Mo Wang

Are all-cause and diagnosis-specific sickness absence, and sick-leave duration risk indicators for suicidal behaviour? A nationwide register-based cohort study of 4.9 million inhabitants of Sweden

Objectives Recent studies have found an increased risk of suicide in people on sickness absence, but less is known about to what extent diagnosis-specific sickness absence is a risk indicator for suicidal behaviour. This study aimed to examine all-cause and diagnosis-specific sickness absence and sick-leave duration as risk indicators for suicide attempt and suicide. Methods This is a population-based prospective cohort study. All non-retired adults (n=4 923 404) who lived in Sweden as on 31 December 2004 were followed-up for 6 years regarding suicide attempt and suicide (2005–2010). HRs and 95% CIs for suicidal behaviour were calculated, using people with no sick-leave spells in 2005 as reference. Results In analyses adjusted for sociodemographic factors and previous mental healthcare, suicide attempt and current antidepressants prescription, sickness absence predicted suicide attempt (HR 2.37; 95% CI 2.25 to 2.50 for women; HR 2.69; 95% CI 2.53 to 2.86 for men) and suicide (HR 1.91; 95% CI 1.60 to 2.29 for women; HR 1.92; 95% CI 1.71 to 2.14 for men), particularly mental sickness absence (range of HR: 2.74–3.64). The risks were also increased for somatic sickness absence, for example, musculoskeletal and digestive diseases and injury/poisoning (range of HR: 1.57–3.77). Moreover, the risks increased with sick-leave duration. Conclusions Sickness absence was a clear risk indicator for suicidal behaviour, irrespective of sick-leave diagnoses, among women and men. Awareness of such risks is recommended when monitoring sickness certification. Further studies are warranted in order to gain more detailed knowledge on these associations.

Parental Rearing, Attachment, and Social Anxiety in Chinese Adolescents.

This cross-sectional study investigated associations between perceived parental rearing, attachment, and social anxiety. 510 Chinese middle school students, aged 12 to 20 years, completed a set of questionnaires including “Egna Minnen Beträffande Uppfostran” for Children (EMBU-C), Inventory for Parent and Peer Attachment (IPPA) and Social Anxiety Scale for Adolescents (SAS-A). The results showed that intercorrelations between adolescents’ rated attachment to parents were stronger than betweenparental and peer attachment. Girls scored higher on attachment to mother and peer than boys. Lack of parental rejection and presence of emotional warmth were strongly related to parental attachment. The rated level of total anxiety was not related to gender or age, but it was lower than what has earlier been reported from China. Perceived rejection from fathers and mothers’ as well as attachment to peer and mother acted as predictors; together they explained 19% of the variance in social anxiety.

Predictors of not starting and dropping out from psychotherapy in Swedish public service settings

This naturalistic study examines potential predictors of treatment attendance and discontinuation among patients in the three most common psychotherapy types in Swedish public health service settings. Patients who did not start psychotherapy after pretherapy assessment are compared with patients who started psychotherapy. Patients who discontinued psychotherapy are compared with those remaining in treatment. Data were collected over a 3-year period at 13 outpatient psychiatric clinics, using online patient and therapist questionnaires. Of the 1498 registered patients, 14% never started psychotherapy, 17% dropped out from treatment, 33% continued in treatment, while 36% dropped out from data collection. Being dangerous to others, having Axis I diagnosis according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), lower level of therapeutic alliance, organizational factors, having younger therapists, psychotic features, and being older were predictive of not starting treatment, while organizational factors, more acting out and criminality, less mental ill-health, and being younger predicted dropout from treatment. Significantly more nonstarters and dropouts were found at clinics with lower levels of organizational structure and stability. Organizational factors predicted both starting and continuing in treatment.

Morbidity and suicide mortality following sick leave in relation to changes of social insurance regulations in Sweden

BACKGROUNDS Stricter regulations including time limits for sick leave have been introduced in Sweden in 2008, which might have resulted in higher morbidity in those on longer sick-leave spells after the introduction. This study aimed to examine (i) the association between all-cause and diagnosis-specific sickness absence and sick-leave duration with subsequent morbidity and suicide mortality and (ii) differences in socio-demographics and morbidity in individuals on sickness absence regarding changes of social insurance regulations. METHODS A population-based prospective study was conducted of two cohorts of individuals who lived in Sweden, aged between 20 and 64 years at 31 December 2005 (n = 4 477 678) and at 31 December 2008 (n = 4 500 400), respectively. Each of the cohorts was followed regarding inpatient healthcare and suicide. Hazard ratios (HR) and 95% confidence intervals were estimated by Cox regression models. RESULTS In the multivariate analyses, all-cause and diagnosis-specific sickness absence and sick-leave duration showed higher HRs for inpatient care and suicide in both cohorts (range of HR:1.10-2.59). HRs of inpatient care and suicide among individuals with mental sickness absence 2009 were reduced more after controlling for morbidity-related covariates, than such sickness absence in 2006. Individuals with mental and somatic sickness absence and sickness absence > 180 days in 2009 had higher HRs of somatic inpatient care than those on sickness absence in 2006. CONCLUSIONS Diagnosis-specific sickness absence and long-term sickness absence in 2009 might be associated with more severe morbidity or work incapacity than in 2006 due to the stricter regulations.

Labour market marginalisation subsequent to suicide attempt in young migrants and native Swedes

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

Trajectories and characteristics of work disability before and after acute myocardial infarction

Objective Scientific knowledge on work disability in terms of sickness absence and disability pension (SA/DP) among patients with acute myocardial infarction (AMI) is scarce. The study aimed to investigate trajectories of SA/DP among individuals with or without AMI and examined the associations between sociodemographic, morbidity and coronary revascularisation characteristics with such trajectories among patients with AMI. Methods This is a population-based cohort study of 10 255 individuals aged 30–60 years who had a first AMI during 2008–2010 and were alive 30 days after AMI. Each case was matched by sociodemographics to one control without AMI. Trajectories of annual SA/DP months over a 6-year period for cases and controls were analysed by group-based trajectory modelling. Associations of characteristics with trajectory groups were estimated by Χ2 test and multinomial logistic regression. Results The majority of patients (59%) had slightly increased annual levels of SA/DP (1 month) at the time of AMI, which returned to no SA/DP 2 years after the event. One group (4%) had increasing SA/DP months preceding and after AMI. Three groups showed constant SA/DP months on low (14%), medium (9%) and high (15%) levels. Sex, unemployment, education, musculoskeletal disorders and prescription of antidepressants were the strongest factors discriminating the SA/DP trajectories (R2 difference=0.02–0.03, p<0.01). Conclusions The majority of patients with AMI have a good outcome in terms of low levels of work disability within 2 years after AMI. Patterns of SA/DP before AMI, sex, socioeconomic status as well as comorbid musculoskeletal and mental disorders provide crucial clinical information on work disability after AMI.

Determinants of work disability following lumbar spine decompression surgery

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

Healthcare use among immigrants and natives in Sweden on disability pension, before and after changes of regulations

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

Period effects in the risk of subsequent labour market marginalisation in young suicide attempters

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

Not starting psychotherapy is more often initiated by the therapist than the patient

The phenomenon of not starting psychotherapy is seldom investigated. The present study of psychotherapy in the Swedish mental health services differentiates between patients applying for and being offered psychotherapy but choosing not to start (n = 69), patients recommended to receive no treatment, another type of treatment or treatment at another clinic (n = 133), and therapy starters (n = 1294). After the initial assessment, nearly twice as many patients did not start based on the therapist’s decision than on the patient’s. Cases of not starting psychotherapy decided by the therapist were more frequent among patients whose occupational status was less stable, presented a danger to others, had lower levels of initial therapeutic alliance, and by therapists with lower levels of psychotherapy training and those at less structured and more unstable clinics. Patients choosing not to start therapy had lower levels of mental ill-health than both starters and therapist-initiated nonstarters. The most frequently presented reason for a patient-initiated decision to not start therapy was “patient wished another treatment or therapist,” whereas the most common therapist-initiated reason was “recommended or referred to another treatment or clinic”.