 who were first diagnosed with ADHD between January 2006 and December 2016 (n = 59224). ADHD medication initiation was defined as the first prescription of ADHD medication in the period from 3 months before to 6 months after the cohort entry date. Those who initiated ADHD medication were followed up for medication use until discontinuation, death/emigration, or until 2019. Logistic and Cox regression models were used to investigate the associations between sociodemographics, health-related predictors and initiation, as well as discontinuation. Overall, 48.7% of the 41399 individuals initiated ADHD medication, most often methylphenidate (87%). Among the initiators, 15462 (77%) discontinued medication use during the follow-up (median time: 150 days). After mutually adjusting all other predictors, initiation was positively associated with older age, male sex, higher level of education, and negatively associated with living at home with parents, immigrant status, being unemployed during the year before inclusion, being on disability pension, having autism, substance use, schizophrenia-spectrum disorders, other mental disability/developmental disorders, cardiovascular diseases or previous accidents. Discontinuation was positively associated with being born abroad, living in big cities, being unemployed during the year before inclusion, having cancer, and negatively associated with a higher educational level, having depression, anxiety or stress-related disorder, autism spectrum disorder or diabetes.ConclusionBesides medical factors, sociodemographics, such as educational attainment and immigrant status might also play a role in the initiation and discontinuation of ADHD medication use among young adults newly diagnosed with ADHD.

BackgroundCommon mental disorders (CMDs), multimorbidity, and refugee status are associated with poor labor market outcome. Little is known about how these factors interact in young adults.ObjectiveWe aimed to i) investigate whether the association of CMDs and multimorbidity with labor market marginalization (LMM) differs between refugee and Swedish-born young adults and ii) identify diagnostic groups with particularly high risk for LMM.MethodsThis longitudinal registry-based study included individuals aged 20–25 years followed from 2012 to 2016 in Sweden (41,516 refugees and 207,729 age and sex-matched Swedish-born individuals). LMM was defined as granted disability pension (DP) or > 180 days of unemployment (UE). A disease co-occurrence network was constructed for all diagnostic groups from 2009 to 2011 to derive a personalized multimorbidity score for LMM. Multivariate logistic regression was used to estimate odds ratios of LMM in refugee and Swedish-born youth as a function of their multimorbidity score. The relative risk (RR, 95% CI) of LMM for refugees with CMDs compared to Swedish-born with CMDs was computed in each diagnostic group.ResultsIn total, 5.5% of refugees and 7.2% of Swedish-born with CMDs were granted DP; 22.2 and 9.4%, respectively received UE benefit during follow-up. While both CMDs and multimorbidity independently elevated the risk of DP considerably in Swedish-born, CMDs but not multimorbidity elevated the risk of UE. Regarding UE in refugees, multimorbidity with the presence of CMDs showed stronger estimates. Multimorbidity interacted with refugee status toward UE (p < 0.0001) and with CMDs toward DP (p = 0.0049). Two diagnostic groups that demonstrated particularly high RR of UE were schizophrenia, schizotypal and delusional disorders (RR [95% CI]: 3.46 [1.77, 6.75]), and behavioral syndromes (RR [95% CI]: 3.41 [1.90, 6.10]).ConclusionTo combat LMM, public health measures and intervention strategies need to be tailored to young adults based on their CMDs, multimorbidity, and refugee status.

Background Psychological and pharmacological therapies are the recommended first-line treatments for common mental disorders (CMDs) but may not be universally accessible or utilised. Aims To determine the extent to which primary care patients with CMDs receive treatment and the impact of sociodemographic, work-related and clinical factors on treatment receipt. Method National registers were used to identify all Stockholm County residents aged 19–64 years who had received at least one CMD diagnosis (depression, anxiety, stress-related) in primary care between 2014 and 2018. Individuals were followed from the date of their first observed CMD diagnosis until the end of 2019 to determine treatment receipt. Associations between patient factors and treatment group were examined using multinomial logistic regression. Results Among 223 271 individuals with CMDs, 30.6% received pharmacotherapy only, 16.5% received psychological therapy only, 43.1% received both and 9.8% had no treatment. The odds of receiving any treatment were lower among males (odds ratio (OR) range = 0.76 to 0.92, 95% CI[minimum, maximum] 0.74 to 0.95), individuals born outside of Sweden (OR range = 0.67 to 0.93, 95% CI[minimum, maximum] 0.65 to 0.99) and those with stress-related disorders only (OR range = 0.21 to 0.51, 95% CI[minimum, maximum] 0.20 to 0.53). Among the patient factors examined, CMD diagnostic group, prior treatment in secondary psychiatric care and age made the largest contributions to the model (R2 difference: 16.05%, 1.72% and 1.61%, respectively). Conclusions Although over 90% of primary care patients with CMDs received pharmacological and/or psychological therapy, specific patient groups were less likely to receive treatment.

Objectives To investigate working life courses in women and men and possible associations with socioeconomic, health-, and work-related factors. Methods A 15-year prospective cohort study of individuals aged 18–50 in paid work at baseline and answering the Swedish Living Conditions Surveys (2000–2003, N = 9269) and their annual economic activity, using nationwide registers. We used sequence and cluster analyses to identify and group similar working life sequences. Multinomial logistic regression was used to examine associations of sex, socioeconomic, health-, and work-related factors with sequence cluster memberships. Results We identified 1284 working life sequences, of which 65% represented continuous active (in paid work/studying) states. We then identified five sequence clusters, the largest one with individuals who were continuously active (n = 6034, 65% of the participants; 54% of women and 76% of men) and smaller ones with interruptions of the active state by long-term parental-leave, unemployment, and/or sickness absence/disability pension (SA/DP), or retirement. Women were more likely than men to belong to the “Parental-leave periods” (odds ratio [OR]: 33.2; 95% confidence intervals [CI]: 25.6, 43.1) and the “SA/DP periods” sequence clusters (OR: 1.8; 95% CI: 1.4, 2.1), also after adjustment for covariates. In both sexes, low education and poor health were the strongest predictors of belonging to the sequence cluster “Unemployment & SA/DP periods”. Predictors of the “Parental-leave periods” sequence cluster differed between women and men. Conclusions In a cohort of individuals in paid work at baseline, the majority of women and men worked most of each year although women were more likely to have some interruptions characterized by long-term parental-leave or SA/DP periods than men, independently of socioeconomic, health-, and work-related factors.

Summary: Background: Predicted increases in suicide were not generally observed in the early months of the COVID-19 pandemic. However, the picture may be changing and patterns might vary across demographic groups. We aimed to provide a timely, granular picture of the pandemic's impact on suicides globally. Methods: We identified suicide data from official public-sector sources for countries/areas-within-countries, searching websites and academic literature and contacting data custodians and authors as necessary. We sent our first data request on 22nd June 2021 and stopped collecting data on 31st October 2021. We used interrupted time series (ITS) analyses to model the association between the pandemic's emergence and total suicides and suicides by sex-, age- and sex-by-age in each country/area-within-country. We compared the observed and expected numbers of suicides in the pandemic's first nine and first 10-15 months and used meta-regression to explore sources of variation. Findings: We sourced data from 33 countries (24 high-income, six upper-middle-income, three lower-middle-income; 25 with whole-country data, 12 with data for area(s)-within-the-country, four with both). There was no evidence of greater-than-expected numbers of suicides in the majority of countries/areas-within-countries in any analysis; more commonly, there was evidence of lower-than-expected numbers. Certain sex, age and sex-by-age groups stood out as potentially concerning, but these were not consistent across countries/areas-within-countries. In the meta-regression, different patterns were not explained by countries’ COVID-19 mortality rate, stringency of public health response, economic support level, or presence of a national suicide prevention strategy. Nor were they explained by countries’ income level, although the meta-regression only included data from high-income and upper-middle-income countries, and there were suggestions from the ITS analyses that lower-middle-income countries fared less well. Interpretation: Although there are some countries/areas-within-countries where overall suicide numbers and numbers for certain sex- and age-based groups are greater-than-expected, these countries/areas-within-countries are in the minority. Any upward movement in suicide numbers in any place or group is concerning, and we need to remain alert to and respond to changes as the pandemic and its mental health and economic consequences continue. Funding: None.

BackgroundHealthcare workers (HCWs) from COVID-19 hotspots worldwide have reported poor mental health outcomes since the pandemic's beginning. The virulence of the initial COVID-19 surge in Spain and the urgency for rapid evidence constrained early studies in their capacity to inform mental health programs accurately. Here, we used a qualitative research design to describe relevant mental health problems among frontline HCWs and explore their association with determinants and consequences and their implications for the design and implementation of mental health programs.Materials and methodsFollowing the Programme Design, Implementation, Monitoring, and Evaluation (DIME) protocol, we used a two-step qualitative research design to interview frontline HCWs, mental health experts, administrators, and service planners in Spain. We used Free List (FL) interviews to identify problems experienced by frontline HCWs and Key informant (KI) interviews to describe them and explore their determinants and consequences, as well as the strategies considered useful to overcome these problems. We used a thematic analysis approach to analyze the interview outputs and framed our results into a five-level social-ecological model (intrapersonal, interpersonal, organizational, community, and public health).ResultsWe recruited 75 FL and 22 KI interviewees, roughly balanced in age and gender. We detected 56 themes during the FL interviews and explored the following themes in the KI interviews: fear of infection, psychological distress, stress, moral distress, and interpersonal conflicts among coworkers. We found that interviewees reported perceived causes and consequences across problems at all levels (intrapersonal to public health). Although several mental health strategies were implemented (especially at an intrapersonal and interpersonal level), most mental health needs remained unmet, especially at the organizational, community, and public policy levels.ConclusionsIn keeping with available quantitative evidence, our findings show that mental health problems are still relevant for frontline HCWs 1 year after the COVID-19 pandemic and that many reported causes of these problems are modifiable. Based on this, we offer specific recommendations to design and implement mental health strategies and recommend using transdiagnostic, low-intensity, scalable psychological interventions contextually adapted and tailored for HCWs.

Abstract Background To identify key information regarding potential treatment differences in refugees and the host population, we aimed to investigate patterns (trajectories) of antidepressant use during 3 years before and after a suicide attempt in refugees, compared with Swedish-born. Association of the identified trajectory groups with individual characteristics were also investigated. Methods All 20–64-years-old refugees and Swedish-born individuals having specialised healthcare for suicide attempt during 2009–2015 (n = 62,442, 5.6% refugees) were followed 3 years before and after the index attempt. Trajectories of annual defined daily doses (DDDs) of antidepressants were analysed using group-based trajectory models. Associations between the identified trajectory groups and different covariates were estimated by chi2-tests and multinomial logistic regression. Results Among the four identified trajectory groups, antidepressant use was constantly low (≤15 DDDs) for 64.9% of refugees. A ‘low increasing’ group comprised 5.9% of refugees (60–260 annual DDDs before and 510–685 DDDs after index attempt). Two other trajectory groups had constant use at medium (110–190 DDDs) and high (630–765 DDDs) levels (22.5 and 6.6% of refugees, respectively). Method of suicide attempt and any use of psychotropic drugs during the year before index attempt discriminated between refugees’ trajectory groups. The patterns and composition of the trajectory groups and their association, discriminated with different covariates, were fairly similar among refugees and Swedish-born, with the exception of previous hypnotic and sedative drug use being more important in refugees. Conclusions Despite previous reports on refugees being undertreated regarding psychiatric healthcare, no major differences in antidepressant treatment between refugees and Swedish-born suicide attempters were found.

Abstract Background Women’s return to work after diagnosis of breast cancer (BC) is becoming more prevalent. However, register-based national investigation on sickness absence (SA) and disability pension (DP) in BC women is lacking. The aim of the study was to explore SA and DP before and after a first BC diagnosis and the possibility to predict new cancer-related SA by using disease-related and sociodemographic factors. Methods A longitudinal register study of the 3536 women in Sweden aged 19–64 with a first BC diagnosis in 2010 was conducted by linkage of five nationwide registers. Particularly, detailed information on SA and DP was obtained from the National Social Insurance Agency. Descriptive statistics on SA and DP 2 years before through 3 years after the BC diagnosis were performed. The risk of having a new SA spell due to BC or BC-related diagnoses was modeled using logistic regression. Results The proportion of women with SA increased during the year following the BC diagnosis date and declined over the next 2 years to proportions before diagnosis. At the time of BC diagnosis, half of the women began a new SA spell > 14 days with cancer, cancer-related, or mental diagnosis. Disease-related and sociodemographic factors including occupational sector, living area, age, cancer stage, educational level, and number of previous SA days showed statistical significance (p

BackgroundInternational migration has increased during the past years and little is known about the mortality of young adult immigrants and refugees that came to Sweden as children. This study aimed to investigate 1) the risk of all-cause and cause-specific mortality in young accompanied and unaccompanied refugees and non-refugee immigrants compared to Swedish born individuals; and 2) to determine the role of educational level and migrations-related factors in these associations.MethodsThis register linkage study is based on 682,358 individuals (633,167 Swedish-born, 2,163 unaccompanied and 25,658 accompanied refugees and 21,370 non-refugee immigrants) 19-25 years old, who resided in Sweden 31.12.2004. Outcomes were all-cause mortality and mortality due to suicide and external causes. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox regression models with a maximum follow-up to 2016.ResultsAfter adjusting for covariates, all-cause mortality was significantly lower in non-refugee immigrants (aHR 0.70, 95% CI 0.59-0.84) and refugees (aHR 0.76, 95% CI 0.65-0.88) compared to Swedish-born individuals. The same direction of association was observed for mortality due to suicide and external causes. No differences between accompanied and unaccompanied refugees were found. Risk estimates for all migrant groups varied with educational level, duration of residency, age at arrival and country of birth. Further, the mortality risk of migrants arriving in Sweden before the age of 6 years did not significantly differ from the risk of their Swedish-born peers. Low education was a considerable risk factor.ConclusionIn general, young adult refugees and non-refugee immigrants have a lower risk of all-cause and cause-specific mortality than Swedish-born individuals. The identified migrant groups with higher mortality risk need specific attention.

BackgroundChildhood cancer survivors are at high risk of chronic health conditions. We aimed to explore future long-term sickness absence and disability pension in young adult childhood cancer survivors and matched references.MethodsWe performed a prospective cohort study using microdata from five Swedish nationwide registers. Among all individuals born 1976-1998 and living in Sweden, we included 3632 childhood cancer survivors and 17,468 matched references that could be followed-up for 15, 10, or 5 years, respectively. A group-based trajectory model was applied to identify trajectories of mean annual sickness absence and/or disability pension days (SADP) in each sub-cohort, with 95% confidence intervals (CI). Potential risk factors for trajectory belonging were explored using χ2 test and multinomial logistic regression.ResultsMost young adult childhood cancer survivors (90.2-96.5%) and references (97.4-98.8%) followed a No SADP trajectory. A larger proportion of childhood cancer survivors than references followed a Moderate (33-102 days/year) or High (115-260 days/year) SADP trajectory (15-year follow-up cohorts: Moderate 4.6% versus 1.2%; High 5.1% versus 1.5%). Childhood cancer survivors of central nervous system (CNS) tumors were at higher risk of the High SADP trajectory than childhood cancer survivors of hematological or non-CNS solid tumors (hematological versus CNS: odds ratio = 2.30, 95% CI 1.23-4.30; hematological versus non-CNS: odds ratio = 0.32, 95% CI 0.13-0.79).ConclusionsAlthough most young adult childhood cancer survivors had no SADP during follow-up, 9.7% experienced moderate or high numbers of SADP days/year throughout the 15-year follow-up; compared to 2.7% among references. CNS tumor survivors were at particular risk of SADP long-term and need extra attention in their future work prospect.

BackgroundDue to the circumstances of their early lives, young refugees are at risk of experiencing adverse labour market and health outcomes. The post-settlement environment is thought to play a decisive role in determining how this vulnerability plays out. This study compared trends in labour market marginalisation in young refugees and their majority peers during early adulthood in two national contexts, Denmark and Sweden, and explored the mediating role of common mental disorders and secondary school completions.MethodsUsing registry data, 13,390/45,687 refugees were included in Denmark/Sweden and 1:5 matched to majority peers. Inequalities in labour market marginalisation were investigated during 2012-2015 in each country using linear probability models and mediation analysis. Country trends were standardised to account for differences in observed population characteristics.ResultsThe risk of marginalisation was 2.1-2.3 times higher among young refugees compared with their majority peers, but the risk decreased with age in Sweden and increased in Denmark for refugees. Birth-cohort differences drove the increase in Denmark, while trends were consistent across birth-cohorts in Sweden. Differences in population characteristics did not contribute to country differences. Common mental disorders did not mediate the inequality in either country, but secondary school completions did (77-85% of associations eliminated).ConclusionsThe findings document both the vulnerability of young refugees to labour market marginalisation and the variability in this vulnerability across post-settlement contexts. While the contrast in policy climates in Denmark and Sweden sharpened over time, the risk of marginalisation appeared more similar in younger cohorts, pointing to the importance of factors other than national immigration and integration policies. Institutional efforts to assist young refugees through secondary education are likely to have long-lasting consequences for their socio-economic trajectories.

OBJECTIVES: Attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders (ASD) and learning disabilities (LD) have an early onset and often persist into adulthood, although their relative contribution to incapacity for work is unclear. We examined this issue among young adults with ADHD, ASD or LD taking into account socioeconomic factors and comorbid mental disorders. METHODS: Recorded diagnoses between the ages of 10–35 years between 2001 and 2010 were derived from nationwide inpatient and specialized outpatient hospital registers in Sweden. We identified 15 632 individuals with a main diagnosis of ADHD, 8238 with ASD, and 1038 with LD, and the matched control group without recorded mental disorders (N=124 536). The outcome was the number of register-based sickness absence and work disability pension (SA-DP) days during a maximum of three years follow-up. RESULTS: Among men, the rate ratio (RR) of SA-DP was 11.17 [95% confidence interval (CI) 9.89–12.60] for ADHD, 35.59 (95% CI 30.30–41.81) for ASD, and 9.20 (95% CI 5.76–14.70) for LD, in comparison to those in the reference group. The corresponding risks among women were RR 12.05 (95% CI 10.30–14.09) for ADHD, RR 28.36 (95% CI 22.96–35.02) for ASD, and RR 9.60 (95% CI 5.83–15.81) for LD. The findings were, to a large extent, similar when individuals on DP at baseline were excluded. Comorbid mental disorders further increased the risk of SA-DP. Educational differences were smaller among the patients than in the reference group. CONCLUSIONS: Early-onset neurodevelopmental disorders, particularly with comorbidity, have a far-reaching impact on adult life in terms of SA and DP.

Abstract Background Treatment resistant depression (TRD) is common among patients with depression, and is associated with clinical and functional disability. However, the risk and risk factors for being granted disability pension (DP) among patients with TRD have not been investigated. Methods All antidepressant initiators in Sweden with a diagnosis of depression in specialized care were identified in nationwide registers 2006–2013 and followed regarding treatment trials. TRD was defined as the start of a third sequential trial. Patients with TRD who were not on DP (N = 3204) were matched by age, sex, history of depression, calendar year, and time for treatment start with 3204 comparators with depression and ongoing antidepressant treatment. A proportional Cox Regression was performed with DP as outcome, adjusted for various sociodemographic and clinical covariates. Results Compared to the comparison cohort, TRD was associated with a doubled risk for all-cause DP (aHR 2.07; 95%CI 1.83–2.35), DP due to depression (2.28; 1.82–2.85) and to any mental disorder (2.24; 1.95–2.57) but not due to somatic diagnoses (1.25; 0.84–1.86). Among significant risk factors for DP in TRD were female sex, being > 29 years of age, unemployment and a diagnosis of comorbid personality disorder (ICD-10 codes F60.0–9). Conclusion TRD is associated with an elevated risk for DP compared to other patients with depression, with large potential costs for the affected patients and for society. Clinical and therapeutic implications for patients with TRD who are granted DP should be further investigated. Limitation: No clinical data, e.g. type of depression or reason for treatment switch, was available for this study.

Abstract Background Chronic musculoskeletal pain affects over 20% of the adult population and is one of the most common reasons for sick leave in Sweden. The aim of this study was to investigate which demographic, health and psychosocial work environment factors are of importance for a lower risk of future work disability and unemployment among workers with low back pain (LBP) and/or neck shoulder pain (NSP), and if familial factors influence these associations. Methods All 5556 persons that reported having LBP and/or NSP in a web-based questionnaire study in 2004–2006 were included. They were followed up for work disability (sick leave > 90 days or disability pension), and unemployment (> 180 days in a year) until 31 December 2013. Hazard ratios (HR) with 95% confidence intervals were calculated using cox proportional hazard models of the whole sample, adjusting for covariates. In addition, co-twin analyses of outcome discordant twin pairs were conducted to assess the impact of familial confounding on the associations. Results Being male, 19–28 years old, having higher education, only NSP, no history of depression or anxiety, good self-rated health, low job demands and high job control were associated with a lower risk of work disability (adjusted HR ranging between 0.29–0.85). No history of anxiety and depression and high job control was associated with a lower risk of unemployment (adjusted HR ranging from 0.53 and 0.67). Familial factors were found to affect the association between education and work disability, but none of the other associations investigated. Conclusions Among those with LBP or NSP, good health in terms of mental- and self-rated health, few pain sites, as well as good psychosocial working conditions seem to indicate a lower risk for work disability.

Abstract 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 (R2 difference = 0.02–0.05, p

Background Electroconvulsive therapy (ECT) is a safe and effective treatment for major depressive disorder (MDD). ECT treatment effect relies on induced generalised seizures. Most anaesthetics raise the seizure threshold and shorten seizure duration. There are no conclusive studies on the effect of anaesthetic dose on response and remission rates with ECT for MDD. Aims We aimed to examine the effect of different dose intervals of anaesthetics on response and remission after ECT for MDD. Method We conducted a nationwide cohort study, using data from Swedish registers. Low-, medium- and high-dose intervals, adjusted for age and gender, were constructed for each anaesthetic drug. Response and remission were measured with the Clinical Global Impression – Severity and Improvement scales (CGI-I and CGI-S), and a self-rated version of the Montgomery–Åsberg Depression Rating Scale (MADRS-S). Logistic regression models were used to calculate adjusted odds ratios for response and remission rates. Results The study included 7917 patients who received ECT for MDD during 2012–2018. Patients were given either thiopental (64.1%) or propofol (35.9%). Low-dose intervals of anaesthetics were associated with increased rates of response (CGI-I: odds ratio 1.22, 95% CI 1.07–1.40, P = 0.004; MADRS-S: odds ratio 1.31, 95% CI 1.09–1.56, P = 0.004) and remission (CGI-S: odds ratio 1.37, 95% CI 1.17–1.60, P ≤ 0.001; MADRS-S: odds ratio 1.31, 95% CI 1.10–1.54, P = 0.002). Conclusions We found improved treatment outcomes with low- compared with high-dose anaesthetic during ECT for MDD. To enhance treatment effect, deep anaesthesia during ECT for MDD should be avoided.

Background: Refugee youth experience hardships associated with exposure to trauma in their homelands and during and after displacement, which results in higher rates of common mental disorders. The World Health Organization (WHO) developed Problem Management Plus (PM+), a non-specialist-delivered brief psychological intervention, for individuals who have faced adversity. PM+ comprises problem-solving, stress management, behavioural activation and strengthening social support. However, it does not include an emotional processing component, which is indicated in trauma-exposed populations. Objective: This pilot randomized controlled trial (RCT) aims to evaluate the feasibility and acceptability of PM+, adapted to Syrian, Eritrean and Iraqi refugee youth residing in the Netherlands, with and without a newly developed Emotional Processing (EP) Module. Methods: Refugee youth (N = 90) between 16 and 25 years of age will be randomized into PM+ with care-as-usual (CAU), (n = 30), PM+ with Emotional Processing (PM+EP) with CAU (n = 30) or CAU only (n = 30). Inclusion criteria are self-reported psychological distress (Kessler Psychological Distress Scale; K10 > 15) and impaired daily functioning (WHO Disability Assessment Schedule; WHODAS 2.0 > 16). Participants will be assessed at baseline, one-week post-intervention and three-month follow-up. The main outcome is the feasibility and acceptability of the adapted PM+ and PM+EP. The secondary outcomes are self-reported psychological distress, functional impairment, post-traumatic stress disorder (PTSD) symptom severity and diagnosis, social support, and self-identified problems. The pilot RCT will be succeeded by a process evaluation including trial participants, participants’ significant others, helpers, and mental health professionals (n = 20) to evaluate their experiences with the PM+ and PM+EP programmes. Results and Conclusion: This is the first study that evaluates the feasibility of PM+ for this age range with an emotional processing module integrated. The results may inform larger RCTs and implementation of PM+ interventions among refugee youth. Trial Registration: Registered to Dutch Trial Registry, NL8750, on 3 July 2020. Medical Ethical Committee of the Amsterdam University Medical Centre, location Vrije Universiteit Medical Centre, Protocol ID: 2020.224, 1 July 2020.

BackgroundIn recent decades, millions of refugees and migrants have fled wars and sought asylum in Europe. The aim of this study was to quantify the risk of mortality and major diseases among migrants during the 1991-2001 Balkan wars to Sweden in comparison to other European migrants to Sweden during the same period.Methods and findingsWe conducted a register-based cohort study of 104,770 migrants to Sweden from the former Yugoslavia during the Balkan wars and 147,430 migrants to Sweden from 24 other European countries during the same period (1991-2001). Inpatient and specialized outpatient diagnoses of cardiovascular disease (CVD), cancer, and psychiatric disorders were obtained from the Swedish National Patient Register and the Swedish Cancer Register, and mortality data from the Swedish Cause of Death Register. Adjusting for individual-level data on sociodemographic characteristics and emigration country smoking prevalence, we used Cox regressions to contrast risks of health outcomes for migrants of the Balkan wars and other European migrants. During an average of 12.26 years of follow-up, being a migrant of the Balkan wars was associated with an elevated risk of being diagnosed with CVD (HR 1.39, 95% CI 1.34-1.43, p < 0.001) and dying from CVD (HR 1.45, 95% CI 1.29-1.62, p < 0.001), as well as being diagnosed with cancer (HR 1.16, 95% CI 1.08-1.24, p < 0.001) and dying from cancer (HR 1.27, 95% CI 1.15-1.41, p < 0.001), compared to other European migrants. Being a migrant of the Balkan wars was also associated with a greater overall risk of being diagnosed with a psychiatric disorder (HR 1.19, 95% CI 1.14-1.23, p < 0.001), particularly post-traumatic stress disorder (HR 9.33, 95% CI 7.96-10.94, p < 0.001), while being associated with a reduced risk of suicide (HR 0.68, 95% CI 0.48-0.96, p = 0.030) and suicide attempt (HR 0.57, 95% CI 0.51-0.65, p < 0.001). Later time period of migration and not having any first-degree relatives in Sweden at the time of immigration were associated with greater increases in risk of CVD and psychiatric disorders. Limitations of the study included lack of individual-level information on health status and behaviors of migrants at the time of immigration.ConclusionsOur findings indicate that migrants of the Balkan wars faced considerably elevated risks of major diseases and mortality in their first decade in Sweden compared to other European migrants. War migrants without family members in Sweden or with more recent immigration may be particularly vulnerable to adverse health outcomes. Results underscore that persons displaced by war are a vulnerable group in need of long-term health surveillance for psychiatric disorders and somatic disease.

Abstract Background Early retirement caused by disability pension (DP) due to common mental disorders (CMDs) is frequent in European countries. Inadequate treatment, e.g., suboptimal antidepressant (AD) medication before DP can be crucial in such DP. This explorative study aimed to disentangle trajectories of AD based on defined daily dose (DDD) before and after granted DP, and to characterize the trajectories by socio-demographics and medical factors. Methods All 4642 individuals in Sweden aged 19–64 with incident DP due to CMD in 2009–2010 were included. Trajectories of annual DDDs of AD were analysed over a 6-year period by a group-based trajectory method. Associations between socio-demographic or medical factors and different trajectories were estimated by chi2-test and multinomial logistic regression. Results Five trajectories of ADs were identified. Three groups, comprising 34%, 34%, and 21% of the cohort, had constant AD levels before and after DP with mean annual DDDs of 29, 234, and 580, respectively. Two groups, each including 6% of the cohort, had increasing levels of DDDs, levelling off at around 1150 and 785 DDDs after DP. Particularly age, outpatient care due to mental diagnoses and DP diagnoses were significantly associated with different trajectories (p 50%, 45–64 years), except for the ‘increasing low’ group, where younger individuals were in majority (> 60%, 18–44 years), who more frequently exited labour market due to ‘anxiety disorders’, with lower education and more specialised healthcare before DP than the other groups. Conclusion The heterogeneity among the five trajectory groups was partly explained by age, the severity of the mental disorder and the DP diagnoses. DDDs of ADs, though on different levels, varied marginally before and after granted DP in the majority. Moreover, AD levels were very low in one third of the individuals. Early identification and focus on the ‘increasing low’ group might be important in order to identify individuals at risk for further increase in annual DDDs of ADs even after granted DP, and might also contribute in prevention of DP. Further detailed research regarding different groups is warranted.

Background: Young refugees are at increased risk of labor market marginalization (LMM). We sought to examine whether the association of multimorbidity patterns and LMM differs in refugee youth compared to Swedish-born youth and identify the diagnostic groups driving this association. Methodology: We analyzed 249,245 individuals between 20–25 years, on 31 December 2011, from a combined Swedish registry. Refugees were matched 1:5 to Swedish-born youth. A multimorbidity score was computed from a network of disease co-occurrences in 2009–2011. LMM was defined as disability pension (DP) or >180 days of unemployment during 2012–2016. Relative risks (RR) of LMM were calculated for 114 diagnostic groups (2009–2011). The odds of LMM as a function of multimorbidity score were estimated using logistic regression. Results: 2841 (1.1%) individuals received DP and 16,323 (6.5%) experienced >180 annual days of unemployment during follow-up. Refugee youth had a marginally higher risk of DP (OR (95% CI): 1.59 (1.52, 1.67)) depending on their multimorbidity score compared to Swedish-born youth (OR (95% CI): 1.51 (1.48, 1.54)); no differences were found for unemployment (OR (95% CI): 1.15 (1.12, 1.17), 1.12 (1.10, 1.14), respectively). Diabetes mellitus and influenza/pneumonia elevated RR of DP in refugees (RRs (95% CI) 2.4 (1.02, 5.6) and 1.75 (0.88, 3.45), respectively); most diagnostic groups were associated with a higher risk for unemployment in refugees. Conclusion: Multimorbidity related similarly to LMM in refugees and Swedish-born youth, but different diagnoses drove these associations. Targeted prevention, screening, and early intervention strategies towards specific diagnoses may effectively reduce LMM in young adult refugees.

Abstract 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.

Abstract 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.

Abstract We examined the trajectories of work disability before and after IHD and stroke events. New IHD (n = 13521) and stroke (n = 7162) cases in 2006–2008 were retrieved from nationwide Swedish hospital records and their annual work disability days five years before and after the date of diagnosis were retrieved from a nationwide disability register. There was no pre-event differences in disability days between the IHD and stroke cases and five years prior to the event, they were close to those observed in the general population. In the first post-event year, the adjusted mean days increased to 83.9 (95% CI 80.6–86.5) in IHD; to 179.5 (95% CI 172.4–186.8) in stroke, a six-fold increase in IHD and 14-fold in stroke. Work disability leveled off among the IHD cases but not among those who had stroke. The highest disability levels for the fifth post-event year after a stroke event was associated with pre-existing diabetes (146.9), mental disorder (141.2), non-employment (137.0), and immigrant status (117.9). In a working-age population, the increase in work disability after a cardiovascular event decreases close to the pre-event level in IHD but remains particularly high after stroke; among patients with comorbid depression or diabetes, immigrants, and those not in employment.

OBJECTIVES: Using Swedish population-based register data, we examined the extent to which comorbid conditions contribute to the risk of disability pension among people with diabetes. METHODS: We carried out Cox proportional hazard analyses with comorbid conditions as time-dependent covariates among 14 198 people with newly diagnosed diabetes in 2006, and 39 204 people free from diabetes during the follow-up from 2007–2010. The average follow-up times were 46 and 48 months for those with and without diabetes, respectively. RESULTS: For those with diabetes only, the incidence of all-cause disability pension was 9.5 per 1000 person-years. The highest incidence of disability pension were for those with: diabetes and depression (23.6); diabetes and musculoskeletal disorder (30.6), and those with diabetes and more than one comorbid condition (36.5). The incidence rate was 5.8 for those without diabetes. Diabetes was associated with a 2.30 times [95% confidence interval (95% CI) 2.09–2.54] higher risk of disability pension (adjusted for sociodemographic factors). This association attenuated by 41% after further adjustment for comorbid chronic conditions. While diabetes was a risk factor for disability pension due to musculoskeletal disorders and diseases of the circulatory system, even after accounting for the above-mentioned conditions, the association between disability pension due to mental disorders and diabetes was diluted after adjustment for mental disorders. CONCLUSIONS: Although diabetes is an independent risk factor for disability pension, comorbid conditions contribute to this risk to a large degree.

BackgroundAlthough a stroke event often leads to work disability, diagnoses behind work disability before and after stroke are largely unknown. We examined the pre‐event and postevent trends in diagnosis‐specific work disability among patients of working age. Methods and ResultsWe included all new nonfatal stroke events in 2006–2008 from population‐based hospital registers in Sweden among women and men aged 25 to 60 years (n=12 972). Annual days of diagnosis‐specific work disability were followed for 4 years before and after stroke. Repeated measures negative binomial regression models using the generalized estimating equations method were fitted to examine trends in diagnosis‐specific work disability before and after the event. Already during the 4 pre‐event years, work disability attributed to circulatory diseases increased among women (rate ratio, 1.99; 95% confidence interval, 1.68–2.36) and men (rate ratio, 2.20; 95% confidence interval, 1.88–2.57). Increasing trends before stroke were also found for work disability attributed to mental disorders, musculoskeletal diseases, neoplasms, diseases of the nervous, respiratory, and digestive systems, injuries, and diabetes mellitus. As expected, a sharp increase in work disability days attributed to circulatory diseases was found during the first year after the event among both sexes. Overall, during 4 years after the stroke, there was a decreasing trend for circulatory diseases and injuries, whereas the trend was increasing for nervous diseases and diabetes mellitus. ConclusionsWork disability attributed to several mental and somatic diagnoses is higher already before a stroke event.

Objective Adverse health outcomes, including suicide, in individuals on disability pension (DP) due to mental diagnoses have been reported. However, scientific knowledge on possible risk factors for suicidal behaviour (suicide attempt and suicide) in this group, such as age, gender, underlying DP diagnoses, comorbidity and DP duration and grade, is surprisingly sparse. This study aimed to investigate associations of different measures (main and secondary diagnoses, duration and grade) of DP due to common mental disorders (CMD) with subsequent suicidal behaviour, considering gender and age differences.Design Population-based prospective cohort study based on Swedish nationwide registers.Methods A cohort of 46 515 individuals aged 19–64 years on DP due to CMD throughout 2005 was followed-up for 5 years. In relation to different measures of DP, univariate and multivariate HRs and 95% CIs for suicidal behaviour were estimated by Cox regression. All analyses were stratified by gender and age.Results During 2006–2010, 1036 (2.2%) individuals attempted and 207 (0.5%) completed suicide. Multivariate analyses showed that a main DP diagnosis of ‘stress-related mental disorders’ was associated with a lower risk of subsequent suicidal behaviour than ‘depressive disorders’ (HR range 0.4–0.7). Substance abuse or personality disorders as a secondary DP diagnosis predicted suicide attempt in all subgroups (HR range 1.4–2.3) and suicide in women and younger individuals (HR range 2.6–3.3). Full-time DP was associated with a higher risk of suicide attempt compared with part-time DP in women and both age groups (HR range 1.4–1.7).Conclusions Depressive disorders as the main DP diagnosis and substance abuse or personality disorders as the secondary DP diagnosis were risk markers for subsequent suicidal behaviour in individuals on DP due to CMD. Particular attention should be paid to younger individuals on DP due to anxiety disorders because of the higher suicide risk.

BACKGROUND:Individuals with a history of suicide attempt have a high risk for subsequent labour market marginalization. This study aimed at assessing the effect of individual and parental factors on different measures of marginalization. METHODS:Prospective cohort study based on register linkage of 5 649 individuals who in 1994 were 16-30 years old, lived in Sweden and were treated in inpatient care for suicide attempt during 1992-1994. Hazard ratios (HRs) for labour market marginalization defined as long-term unemployment (>180 days), sickness absence (>90 days), or disability pension in 1995-2010 were calculated with Cox regression. RESULTS:Medical risk factors, particularly any earlier diagnosed specific mental disorders (e.g., schizophrenia: HR 5.4 (95% CI: 4.2, 7.0), personality disorders: HR 3.9, 95% CI: 3.1, 4.9), repetitive suicide attempts (HR 1.6, 95% CI: 1.4, 1.9) were associated with a higher relative risk of disability pension. Individual medical factors were of smaller importance for long-term sickness absence, and of only marginal relevance to long-term unemployment. Country of birth outside Europe had an opposite effect on disability pension (HR 0.6, 95% CI: 0.4, 0.8) and long-term unemployment (HR 1.5, 95% CI: 1.3, 1.8). Female sex was positively correlated with long-term sickness absence (HR 1.6, 95% CI: 1.4, 1.7), and negatively associated with long-term unemployment (HR: 0.8, 95% CI: 0.7, 0.9). CONCLUSIONS:As compared to disability pension, long-term sickness absence and unemployment was more strongly related to socio-economic variables. Marginalization pathways seemed to vary with migration status and sex. These findings may contribute to the development of intervention strategies which take the individual risk for marginalization into account.

Bereavement is thought to be a risk factor for suicide but the association has not been thoroughly investigated according to specific sensitive time periods and risk groups using a self-matched design. We aimed to 1) determine the risk of suicide within the first year after death of a close relative, 2) investigate if and how the risk changes within this time window and 3) determine if sex, age, and type of relationship, affect this association.A self-matched, case-crossover study was performed by linking Swedish registers. In total, 31 059 individuals with suicide between 1990 and 2011 were included. Different periods within the year prior to the suicide were compared with corresponding periods one year earlier in the same individual's life. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for suicide after death of a close relative.Increased ORs of suicide were seen during the first month, OR 1·77 (95% CI 1·35-2·34), and the first half-year, 1·27 (1·13-1·43). An even higher OR was found within the first week, 3·43 (1·89-6·22). Patterns were similar for women and men and across age groups. Death of a partner or child but not death of a sibling or parent was associated with a significantly increased suicide risk. The strongest association was seen after death of a partner in individuals aged 45 and older.These findings provide knowledge of sensitive time periods and at-risk groups in the early period of bereavement. Due to the use of a self-matched study design, methodological challenges of unmeasured residual confounding could be overcome.

Work-related functional impairment in terms of sickness absence and disability pension (SA/DP) has been reported to be associated with subsequent suicide. However, there is only limited knowledge on SA/DP patterns prior to suicide. The aim was to identify trajectories of work-related functional impairment prior to suicide and to describe associations of socio-demographic and medical factors with such trajectories.This is a population-based retrospective cohort study of the 4 209 individuals aged 22-65 years who committed suicide during 2007-2010 in Sweden. Work-related functional impairment was measured as mean annual number of months of SA/DP. We analyzed trajectories of SA/DP during five years prior to suicide (i.e., 2002-2009) by a group-based trajectory method. Associations between socio-demographic and medical factors with different groups of trajectories were estimated by chi2-test and multinomial logistic regression.Five different functional impairment trajectory groups were identified prior to suicide. One group had constant low levels of SA/DP (46%), while 30% had constant high levels of SA/DP. Two groups (16%) showed increasing number of SA/DP months. The remaining 7% showed decreasing number of SA/DP months before the suicide. Sex, age, educational level, family situation, and diagnosis-specific healthcare were significantly associated with different trajectory groups (Likelihood ratio X2 tests

BackgroundCommon mental disorders (CMD) have become one of the leading causes for disability pension (DP). Studies on predictors of adverse health outcome following DP are sparse. This study aimed to examine the association of different socio-demographic factors and health care consumption with subsequent suicidal behaviour among individuals on DP due to CMD.MethodThis is a population-based prospective cohort study based on register data. All individuals aged 18-64 years, living in Sweden on 31-Dec-2004 who in 2005 were on DP due to CMD (N = 46 745) were followed regarding suicide attempt and suicide (2006-10). Univariate and multivariate hazard ratios (HR) and 95% confidence intervals (CI) for suicidal behaviour were estimated by Cox regression.ResultsDuring the five-year follow-up, 1 046 (2.2%) and 210 (0.4%) individuals attempted and committed suicide, respectively. Multivariate analyses showed that young age (18-24 years) and low education predicted suicide attempt, while living alone was associated with both higher suicide attempt and suicide (range of HRs 1.23 to 1.68). Combined prescription of antidepressants with anxiolytics during 2005 and inpatient care due to mental diagnoses or suicide attempt (2001-05) were strongly associated with suicide attempt and suicide (range of HRs 1.3 to 4.9), while inpatient care due to somatic diagnoses and specialized outpatient care due to mental diagnoses during 2001-05 only predicted suicide attempt (HR 1.45; 95% CI: 1.3-1.7; HR 1.30; 95% CI: 1.1-1.7).ConclusionsAlong with socio-demographic factors, it is very important to consider type of previous healthcare use and medication history when designing further research or intervention aiming at individuals on DP due to CMD. Further research is warranted to investigate both characteristics of disability pension due to CMD, like duration, diagnoses and grade as well as mechanisms to subsequent suicidal behavior, taking potential gender differences into consideration.

BackgroundDepression ranges among the leading causes of early exit from the labor market worldwide. We aimed to investigate the associations of socio-demographic factors, sickness absence, health care and prescription patterns with the risk of being granted a disability pension in psychiatric outpatients with depression.MethodsAll non-retired patients aged 18-60 years and living in Sweden 31.12.2005 with at least one psychiatric outpatient care visit due to a depressive episode during 2006 (N = 18,034): were followed from 01.01.2007 to 31.12.2010 with regard to granting of all-cause and diagnosis-specific disability pension. Uni- and multivariate Rate Ratios (RR) and 95% Confidence Intervals (CI) were estimated for the various risk markers by Poisson Regression.ResultsDuring the four years of follow-up, 3044 patients (16.8%) were granted a disability pension, the majority due to mental disorders (2558, 84%). In the multivariate analyses, being female, below 25 or above 45 years of age, with low educational level, living alone, residing outside big cities and being born outside Europe were predictive of a granted disability pension. Frequent in- and outpatient care due to mental disorders, prescription of antidepressants and long sickness absence spells were also associated with an increased risk of disability pension (range of RRs 1.10 to 5.26). Somatic health care was only predictive of disability pension due to somatic disorders. The risk of being granted a disability pension remained at the same level as at the start of follow-up for about 1.5 years, when it started to decrease and to level off at about 20% of the risk at the end of follow-up.ConclusionsIdentified risk markers should be considered when monitoring individuals with depression and when designing intervention programs.

OBJECTIVE: Increasing rates of disability pension (DP) have been observed among young adults. We studied specific psychiatric DP diagnoses and subsequent risk of suicidal behaviour in a series of three cohorts of young adult in Sweden. METHOD: In a nationwide register study, we included all young adults who in 1995, 2000, and 2005, respectively, were 19-23 years old and lived in Sweden (n≈500,000 per cohort). Rates of DP and specific psychiatric DP diagnoses were recorded in each cohort. Hazard ratios (HRs) and 95% confidence intervals (CIs) for suicidal behaviour during the following five years, with the corresponding age group as reference, were calculated by Cox proportional hazard regression, adjusted for demographic variables and previous own and parental suicidal behaviour. RESULTS: The overall proportion with DP in this age group increased from 0.92% in 1995 to 2.29% in 2005, with particularly large increases in psychiatric diagnoses such as hyperkinetic disorders, pervasive developmental disorders, and depression/anxiety. The overall proportion of young disability pensioners attempting suicide during the five-year follow-up increased from 2.21% in the 1995 cohort to 3.81% in the 2005 cohort. Within most psychiatric DP diagnoses, the risk of attempted suicide did not change significantly over time, whereas suicide attempts increased in the reference group. Accordingly, the HRs for suicide attempt decreased in some psychiatric DP diagnoses. The highest adjusted HRs were observed for depression/anxiety (16.41; CI: 9.06 to 29.74) and schizophrenia (9.37; 6.13 to 14.31) in the 1995 cohort. The rate of suicide among young disability pensioners during follow-up ranged from 0.19% in 1995 to 0.37% in 2005, mainly occurring in individuals with psychiatric diagnoses. CONCLUSION: Suicidal behaviour has become more prevalent among young disability pensioners, which co-occurred with an increased tendency to grant DP in psychiatric diagnoses with a known high risk of suicidal behaviour. Preventive measures are warranted.

Psychiatric comorbidity is common among multiple sclerosis (MS) patients. The majority of MS patients of working ages are on disability pension. The aims of this study were to chart the prevalences of psychiatric diagnoses and medications among MS patients of working ages, and to investigate their association with the risk for future disability pension.This nationwide, population-based prospective cohort study includes 10,750 MS patients and 5,553,141 non-MS individuals who in 2005 were aged 17-64 years. Psychiatric diagnoses and medications were identified using nationwide registers. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated adjusting for socio-demographics. Furthermore, a survival analysis with five-year follow-up was performed among the 4,571 MS patients not on disability pension in 2005, with psychiatric diagnoses and medication as risk factors, and disability pension as the outcome.Among MS patients, 35% had been prescribed psychiatric medication compared to 10% of non-MS individuals, adjusted OR 3.72 (95% CI 3.57 to 3.88). Ten percent of MS patients had received a psychiatric diagnosis, compared to 5.7% of non-MS individuals, OR 1.82 (95% CI 1.71 to 1.94). Serotonin reuptake inhibitors (SSRIs), were the most commonly prescribed drugs (17%) among MS patients, while depression (4.8%) was the most common psychiatric diagnosis. In the survival analysis, MS patients with any psychiatric diagnosis had a hazard ratio (HR) of 1.83 (95% CI 1.53 to 2.18) for disability pension compared to other MS patients. MS patients with any psychiatric drug prescription had a HR for disability pension of 2.09 (95% CI 1.84 to 2.33).Psychiatric diagnoses and medications are common among MS patients and adversely affect risk for disability pension. This highlights the importance of correct diagnosis and management of psychiatric comorbidity, in a clinical as well as in a societal perspective.

OBJECTIVE:The aim was to examine if long-term psychiatric sickness absence was associated with all-cause and diagnosis-specific (cardiovascular disease (CVD), cancer and suicide) mortality for the period 1990-2007. An additional aim was to examine these associations for psychiatric sickness absence in 1990 and 2000, with follow-up on mortality during 1991-1997 and 2001-2007, separately. METHODS:Employees within municipalities and county councils, 244,990 individuals in 1990 and 764,137 individuals in 2000, were followed up to 2007 through register linkages. Analyses were conducted with flexible parametric survival models comparing sickness absentees due to psychiatric diagnoses (>90 days) with those not receiving sick leave benefit. RESULTS:Long-term sickness absence for psychiatric disorders was associated with an increased risk of mortality due to all causes; CVD; cancer (smoking and non-smoking related); and suicide during the period 1990-2007. After full adjustment for socio-demographic covariates and previous inpatient care due to somatic and psychiatric diagnoses, these associations remained significant for all-cause mortality (Hazard ratios (HR) and 95% confidence interval (CI)): HR 1.56, 95% CI 1.3-1.8; CVD: HR 1.35, 95% CI 1.0-1.9, and suicide: HR 3.84, 95% CI 2.4-6.1. For both cohorts 1990 and 2000 estimates point in the same direction. For the time-period 2000-2007, we found increased risks of mortality in the fully adjusted model due to all causes: HR 1.47, 95% CI 1.2-1.7; CVD: HR 1.83, 95% CI 1.2-2.7; overall cancer: HR 1.33, 95% CI 1.0-1.7; and suicide: HR 2.15, 95% CI 1.3-3.7. CONCLUSION:Long-term sickness absence for psychiatric disorders predicted premature mortality from all-causes, cardiovascular disease, cancer, and suicide.

PURPOSE: Stressful childhood experiences have negative long-term health consequences. The present study examines the association between adverse childhood experiences, socioeconomic position, and risk of psychotropic medication in young adulthood. METHODS: This register-based cohort study comprises the birth cohorts between 1985 and 1988 in Sweden. We followed 362 663 individuals for use of psychotropic medication from January 2006 until December 2008. Adverse childhood experiences were severe criminality among parents, parental alcohol or drug abuse, social assistance recipiency, parental separation or single household, child welfare intervention before the age of 12, mentally ill or suicidal parents, familial death, and number of changes in place of residency. Estimates of risk of psychotropic medication were calculated as odds ratio (OR) with 95% confidence intervals (CIs) using logistic regression analysis. RESULTS: Adverse childhood experiences were associated with increased risks of psychotropic medication. The OR for more than three adverse childhood experiences and risk of psychotropic medication was for women 2.4 (95% CI 2.3-2.5) and for men 3.1 (95% CI 2.9-3.2). The risk of psychotropic medication increased with a higher rate of adverse childhood experiences, a relationship similar in all socioeconomic groups. CONCLUSIONS: Accumulation of adverse childhood experiences increases the risk of psychotropic medication in young adults. Parental educational level is of less importance when adjusting for adverse childhood experiences. The higher risk for future mental health problems among children from lower socioeconomic groups, compared to peers from more advantaged backgrounds, seems to be linked to a higher rate of exposure to adverse childhood experiences.

BackgroundHearing difficulties are a large public health problem. Knowledge is scarce regarding risk of disability pension among people who have been sickness absent due to these difficulties.MethodsA cohort including all 4,687,756 individuals living in Sweden in 2005, aged 20-64, and not on disability or old-age pension, was followed through 2009. Incidence rate ratios (RR) of disability pension with 95% confidence intervals (CI) were estimated using Cox proportional hazard models.ResultsIn multivariable models, individuals who had a sick-leave spell due to otoaudiological diagnoses in 2005 had a 1.52-fold (95% CI: 1.43-1.62) increased risk of being granted a disability pension compared to individuals on sick leave due to other diagnoses. Hearing and tinnitus sick-leave diagnoses were associated with risk of disability pension: RR 3.38, 95% CI: 3.04-3.75, and 3.30, 95% CI: 2.95-3.68, respectively. No association was observed between sick leave due to vertigo diagnoses and disability pension whereas otological diagnoses and no sick leave were inversely associated with risk of disability pension compared to non-otoaudiological sick-leave diagnoses. Sick leave due to otoaudiological diagnoses was positively associated with risk of disability pension due to otoaudiological diagnoses and sick leave due to a tinnitus diagnosis was also associated with risk of disability pension due to mental diagnoses. The risk of disability pension among individuals with hearing or tinnitus sick-leave diagnoses was highest in the age group 35-44. Moreover, men had a slightly higher risk.ConclusionThis large cohort study suggests an increased risk of disability pension among those with sickness absence due to otoaudiological diagnoses, particularly hearing and tinnitus diagnoses, compared to those with sickness absence due to non-otoaudiological diagnoses.

BackgroundResearch on the temporal relationship of parental risk factors with offspring's suicide attempt is scarce and a life course approach has not been applied to date. We investigated the temporal relationship of parental morbidity and mortality with offspring's suicide attempt and whether any such association was modified by offspring's age at attempt.MethodsWe designed a case-control study through linkage of Swedish registers. Cases comprised all individuals in Sweden born 1973-1983 with inpatient care due to suicide attempt (15-31 years of age) and with information on both biological parents (N = 15 193). Ten controls were matched to each case (National Patient register with national complete coverage). Conditional logistic and spline regressions were applied.ResultsParticularly for women, most parental markers showed the strongest effect sizes if exposure was short-term (within 2 years after exposure) and related to the mother. Especially short-term exposure to maternal inpatient care due to psychiatric diagnoses had a significantly stronger effect on suicide attempt risk in women compared to men. Regarding exposure to parental inpatient care due to psychiatric diagnoses, short-term as opposed to long-term (exceeding 2 years after exposure) effects were highest during adolescence and decreased significantly with age for female and male offspring, respectively.ConclusionsAlthough limited by the fact that data on parental morbidity and the outcome of suicidality were based on in-patient data only, the data suggest that the high risks of suicide attempt in case of exposure to parental psychopathology and suicidal behavior particularly during adolescence and the strong short-term effects associated with maternal psychopathology for female offspring are of direct clinical importance.

Despite the magnitude and increase of sickness absence due to mental diagnoses, little is known regarding long-term health outcomes. The aim of this nationwide population-based, prospective cohort study was to investigate the association between sickness absence due to specific mental diagnoses and the risk of all-cause and cause-specific mortality.A cohort of all 4 857 943 individuals living in Sweden on 31.12.2004 (aged 16-64 years, not sickness absent, or on retirement or disability pension), was followed from 01.01.2005 through 31.12.2008 for all-cause and cause-specific mortality (suicide, cancer, circulatory disease) through linkage of individual register data. Individuals with at least one new sick-leave spell with a mental diagnosis in 2005 were compared to individuals with no sickness absence. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated by Cox regression, adjusting for age, sex, education, country of birth, family situation, area of residence, and pre-existing morbidity (diagnosis-specific hospital inpatient (2000-2005) and outpatient (2001-2005) care).In the multivariate analyses, mental sickness absence in 2005 was associated with an increased risk for all-cause mortality: HR: 1.65, 95% CI: 1.47-1.86 in women and in men: 1.73, 1.57-1.91; for suicide, cancer (both smoking and non-smoking related) as well as mortality due to circulatory disease only in men. Estimates for cause-specific mortality ranged from 1.48 to 3.37. Associations with all-cause mortality were found for all mental sickness absence diagnostic groups studied.Knowledge about the prognosis of patients sickness absent with specific mental diagnoses is of crucial clinical importance in health care. Sickness absence due to specific mental diagnoses may here be used as a risk indictor for subsequent mortality.