Five-year follow-up study of disability pension rates in first-onset schizophrenia with special focus on regional differences and mortality

Regional differences in annual prevalence of sustainable working life in Swedish twin cohort

The global rise in life expectancy transforms age structure consequently having impact to the sustainability of social protection systems and working life. This descriptive study aimed to illustrate the annual prevalence of sustainable working life across Swedish residential regions, and investigate differences between age groups, sex, or being identical or fraternal twin. The study sample included 81,231 twins with linkage to national register data on sickness absence, disability pension, unemployment, and residential regions. Regions were classified by Swedish municipalities into nine groups. Sustainable working life were then followed in 1998, 2003, 2008, and 2013. Annual prevalence and Generalized Estimating Equation (GEE) with log linear models for interaction test were used. Medium to large size municipalities (15-24%) had higher annual prevalence of sustainable working life than smaller municipalities (1-7%). Young adults in medium to large size municipalities had high annual prevalence of sustainable working life. We found no differences for sexes or being identical or fraternal twin. To conclude, annual prevalence of sustainable working life in 1998, 2003, 2008 and 2013 differed by region being highest in medium to large size municipalities which may have importance for targeting policies, regulations, and practices in a region-specific way. Further studies on residential regions and sustainable working life would be merited to confirm associations and other influential factors.

Polygenic liabilities underlying job stress and exhaustion over a 10-year follow-up: A general population study

We investigated whether individuals, who have a high polygenic loading for schizophrenia and major depression (PGL) but have not developed the respective disorders, are still susceptible to experience milder forms of ill-being in terms of job strain or exhaustion. We used the population-based Young Finns Study data (n = 928). PGL was assessed with a cumulative score of the polygenic risk scores for schizophrenia and depression. Participants (24-49-year-olds) evaluated their exhaustion levels and perceived job characteristics over a 10-year follow-up (2001, 2007, 2011). Participants with diagnosed psychotic or affective disorders were excluded. We found that high PGL did not predict less favorable perceptions of job environment (job strain, demands, control, satisfaction, social support at work) but high PGL predicted a higher trajectory of exhaustion in early adulthood and middle age. Additionally, high (vs. low) PGL predicted a stronger increase in exhaustion at increased levels of job strain. These findings remained after controlling for sex, socioeconomic factors, health behaviors, and cognitive performance. In conclusion, individuals with high PGL may have an elevated liability to experience exhaustion especially in early adulthood and middle age (despite they perceive their job environment similarly than others), and especially and at high levels of job strain.

Employment trajectories until midlife in schizophrenia and other psychoses: the Northern Finland Birth Cohort 1966

PURPOSE

Psychoses are associated with poor labour market attachment, but few studies have compared schizophrenia (SZ) and other psychoses (OP). Moreover, studies on long-term employment trajectories over individuals' working life courses are lacking. We compared 30 year employment trajectory patterns in a general population sample among individuals with SZ, OP, and those with no psychosis (NP).

METHODS

Utilising the Northern Finland Birth Cohort 1966, we collected survey data on employment from ages 16 to 45 and detected individuals with register-based history of SZ (n = 62), OP (n = 87), or NP (n = 6464) until age 46. Through gender-specific latent class analyses on annual employment roles, we identified traditional, highly educated, self-employed, delayed and floundering employment trajectories with distinct socioeconomic characteristics. We addressed attrition by conducting weighted analyses.

RESULTS

Floundering trajectories were common among individuals with SZ (79% of men, 73% of women) and OP (52% of men, 51% of women). In NP, a traditional employee trajectory was most common in men (31%), and a highly educated trajectory in women (28%). A history of psychosis was associated with heightened odds ratios (ORs; 95% confidence intervals (CIs)) for floundering trajectories in both men (SZ: 32.9 (13.3-81.4); OP: 7.4 (4.0-13.9)) and women (SZ: 9.9 (4.6-21.5); OP: 3.9 (2.1-7.1)) compared to NP. Weighted analyses produced similar results.

CONCLUSION

Most individuals with SZ or OP have floundering employee trajectories reflecting an elevated risk of unemployment and part-time work until midlife. These results indicate the importance of improving labour market attachment during the early phases of psychoses.

The relationship between work disability and subsequent suicide or self-harm: A scoping review

Work disability occurs when an injury or illness limits the ability of a worker to participate in employment. While evidence suggests that people with work disability are at increased risk of suicide and intentional self-harm, this relationship has not been the subject of systematic review. This scoping review aims to assess and summarise the research literature regarding the relationship between work disability and subsequent suicide or intentional self-harm. Review protocol was published on the Open Science Foundation and is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Peer-reviewed studies published in English from 1st January 2000 were included if they reported suicide or self-harm outcomes in people aged 15 years or older with work disability. Studies were identified via systematic search of Medline, Scopus and Pubmed databases, via recommendation from topic experts, and citation searching of included articles. A narrative synthesis was undertaken. Literature search yielded 859 records of which 47 eligible studies were included, nine set in workers' compensation, 20 in sickness absence, 13 in disability pension systems, and five from mixed cohorts. Of 44 quantitative studies, 41 reported a positive relationship between work disability and suicidal behaviour. The relationship is observed consistently across nations, work disability income support systems and health conditions. Several factors elevate risk of suicidal behaviour, including presence of mental health conditions and longer work disability duration. There were few studies in some nations and no suicide prevention interventions. The risk of suicide and self-harm is elevated in people experiencing work disability. Further observational research is required to fill evidence gaps. This review suggests the need for governments, employers and those involved in the care of people with work disability to focus on identification and monitoring of those at greatest risk of suicidal behaviour, and suicide prevention.

Impact of jet pulverization and wet milling techniques on properties of aripiprazole long-acting injection and absorption mechanism research in vivo

This study aims to explore the influence of wet milling and jet pulverization on the aripiprazole microcrystalline long-acting injection. Crystal form and particle size distribution were taken as inspection indicators in vitro, and process parameters were optimized. The formulation prepared by wet milling (AMLAI-WM) was shown to undergo a slight conversion of crystal form by DSC, PXRD, TG, FT-IR and have a wider particle size distribution with D50 and Span values of 2.967 μm and 3.457 compared to the formulation fabricated by jet pulverization (AMLAI-JP) with 2.887 μm and 2.258 respectively. In addition, the in vitro release of AMLAI-WM was faster, whereby the pharmacokinetic data indicated that AMLAI-WM was absorbed more quickly within five days with AUC_0-5d of 5243.7 μg·L^-1·h and 4818.28 μg·L^-1·h, respectively. Furthermore, no statistically significant differences in C_max, t_max and AUC between AMLAI-JP and the commercial formulation (Abilify Maintena™) were found. The absorption mechanism was studied and showed a 1.4-fold later T_max after depletion of macrophages and significantly lower C_max and AUC after inhibiting angiogenesis, indicating inflammatory granuloma could facilitate drug plasma exposure. Overall, we demonstrated that jet pulverization was a good strategy for long-acting microcrystalline injection, and that the absorption behavior was affected by both particle size distribution and inflammatory granuloma.

Contextual and mental health service factors in mental disorder-based disability pensioning in Finland - a regional comparison

Background

We investigated the regional differences in all mental disorder disability pensions (DP) between 2010 and 2015 in Finland, and separately in mood disorders and non-affective psychotic disorder DP. We also studied the contribution of several district-level contextual and mental health service factors to mental disorder DP.

Methods

Subjects were all those granted mental disorder DP for the first time between 2010 and 2015 in Finland (N = 36,879). Associations between the district-level contextual and mental health service factors and regional DP risks collected from the year 2015 were studied with negative binomial regression analysis in the Finnish hospital districts. The population number on the age (18 to 65 years), gender, occupational status and residential hospital district of the Finnish population from 2015 was used as exposure in the model.

Results

Significant differences in the regional mental disorder DP risks between and within hospital districts did not appear to follow the traditional Finnish health differences. A lower risk of DP was associated with contextual indicators of higher regional socioeconomic level. Furthermore, population density as a proxy for access to mental health services indicated a higher regional DP risk for lower density in all mental (IRR 1.10; 95% CI 1.06–1.14) and mood disorder (IRR 1.12; 95% CI 1.08–1.16) DP. Both the highest and the lowest regional numbers of all mental health outpatient visits were associated with a higher DP risk in all mental and mood disorder DP, whereas particularly low regional numbers of inpatient treatment periods and of patients were associated with a lower risk of DP.

Conclusions

In this comprehensive population-level study, we found evidence of significant regional variation in mental disorder DP and related district-level factors. This variation may at least partly relate to differences in regional mental health service systems and treatment practices. Adapting to the needs of the local population appears to be indicated for both regional mental health service systems and treatment practices to achieve optimal performance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07099-4.

A short survival time after last psychiatric hospitalization in drivers with psychotic disorder killed in fatal motor vehicle accidents

BACKGROUND

Research-based evidence on patients with psychotic disorders involved in fatal motor vehicle accidents (FMVA) remains limited. The current study analyzes the characteristics of FMVA drivers, who had been hospitalized due to psychotic disorders within a five-year-time-period prior to their death in traffic accidents.

MATERIAL AND METHODS

Data sources included three national registers: The Finnish Database of Road and Cross-Country Accidents, the Care Register for Health Care and the National Cause of Death Register. The register-linkage was made using personal identity codes, unique for each Finnish citizen. The initial study population consisted of 4930 drivers killed in FMVA in Finland between the years 1990-2011. A total of 94 (1.9%) Finnish drivers had a hospital-diagnosed psychotic disorder made during the five years preceding their FMVA. The psychotic disorders of the study subjects were categorized into: schizophrenia (n = 27, 28.7%), other specified psychoses (n = 39, 41.5%) and unspecified psychoses (n = 28, 29.8%).

RESULTS

About one half of the FMVA drivers with schizophrenia or unspecified psychoses and 41% of those with other specified psychoses had been discharged from psychiatric care within three months prior to their death in traffic accidents.

CONCLUSIONS

Based on our study findings and the lack of concise guidelines for assessing psychotic patients' fitness-to-drive, we recommend a minimum temporary driving restriction of three months for all patients after hospitalization for psychosis.

Involuntary hospitalization among young people with early psychosis: A population-based study using health administrative data

OBJECTIVE

Early psychosis is an important window for establishing long-term trajectories. Involuntary hospitalization during this period may impact subsequent service engagement in people with newly diagnosed psychotic disorder. However, population-based studies of involuntary hospitalization in early psychosis are lacking. We sought to estimate the proportion of people aged 16 to 35 years with early psychosis in Ontario who are hospitalized involuntarily at first admission, and to identify the associated risk factors and outcomes.

METHODS

Using linked population-based health administrative data, we identified incident cases of non-affective psychosis over a five-year period (2009-2013) and followed cases for two years to ascertain the first psychiatric hospitalization. We used modified Poisson regression to model sociodemographic, clinical, and service-related risk factors, and compared service-related outcomes for cases admitted on an involuntary versus voluntary basis.

RESULTS

Among 17,725 incident cases of non-affective psychosis, 38% were hospitalized within two years, and 81% of these admissions occurred on an involuntary basis (26% of cohort). Sociodemographic factors associated with an increased risk of involuntary admission included younger age (16-20), and first-generation migrant status. The strongest risk factors were poor illness insight, recent police involvement, and admission to a general (versus psychiatric) hospital. Outcomes associated with involuntary admission included increased likelihood of control intervention use and a shorter length of stay.

CONCLUSIONS

One in four young people with first-episode psychosis will have an involuntary admission early in the course of their illness. Our findings highlight areas for intervention to improve pathways to care for people with psychotic disorder.

Contribution of rare and common variants to intellectual disability in a sub-isolate of Northern Finland

The contribution of de novo variants in severe intellectual disability (ID) has been extensively studied whereas the genetics of mild ID has been less characterized. To elucidate the genetics of milder ID we studied 442 ID patients enriched for mild ID (>50%) from a population isolate of Finland. Using exome sequencing, we show that rare damaging variants in known ID genes are observed significantly more often in severe (27%) than in mild ID (13%) patients. We further observe a significant enrichment of functional variants in genes not yet associated with ID (OR: 2.1). We show that a common variant polygenic risk significantly contributes to ID. The heritability explained by polygenic risk score is the highest for educational attainment (EDU) in mild ID (2.2%) but lower for more severe ID (0.6%). Finally, we identify a Finland enriched homozygote variant in the CRADD ID associated gene.

Suicidality, self-stigma, social anxiety and personality traits in stabilized schizophrenia patients - a cross-sectional study

BACKGROUND AND AIM

Patients who have schizophrenia are more prone to suicidal behavior than the general population. This study aimed to find connections between suicidality and self-stigma, hope, and personality traits in patients with schizophrenia.

METHODS

Forty-eight stabilized outpatients with schizophrenia attended this cross-sectional study. Patients were diagnosed by the Mini International Neuropsychiatric Interview (MINI) using the ICD-10 research diagnostic criteria. The assessments included Positive and Negative Syndrome Scale, objective and subjective Clinical Global Impression, Liebowitz Social Anxiety Scale, Beck Depression Inventory-second edition, Internalized Stigma of Mental Illness, the Temperament and Character Inventory, and Adult Dispositional Hope Scale.

RESULTS

The individual rate of suicidality (suicidal index from MINI) strongly positively correlated with self-stigma, level of depression, social anxiety, and harm-avoidance, and negatively correlated with hope, self-directedness, and stigma resistance.

CONCLUSION

Individuals with additional symptoms of depression, social anxiety, trait-like anxiety, and self-stigma should be carefully monitored for suicidal ideation. On the opposite side, patients with sufficient hope, self-esteem, and goal-directed attitudes are less likely to have suicidal thoughts and may potentially be role models in group rehabilitation programs, motivating more distressed colleagues and showing them ways to cope.

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio-environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual-focused, health system-focused, and community level and policy-focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.

The effect of municipality characteristics on disability retirement

OBJECTIVES

In addition to individual-level characteristics also contextual factors may contribute to the large regional variation seen in disability retirement. We examined the associations of municipality-level characteristics and disability retirement due to all causes, musculoskeletal diseases, mental disorders and other diseases.

METHODS

A register-based study was conducted with a 20% random sample of the Finnish population aged 25-62 years. Municipalities were separately divided into quintiles by their proportion of manual workers, unemployed and industrial employees. Multilevel Poisson regression analysis was applied to examine associations between the three municipality characteristics and disability retirement during a 5-year follow-up.

RESULTS

All three municipality-level indicators were associated with disability retirement, but the association between the proportion of industrial workers and disability retirement disappeared after adjustment for age, gender, marital status, socioeconomic position, unemployment and industrial employee status at the individual level. The associations were particularly strong for disability retirement due to musculoskeletal diseases: in the municipalities with the highest proportion of manual workers, the risk for disability retirement due to musculoskeletal diseases was 2.5 times higher than in the municipalities with least manual workers. After adjustment for the individual-level factors, the risk was 1.5 times higher. Cross-level interactions showed that the risk of disability retirement increased with the increasing proportion of unemployment in the municipality only among those who had not experienced unemployment themselves.

CONCLUSIONS

Municipality-level characteristics made an independent contribution to the probability of disability retirement in particular due to musculoskeletal diseases. Also, area-level characteristics should be considered when targeting disability retirement.

Occupational functioning, symptoms and neurocognition in patients with psychotic disorders: investigating subgroups based on social security status

PURPOSE

Reported employment rates for patients with psychosis are low, but vary partly depending on illness phase. Illness-related factors such as neurocognition and negative symptoms are associated with occupational functioning, while external factors may also act as barriers for employment. The current study investigated the relationship between neurocognition, symptoms and employment using a threefold division of employment status: employed, receiving temporary benefits and receiving disability benefits. The latter group was divided into two based on level of social functioning.

METHODS

A total of 155 patients with broad DSM-IV schizophrenia spectrum disorder were assessed with clinical, neurocognitive and social and occupational functioning measures. Group differences were analyzed with ANOVAs and hierarchical regression analysis.

RESULTS

Thirteen percent were employed, 52 % received temporary benefits and 35 % received disability benefits. There were no differences in symptom level and neurocognitive functioning between groups. Among patients on disability benefits, the subgroup with higher social functioning had fewer negative and general symptoms and a trend for better neurocognition compared with those with lower social functioning, thus being more similar to employed patients. Negative symptoms and executive functioning explained 26 % of the variance in social functioning for patients receiving disability benefits.

CONCLUSIONS

The association between neurocognition and employment may not be as strong as previously assumed, due to external factors that may influence this relationship. Patients on disability benefits rated high on social functioning showed similarities with employed patients. This could imply that these patients have some work capacity. This issue needs further investigation.

Association between the duration of untreated psychosis and short- and long-term outcome in schizophrenia within the Northern Finland 1966 Birth Cohort

BACKGROUND

Long duration of untreated psychosis (DUP) may relate to poor outcome in schizophrenia. However, the associations between DUP and outcomes, particularly in later course of illness, remain unclear. Our aim was to explore the associations between DUP and short- and long-term outcomes in schizophrenia.

METHODS

Data was collected for subjects with schizophrenia (n=89) in the population-based Northern Finland 1966 Birth Cohort. DUP was obtained from medical records, and its associations with short- (under 2years) and long-term clinical and social outcomes were assessed extending to 20years after the onset of the illness.

RESULTS

Longer DUP predicted longer length of first hospitalisation and increased the risk of rehospitalisation during the first two years. Longer DUP associated with decreased probability of disability pension, smaller amount of time spent in hospital, and higher proportion of time at work during the first 10years of the follow-up.

CONCLUSIONS

Regarding early outcome, long DUP may be a modest marker and proxy measure of a more severe clinical phenotype. The divergent results of earlier studies and the association between long DUP and better long-term outcome in our study, indicate that the length of DUP does not necessarily predict poor outcome in long-term follow-up. This may also be due to methodical difficulties, e.g. insufficient power and residual confounding linked to long follow-up studies.