Niina Markkula

Mortality in people with depressive, anxiety and alcohol use disorders in Finland

BACKGROUND Mental disorders are associated with increased mortality, but population-based surveys with reliable diagnostic procedures controlling for somatic health status are scarce. AIMS To assess excess mortality associated with depressive, anxiety and alcohol use disorders and the principal causes of death. METHOD In a nationally representative sample of Finns aged 30-70 years, psychiatric disorders were diagnosed with the Composite International Diagnostic Interview. After an 8-year follow-up period, vital status and cause of death of each participant was obtained from national registers. RESULTS After adjusting for sociodemographic factors, health status and smoking, depressive (hazard ratio (HR) = 1.97) and alcohol use disorders (HR = 1.72) were statistically significantly associated with mortality. Risk of unnatural death was increased among individuals diagnosed with anxiety disorders or alcohol dependence. CONCLUSIONS Individuals with depressive and alcohol use disorders have an increased mortality risk comparable with many chronic somatic conditions, that is only partly attributable to differences in sociodemographic, somatic health status and hazardous health behaviour.

Prevalence and correlates of major depressive disorder and dysthymia in an eleven-year follow-up – Results from the Finnish Health 2011 Survey

BACKGROUND Up-to-date epidemiological data on depressive disorders is needed to understand changes in population health and health care utilization. This study aims to assess the prevalence of major depressive disorder (MDD) and dysthymia in the Finnish population and possible changes during the past 11 years. METHODS In a nationally representative sample of Finns aged 30 and above (BRIF8901), depressive disorders were diagnosed with the Composite International Diagnostic Interview (M-CIDI) in 2000 and 2011. To account for nonresponse, two methods were compared: multiple imputation (MI) utilizing data from the hospital discharge register and from the interview in 2000 and statistical weighting. RESULTS The MI-corrected 12-month prevalence of MDD was 7.4% (95% CI 5.7-9.0) and of dysthymia was 4.5% (95% CI 3.1-5.9), whereas the corresponding figures using weights were 5.4% (95% CI 4.7-6.1) for MDD and 2.0% (95% CI 1.6-2.4) for dysthymia. Women (OR 2.33, 95% CI 1.6-3.4) and unmarried people (OR 1.54, 95% CI 1.2-2.0) had a higher risk of depressive disorders. There was a significant increase in the prevalence of depressive disorders during the follow-up period from 7.3% in 2000 to 9.6% in 2011. Prevalences were two percentage points higher, on average, when using MI compared to weighting. Hospital treatments for depressive disorders and other mental disorders were strongly associated with nonparticipation. LIMITATIONS The CIDI response rate dropped from 75% in 2000 to 57% in 2011, but this was accounted for by MI and weighting. CONCLUSIONS Depressive disorders are a growing public health concern in Finland. Non-participation of persons with severe mental disorders may bias the prevalence estimates of mental disorders in population-based studies.

Socioeconomic inequalities in alcohol consumption in Chile and Finland

BACKGROUND Reasons for socioeconomic inequalities in alcohol harm are not sufficiently understood. One explanation relates to differential exposure to alcohol by socioeconomic status (SES). The present study investigated socioeconomic inequalities in alcohol use in two countries with high alcohol consumption and alcohol harm. METHODS Data from nationally representative surveys in 2009-2010 in Chile and in 2008-2011 in Finland were used. Surveys comprised 3477 participants in Chile and 9994 in Finland aged 30-64 years. Outcome measures included abstinence, weekly consumption of pure alcohol, heavy volume drinking and heavy episodic drinking (HED). We employed a novel method in alcohol research, the concentration index, to measure socioeconomic inequalities. RESULTS Alcohol abstinence showed a strong association with lower SES in Chile and Finland. These were largely driven by inequalities among women in Chile and older subgroups in Finland. In both countries, women aged 45-64 of higher SES showed higher weekly consumption of pure alcohol and heavy volume drinking. Heavy volume drinking among Chilean women aged 45-64 showed the highest inequality, favouring higher SES. HED was equally distributed among SES groups in Chile; in Finland HED disproportionally affected lower SES groups. CONCLUSIONS Lower SES was associated with higher abstinence rates in both countries and heavy episodic drinking in Finland. Heavy volume drinking was more prevalent in middle-aged women of high SES. The results identified groups for targeted interventions, including middle-aged higher SES women, who traditionally have not been specifically targeted. The concentration index could be a useful measure of inequalities in alcohol use.

Incidence and prevalence of mental disorders among immigrants and native Finns: a register-based study

PurposeMigrants appear to have a higher risk of mental disorders, but findings vary across country settings and migrant groups. We aimed to assess incidence and prevalence of mental disorders among immigrants and Finnish-born controls in a register-based cohort study.MethodsA register-based cohort study of 184.806 immigrants and 185.184 Finnish-born controls (1.412.117 person-years) was conducted. Information on mental disorders according to ICD-10 was retrieved from the Hospital Discharge Register, which covers all public health care use.ResultsThe incidence of any mental disorder was lower among male (adjusted HR 0.82, 95% CI 0.77–0.87) and female (aHR 0.76, 95% CI 0.72–0.81) immigrants, being lowest among Asian and highest among North African and Middle Eastern immigrants. The incidence of bipolar, depressive and alcohol use disorders was lower among immigrants. Incidence of psychotic disorders was lower among female and not higher among male immigrants, compared with native Finns. Incidence of PTSD was higher among male immigrants (aHR 4.88, 95% CI 3.38–7.05).ConclusionsThe risk of mental disorders varies significantly across migrant groups and disorders and is generally lower among immigrants than native Finns.

Mortality and causes of death among the migrant population of Finland in 2011–13

Background: Lower mortality among migrants than in the general population has been found in many, but not in all, previous studies. The mortality of migrants has not been studied in Finland, which has a relatively small and recent migrant population. Methods: People who were born abroad and whose mother tongue is not Finnish were identified from the Finnish Central Population Register (n = 185 605). A Finnish-born control matched by age, sex and place of residence was identified for each case (n = 185 605). Information about deaths was collected from the Finnish Causes of Death Register. Cox proportional hazards model was used for assessing the association between migrant status and death in 2011–13. Results: The mortality risk was found to be significantly lower for migrants than for Finnish controls (adjusted hazard ratio 0.77, 95% CI 0.72–0.84), both for migrant men (aHR 0.80, 95% CI 0.73–0.89) and women (aHR 0.78, 95% CI 0.70–0.88). The difference was statistically significant only among people who were not married and among people who were not in employment. There was variation by country of birth, but no migrant group had higher mortality than Finnish controls. No differences in mortality were found by duration of residence in Finland. The higher mortality of Finnish controls was largely explained by alcohol-related conditions and external causes of death. Conclusions: The mortality risk of migrants is lower than of people who were born in Finland. Possible explanations include selection and differences in substance use and other health behaviour.

Mortality in people with psychotic disorders in Finland: A population-based 13-year follow-up study

OBJECTIVES We conducted a population based study aiming at finding predictors of mortality in psychotic disorders and evaluating the extent to which sociodemographic, lifestyle and health-related factors explain the excess mortality. METHODS In a nationally representative sample of Finns aged 30-70years (n=5642), psychotic disorders were diagnosed using structured interviews and medical records in 2000-2001. Information on mortality and causes of death was obtained of those who died by the end of year 2013. Cox proportional hazards models were used to investigate the mortality risk. RESULTS No people with affective psychoses (n=36) died during the follow-up, thus the analysis was restricted to non-affective psychotic disorders (NAP) (n=106). Adjusting for age and sex, NAP was statistically significantly associated with all-cause mortality (hazard ratio (HR) 2.99, 95% CI 2.03-4.41) and natural-cause mortality (HR 2.81, 95% CI 1.85-4.28). After adjusting for sociodemographic factors, health status, inflammation and smoking, the HR dropped to 2.11 (95% CI 1.10-4.05) for all-cause and to 1.98 (95% CI 0.94-4.16) for natural-cause mortality. Within the NAP group, antipsychotic use at baseline was associated with reduced HR for natural-cause mortality (HR 0.25, 95% CI 0.07-0.96), and smoking with increased HR (HR 3.54, 95% CI 1.07-11.69). CONCLUSIONS The elevated mortality risk in people with NAP is only partly explained by socioeconomic factors, lifestyle, cardio-metabolic comorbidities and inflammation. Smoking cessation should be prioritized in treatment of psychotic disorders. More research is needed on the quality of treatment of somatic diseases in people with psychotic disorders.

Health inequality gap in inmigrant versus local children in Chile

Introduction: Children and young international migrants face different health challenges compared with the local population, particularly if they live in insecure environments or adverse social conditions. This study seeks to identify gaps in health outcomes of children between immigrant and local population in Chile. Methods: This study analyses data from three sources: (i) Born in Chile: Electronic records of antenatal visits from all municipal antenatal clinics of Recoleta in 2012; (ii) Growing up in Chile: Population survey “National Socioeconomic Characterization” (CASEN) from 2013 and (iii) Getting sick in Chile: Data of all hospital discharges in 2012, provided by the department of statistics and health information (DEIS) of the Ministry of Health. Results: (I) Born in Chile: Immigrants more frequently have psychosocial risk (62.3% vs 50.1% in Chileans) and enter later into the program (63.1% vs 33.4% enter later than 14 weeks of pregnancy). All birth outcomes were better among immigrants (e.g. caesarean sections rates: 24.2% immigrants vs % Chileans). (ii) Growing up in Chile: A higher proportion of migrant children is outside the school system and lives in multidimensional poverty (40% immigrants vs 23.2% Chileans). (iii) Getting sick in Chile: Injuries and other external causes were more frequent cause of hospitalisation among migrants (23.6%) than the local population (16.7%) aged between 7 and 14 years. Conclusions: Addressing the needs of the children in Chile, regardless of their immigration status, is an ethical, legal and moral imperative.

Determinants of access to health care for depression in 49 countries: A multilevel analysis

BACKGROUND The relative importance of individual and country-level factors influencing access to diagnosis and treatment for depression across the world is fairly unknown. METHODS We analysed cross-national data from the WHO World Health Surveys. Depression diagnosis and access to health care were ascertained using a structured interview. Logistic Bayesian Multilevel analyses were performed to establish individual and country level factors associated with: (1) receiving a diagnosis and (2) accessing treatment for depression if a diagnosis was ascertained. RESULTS The sample included 7870 individuals from 49 countries who met ICD-10 criteria for depressive episode in the past 12 months. A third (32%) of these individuals had ever been diagnosed with depression in their lifetime. Among those diagnosed with depression, 66% reported to have ever received treatment for depression. Although individual factors were more important determinants of access to treatment for depression, country-level factors explained 27.6% of the variance in access to diagnosis and 24.1% in access to treatment. Access to treatment for depression improved with increasing country income. Female gender, better education, the presence of physical co-morbidity, more material assets, and living in urban areas were individual level determinants of better access. LIMITATIONS Data on other contextual factors was not available. Unmet need was likely underestimated, since only lifetime treatment data was available. CONCLUSION This study highlights major inequalities in access to a diagnosis and treatment of depression. Unlike the prevalence of depression, where contextual factors have shown to have less importance, a significant proportion of the variance in access to depression care was explained by country-level income.

The Impact of Universal Health Care Programmes on Improving ‘Realized Access’ to Care for Depression in Chile

Universal health care programmes have the potential to reduce treatment gaps. We explored the potential impact of an equity-oriented universal health care programme on access to care for depression, hypertension and diabetes using data from two nationally representative health surveys in Chile. The likelihood a depressed individual had accessed health care appears to have increased significantly after the programme was introduced whereas those for hypertension and diabetes remained unchanged. Depressed women seem to have benefited mostly from the programme. Universal health care programmes for depression could substantially increase coverage and reduce inequities in access to health care in middle-income countries.

Implementing a Community Model of Mental Health Care in Chile: Impact on Psychiatric Emergency Visits

OBJECTIVE The community model of mental health care (CMMHC) is recommended as the best way to organize mental health care, but evidence of its successful implementation and effectiveness is scarce, particularly in resource-poor settings. This study aimed to evaluate the impact of CMMHC on the rate of psychiatric emergency visits in Santiago, Chile. METHODS The rate of psychiatric emergency visits from 2006 to 2011 was compared between two health care administrative districts: district 1 (D1), in which CMMHC was being systematically implemented, and D2, where CMMHC implementation was very limited and inconsistent. In addition, rates of psychiatric emergency visits in ten D1 municipalities were compared by the degree to which they had implemented CMMHC. RESULTS Compared with D2, D1 had higher rates of psychiatric emergency visits during the observation period. In D1, the rate of visits per 100,000 inhabitants declined from 541 in 2006 to 414 in 2011. In D2, the rate increased from 104 in 2006 to 130 in 2011. In D1 municipalities, the reduction in the rate of psychiatric emergency visits was greater in those with well-implemented CMMHC compared with those with partially implemented CMMHC. When distance to the emergency room was taken into account, the 2011 rate of emergency visits in the ten D1 municipalities was 21% (p<.01) lower in those with well-implemented CMMHC than in those with partially implemented CMMHC. CONCLUSIONS CMMHC implementation leads to reduction in psychiatric emergency visits, which are burdensome to both users and providers. Results support CMMHC implementation in resource-poor settings.