Andreas Lundin

Unemployment and mortality—a longitudinal prospective study on selection and causation in 49321 Swedish middle-aged men

Background: Unemployment is associated with increased risk of mortality. It is, however, not clear to what extent this is causal, or whether other risk factors remain uncontrolled for. The aim of this study was to investigate the association between unemployment and all-cause and cause-specific mortality, adjusting for indicators of mental disorder, behavioural risk factors and social factors over the life course. Methods: This study was based on a cohort of 49321 Swedish males, born 1949/51, tested for compulsory military conscription in 1969/70. Data on employment/unemployment 1990–4 was based on information from the Longitudinal Register of Education and Labour Market Statistics. Information on childhood circumstances was drawn from National Population and Housing Census 1960. Information on psychiatric diagnosis and behavioral risk factors was collected at conscription testing in 1969/70. Data on mortality and hospitalisation 1973–2004 were collected in national registers. Results: An increased risk of mortality 1995–2003 was found among individuals who experienced 90 days or more of unemployment during 1992–4 compared with those still employed (all-cause mortality HR 1.91, 95% CI 1.58 to 2.31. Adjustment for risk factors measured along the life course considerably lowered the relative risk (all cause mortality HR 1.30, 95% CI 1.06 to 1.58). Statistically significant increased relative risk was found during the first 4 years of follow up (all-cause mortality, adjusted HR 1.57, 95% CI 1.13 to 2.18, but not the following 4 years (all cause mortality, adjusted HR 1.17, 95% CI 0.91 to 1.50). Conclusion: The results suggest that a substantial part of the increased relative risk of mortality associated with unemployment may be attributable to confounding by individual risk factors.

Unemployment and suicide

270 www.thelancet.com Vol 374 July 25, 2009 DNA-positive for some HPV types, since the vaccine will provide protection from infection with the other HPV types. Hopefully, additional vaccines will be developed against a broader spectrum of high-risk HPV types than those currently covered. This increase in scope of coverage will be of particular importance to HPV immunisation in the developing world, where the prevalence of HPV types diff ers from that in developed countries. Women have shouldered responsibility for contraception since its inception. The goal to eradicate sexually transmitted carcinogenic viruses can be jointly carried by women and men, and could be accomplished within a few decades.

Unemployment and suicide in the Stockholm population: A register-based study on 771,068 men and women

OBJECTIVES Several studies have reported a higher risk of suicide among the unemployed. Some individuals may be more prone to both unemployment and suicide due to an underlying health-related factor. In that case, suicide among the unemployed might be a consequence of health-related selection. This study aimed to investigate the relationship between unemployment and suicide, and the importance of previous sickness absence to this relationship. STUDY DESIGN The study was based on 771,068 adults aged 25-58 years in Stockholm County in 1990-1991. Data on sickness absence in 1990-1991 and unemployment in 1991-1993 were collected from registers for each individual. Time and cause of death in 1994-1995 were obtained from Swedens Cause of Death Register. METHODS The association between sickness absence in 1990-1991 and unemployment in 1992-1993, and the association between unemployment in 1992-1993 and suicide in 1994-1995 was investigated using logistic regression. RESULTS Unemployment lasting for >90 days in 1992-1993 was associated with suicide in men in 1994-1995 [odds ratio (OR) 2.16, 95% confidence interval (CI) 1.38-3.38], while unemployment lasting for ≤ 90 days in 1992-1993 was associated with suicide in women in 1994-1995 (OR 2.68, 95% CI 1.23-5.85). Higher levels of sickness absence were related to an increased risk of subsequent unemployment in both sexes. The higher prevalence of sickness absence among the unemployed attenuated the association between unemployment and suicide in both men and women. CONCLUSIONS Unemployment is related to suicide. Individuals in poor health are at increased risk of unemployment and also suicide. The higher relative risk of suicide among the unemployed seems to be, in part, a consequence of exclusion of less healthy individuals from the labour market.

The use of Alcohol Use Disorders Identification Test (AUDIT) in detecting alcohol use disorder and risk drinking in the general population: validation of AUDIT using schedules for clinical assessment in neuropsychiatry

BACKGROUND The alcohol use disorders identification test (AUDIT) and AUDIT-Consumption (AUDIT-C) are commonly used in population surveys but there are few validations studies in the general population. Validity should be estimated in samples close to the targeted population and setting. This study aims to validate AUDIT and AUDIT-C in a general population sample (PART) in Stockholm, Sweden. METHODS We used a general population subsample age 20 to 64 that answered a postal questionnaire including AUDIT who later participated in a psychiatric interview (n = 1,093). Interviews using Schedules for Clinical Assessment in Neuropsychiatry was used as criterion standard. Diagnoses were set according to the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Agreement between the diagnostic test and criterion standard was measured with area under the receiver operator characteristics curve (AUC). RESULTS A total of 1,086 (450 men and 636 women) of the interview participants completed AUDIT. There were 96 individuals with DSM-IV-alcohol dependence, 36 DSM-IV-Alcohol Abuse, and 153 Risk drinkers. AUCs were for DSM-IV-alcohol use disorder 0.90 (AUDIT-C 0.85); DSM-IV-dependence 0.94 (AUDIT-C 0.89); risk drinking 0.80 (AUDIT-C 0.80); and any criterion 0.87 (AUDIT-C 0.84). CONCLUSIONS In this general population sample, AUDIT and AUDIT-C performed outstanding or excellent in identifying dependency, risk drinking, alcohol use disorder, any disorder, or risk drinking.

Exercise as treatment for alcohol use disorders: systematic review and meta-analysis

Objectives To conduct a systematic review and meta-analysis investigating effects of exercise for people with alcohol use disorders (AUDs) across multiple health outcomes. We also investigated the prevalence and predictors of dropout from exercise studies in AUDs. Design Systematic review and random effects meta-analysis with meta-regression analyses. Data sources 3 major electronic databases were searched from inception until April 2016 for exercise intervention studies in adults with AUDs. Eligibility criteria Studies of acute exercise in people with AUDs; and randomised and non-randomised trials examining effects of long-term (≥2 weeks) exercise. Results 21 studies and 1204 unique persons with AUDs (mean age 37.8 years, mean illness duration 4.4 years) were included. Exercise did not reduce daily alcohol consumption (standardised mean difference (SMD) =−0.886, p=0.24), or the Alcohol Use Disorders Identification Test (AUDIT) total scores (SMD=−0.378, p=0.18). For weekly consumption (n=3 studies), a statistically significant difference was observed favouring exercise (SMD=−0.656, p=0.04), but not after adjustment for publication bias (SMD=−0.16, 95% CI −0.88 to 0.55). Exercise significantly reduced depressive symptoms versus control (randomised controlled trials (RCTs) =4; SMD=−0.867, p=0.006, I2=63%) and improved physical fitness (VO2) (RCTs=3; SMD=0.564, p=0.01, I2=46%). The pooled dropout rate was 40.3% (95% CI 23.3% to 60.1%) which was no different to control conditions (OR=0.73, p=0.52). Dropouts were higher among men (β=0.0622, p<0.0001, R2=0.82). Limitations It was not possible to investigate moderating effects of smoking. Conclusions Available evidence indicates exercise appears not to reduce alcohol consumption, but has significant improvements in other health outcomes, including depression and physical fitness. Additional long-term controlled studies of exercise for AUDs are required.

The association between masculinity rank and mortality patterns: a prospective study based on the Swedish 1969 conscript cohort

Background: Being male constitutes a risk factor for early death, and this may be connected to concepts of masculinity. The objective of the present study was to investigate the association between masculinity rank during late adolescence and mortality patterns in a cohort of 49 321 Swedish men tested for compulsory military training in 1969. Methods: The measure of masculinity consisted of a five-grade ranking from the conscription information that comprised leisure interests and occupational preferences. Information on all-cause mortality, alcohol-related mortality, suicide, mortality from other violent causes and mortality from cardiovascular disease was collected from national registers for 1970–2003. The analyses were performed using Cox proportional hazard models with hazard ratios as estimates of relative risk. Results: For all-cause mortality, the crude relative risks versus ordinary masculinity were: lowest masculinity 1.98 (95% CI 1.71 to 2.31), low masculinity 1.38 (95% CI 1.24 to 1.53), high masculinity 0.90 (95% CI 0.81 to 1.01) and highest masculinity 0.78 (95% CI 0.62 to 0.97). After adjustments for childhood class, smoking, alcohol drinking, blood pressure, short stature, psychiatric disorder, low intelligence and contact with police or childcare authorities, conscripts who were ranked lowest on masculinity had a remaining increased relative risk of all-cause mortality (1.49; 95% CI 1.28 to 1.75) and suicide (1. 79; 95% CI 1.31 to 2.43). For mortality from violent causes other than suicide, no statistically significant associations were demonstrated. Conclusions: Earlier research has proposed that masculinity may hold both positive and negative aspects regarding lifetime health. The major conclusion here is that being ranked less masculine is associated with higher mortality.

Validity of the 12-item version of the General Health Questionnaire in detecting depression in the general population

OBJECTIVES The 12-item version of the General Health Questionnaire (GHQ-12) is frequently used to measure common mental disorder in public health surveys, but few population-based validations have been made. We validated the GHQ-12 against structured psychiatric interviews of depression using a population-based cohort in Stockholm, Sweden. METHODS We used a population-based cohort of 484 individuals in Stockholm, Sweden (participation rate 62%). All completed the GHQ-12 and a semi-structured psychiatric interview. Last month DSM-III-R symptoms were used to classify major and minor depression. Three scoring methods for GHQ-12 were assessed, the Standard, Likert and Corrected method. Discriminatory ability was assessed with area under the receiver operating characteristic (ROC) curve. RESULTS A total of 9.5% had a major or minor depression. The area under the ROC curve was for the Standard method 0.73 (0.65-0.82), the Likert method 0.80 (0.72-0.87) and the Corrected method 0.80 (0.73-0.87) when using major or minor depression as standard criterion. Adequate sensitivity and specificity for separating those with or without a depressive disorder was reached at ≥12 Likert scored points (80.4 and 69.6%) or ≥6 Corrected GHQ points (78.3 and 73.7%). Sensitivity and specificity was at ≥2 Standard scored points 67.4% and 74.2%. CONCLUSION When scored using the Likert and Corrected methods, the GHQ-12 performed excellently. When scored using the Standard method, performance was acceptable in detecting depressive disorder in the general population. The GHQ-12 appears to be a good proxy for depressive disorder when used in public health surveys.

Cognitive Ability in Late Adolescence and Disability Pension in Middle Age: Follow-Up of a National Cohort of Swedish Males

Low cognitive ability in late adolescence has previously been shown to be associated with disability pension (DP) in young adulthood. However, most DP’s are granted later in working life, and the mechanisms of the association are not fully understood. We aimed to investigate the association between cognitive ability in late adolescence and DP at ages 40-59, and investigate the role of individual and socioeconomic factors. Information on cognitive ability, health status, personality aspects and health behaviours at age 18-20 was obtained from the 1969-70 conscription cohort, comprising 49 321 Swedish men. Data on DP’s 1991-2008 was obtained from the Longitudinal Database of Education, Income and Employment. Information on socioeconomic and work-related factors in childhood and adulthood was obtained from national sociodemographic databases. Hazard ratios for DP during follow-up were estimated by Cox proportional hazards models. We found a graded relationship between cognitive ability in late adolescence and DP in middle age. One step decrease on the nine-point stanine scale of cognitive ability was associated with a crude hazard ratio of 1.26 (95 % CI 1.24-1.27). Socioeconomic and work-related circumstances in adulthood explained much of the association, but factors measured already in late adolescence also showed importance. The findings suggest an accumulation of risks over the life course. Although attenuated, the graded relationship remained after adjusting for all factors.

Psychiatric diagnosis in late adolescence and long-term risk of suicide and suicide attempt

Lundin A, Lundberg I, Allebeck P, Hemmingsson T. Psychiatric diagnosis in late adolescence and long‐term risk of suicide and suicide attempt.

Unemployment and coronary heart disease among middle-aged men in Sweden: 39 243 men followed for 8 years

Background Although unemployment may be a stressful life event, its association with coronary heart disease (CHD) remains unclear. This study examines the association between unemployment and later hospitalisation due to CHD. Methods The study was based on a Swedish military conscription cohort of 18 to 20-year-old men from 1969/1970 (n=49 321) with information provided on health status and health behaviours. Information on unemployment in middle age was obtained from national registers. CHD information was obtained from hospital registers and the cause of death register. Cox proportional hazard analyses were run on the 39 243 individuals who were in paid employment in 1996 and 1997. Results It was found that ≥90 days of unemployment was associated with subsequent CHD during 8 years follow-up (crude HR=1.47, 95% CI 1.23 to 1.75). Controlling for known risk factors for CHD reduced the association but a significant association remained (HR=1.24, 95% CI 1.04 to 1.48); ≥90 days of unemployment was significantly associated with CHD during the first 4 years (HR adjusted for known risk factors=1.31, 95% CI 1.01 to 1.71). Conclusions Unemployment was associated with increased risk of CHD after adjustment for confounders. We interpret the increased risk of CHD associated with unemployment as potentially the somatic result of a process started by stress.