Childhood adversity and risk of later labor market marginalization in young employees in Sweden

Background

The present study examined the independent and combined effects of childhood adversity (CA) and occupational class on the risk of future labor market marginalization (LMM) in young employees in Sweden. Occupational class (non-manual/manual workers) was also explored as a potential mediator.

Methods

This population-based longitudinal cohort study included 556,793 employees, 19-29 years, residing in Sweden in 2009. CAs included parental death, parental mental and somatic disorders, parental separation, household public assistance, single-parent household and residential instability. Measures of LMM included long-term unemployment (LTU), long-term sickness absence (LTSA) and disability pension (DP). Estimates of risk of each LMM measure, between 2010 and 2016 were calculated as Hazard Ratios (HR) with 95% confidence intervals (CI), using a Cox regression analysis.

Results

Those exposed to CA had an elevated risk for all measures of LMM. Manual workers with a history of household public assistance had the highest risk estimates compared to non-manual workers with no CAs (adjusted HR spanning from 1.59 (LTSA) to 2.50 (LTU). Regardless of occupational class, the risk of LMM grew higher with increasing number of CAs (e.g. adjusted HR of LMM in manual workers with 3+ CAs: 1.87, 95% CI: 1.81-1.94). These patterns persisted after adjustments for a range of confounders, including psychiatric and somatic morbidity. Last, we found a small but significant mediating effect of occupational class in the association between CA and LMM.

Conclusions

Information on CAs are important determinants of LMM in young adults, and especially in manual workers.

Key messages

• Those exposed to childhood adversity had an elevated risk of labor market marginalization, in terms of long-term unemployment, long-term sickness absence and disability pension.

• Information on childhood adversity is an important determinant of labor market marginalization in young adults, and especially in manual workers.

Time period effects in work disability due to common mental disorders among young employees

Background

Previous research on period effects in risk for work disability due to common mental disorders across employment sectors and occupational classes in young employees is lacking. Temporal changes in the healthcare system or social insurance policies or other structural/organisational changes could contribute to such time period effects. We aimed to investigate time period effects in the risk of work disability, defined as long-term sickness absence (LTSA) and disability pension (DP) due to common mental disorders (CMDs), among young employees according to their employment sector (private/public) and occupational class (non-manual/manual).

Methods

Three cohorts, including all employed individuals with complete information on employment sector and occupational class, aged 19-29 years and resident in Sweden on the 31-Dec-2004, 2009 and 2014 (n = 573,516, 665,138 and 600,889 individuals in cohort 2004, 2009 and 2014, respectively) were followed for four years. Crude and multivariate-adjusted hazard ratios (HRs and aHRs, respectively) with 95% confidence intervals (CIs) were estimated regarding the risk of LTSA and DP due to CMDs using Cox regression analyses.

Results

In cohort 2004, public sector employees had a higher relative risk for LTSA due to CMDs than private sector employees (aHR, (95%CI): 1.24, 1.16-1.34 and 1.18, 1.11-1.26 among non-manual and manual workers). These associations were similar in the later cohorts. Compared to cohort 2004, the rate of DP due to CMDs was considerably lower in the later cohorts leading to uncertainties in the risk estimates limiting the comparability for time period effects regarding the risk of DP due to CMDs across employment sectors and occupational classes.

Conclusions

Stricter regulation changes regarding the receipt of DP in Sweden, rather than other time period events, may have differentially affected the risk of work disability among young non-manual and manual employees working in the private and public sectors.

Key messages

Does country of resettlement influence the risk of suicide in refugees? A case-control study in Sweden and Norway

Introduction

Little is known regarding how the risk of suicide in refugees relates to their host country. Specifically, to what extent, inter-country differences in structural factors between the host countries may explain the association between refugee status and subsequent suicide is lacking in previous literature.

Objectives

We aimed to investigate the risk of suicide among refugees in Sweden and Norway according to their sex, age, region/country of birth and duration of residence.

Methods

Each suicide case between the age of 18-64 years during 1998 and 2018 (17,572 and 9,443 cases in Sweden and Norway, respectively) was matched with up to 20 population-based controls, by sex and age. Multivariate-adjusted conditional logistic regression models yielding adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) were used to test the association between refugee status and suicide.

Results

The aORs for suicide in refugees in Sweden and Norway were 0.5 (95% CI: 0.5-0.6) and 0.3 (95% CI: 0.3-0.4), compared with the Swedish-born and Norwegian-born individuals, respectively. Stratification by region/country of birth showed similar statistically significant lower odds for most refugee groups in both host countries except for refugees from Eritrea (aOR 1.0, 95% CI: 0.7-1.6) in Sweden. The risk of suicide did not vary much across refugee groups by their duration of residence, sex and age.

Conclusions

The findings of almost similar suicide mortality advantages among refugees in two host countries may suggest that resiliency and culture/religion-bound attitudes could be more influential for suicide risk among refugees than other post-migration environmental and structural factors in the host country.

Disclosure

No significant relationships.

Trajectories of labour market marginalisation among young adults with newly diagnosed attention-deficit/hyperactivity disorder (ADHD)

AIMS

Labour market marginalisation (LMM), i.e. severe problems in finding and keeping a job, is common among young adults with attention-deficit/hyperactivity disorder (ADHD). This study aimed to disentangle the extent of LMM as well as the heterogeneity in patterns of LMM among young adults with ADHD and what characterises those belonging to these distinct trajectories of LMM.

METHODS

This population-based register study investigated all 6287 young adults, aged 22-29 years, who had their first primary or secondary diagnosis of ADHD in Sweden between 2006 and 2011. Group-based trajectory (GBT) models were used to estimate trajectories of LMM, conceptualised as both unemployment and work disability, 3 years before and 5 years after the year of an incident diagnosis of ADHD. Odds ratios (ORs) with 95% confidence intervals (CIs) for the association between individual characteristics and the trajectory groups of LMM were estimated by multinomial logistic regression.

RESULTS

Six distinct trajectories of LMM were found: 'increasing high' (21% belonged to this trajectory group) with high levels of LMM throughout the study period, 'rapidly increasing' (19%), 'moderately increasing' (21%), 'constant low' (12%) with low levels of LMM throughout the study period, 'moderately decreasing' (14%) and finally 'fluctuating' (13%), following a reversed u-shaped curve. Individuals with the following characteristics had an increased probability of belonging to trajectory groups of increasing LMM: low educational level (moderately increasing: OR: 1.4; CI: 1.2-1.8, rapidly increasing: OR: 1.7; CI: 1.3-2.1, increasing high: OR: 2.9; CI: 2.3-3.6), single parents (moderately increasing: OR: 1.6; CI: 1.1-2.4, rapidly increasing: OR: 2.0; CI: 1.3-3.0), those born outside the European Union/the Nordic countries (rapidly increasing: OR: 1.7; CI: 1.1-2.5, increasing high: OR: 2.1; CI: 1.4-3.1), persons living in small cities/villages (moderately increasing: OR: 2.4; CI: 1.9-3.0, rapidly increasing: OR: 2.1; CI: 1.6-2.7, increasing high: OR: 2.6; CI: 2.0-3.3) and those with comorbid mental disorders, most pronounced regarding schizophrenia/psychoses (rapidly increasing: OR: 6.7; CI: 2.9-19.5, increasing high: OR: 12.8; CI: 5.5-37.0), autism spectrum disorders (rapidly increasing: OR: 4.6; CI: 3.1-7.1, increasing high: OR: 9.6; CI: 6.5-14.6), anxiety/stress-related disorders (moderately increasing: OR: 1.3; CI: 1.1-1.7, rapidly increasing: OR: 2.0; CI: 1.6-2.5, increasing high: OR: 1.8; CI: 1.5-2.3) and depression/bipolar disorder (moderately increasing: OR: 1.3; CI: 1.0-1.6, rapidly increasing: OR: 1.7; CI: 1.4-2.2, increasing high: OR: 1.5; CI: 1.2-1.9).

CONCLUSIONS

About 61% of young adults were characterised by increasing LMM after a diagnosis of ADHD. To avoid marginalisation, attention should especially be given to young adults diagnosed with ADHD with a low educational level, that are single parents and who are living outside big cities. Also, young adults with comorbid mental disorders should be monitored for LMM early in working life.

Trajectories of sickness absence, disability pension and unemployment in young immigrants with common mental disorders

BACKGROUND

The aims were to elucidate if trajectories of labour market marginalization (LMM), measured as sickness absence (SA)/disability pension (DP) or unemployment, differed between young immigrants and natives before and after an incident diagnosis of a common mental disorder (CMD), and to investigate if educational level, psychiatric comorbidity and duration of residence in Sweden (in immigrants) had different associations with subsequent LMM in natives compared with immigrants.

METHODS

A total of 28 971 young adults (19-30 years), with an incident CMD (inpatient or specialized outpatient healthcare due to CMDs or dispensed prescribed antidepressants during 2007) were included. Group-based trajectory models were utilized to identify trajectories of annual months of LMM 3 years before and 6 years after the diagnosis. The associations of risk factors with different trajectories were investigated by multinomial logistic regression, χ2-test and Nagelkerke R2 to measure the associations' strength. Immigrants were categorized into Western and non-Western immigrants.

RESULTS

Young natives and immigrants showed similar trajectories of SA/DP. A higher proportion of non-Western immigrants (20.5%) followed trajectories of high levels of unemployment (>2 annual months) compared with Western immigrants (15%) and natives (16.5%). Educational level and duration of residence in Sweden (in immigrants) discriminated trajectories of both SA/DP and unemployment, whereas psychiatric comorbidity only discriminated trajectories of SA/DP.

CONCLUSIONS

Differences in trajectories of unemployment between young natives and immigrants with an incident CMD were found. Educational level and psychiatric comorbidity provided information on differences between natives and immigrants and duration of residence gave information for subgroups of immigrants.

Common mental disorders in young refugees in Sweden: the role of education and duration of residency

Background

Studies investigating risks of common mental disorders (CMDs) in refugee youth are sparse. The current study examined health care use due to CMDs in unaccompanied and accompanied refugee youth and Swedish-born, and the role of education and residency duration.

Methods

This register-based, longitudinal cohort study included 743,671 individuals (whereof 33,501 refugees) between 19-25 years, residing in Sweden in 2009. Refugees were classified as unaccompanied/accompanied. Risk estimates of CMDs, measured as health care and antidepressant treatment, between 2010-2016 were calculated as adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Highest attained education in 2009, and residency duration were examined as potential modifiers.

Results

Compared to Swedish-born youth, refugees had a lower risk of treated major depressive and anxiety disorders (aHR): 0.73 (95% CI 0.68-0.78) and 0.74 (95% CI 0.70-0.79) respectively), but a higher risk for posttraumatic stress disorders (PTSD). Compared to Swedish-born, unaccompanied had an 8-fold elevated risk for PTSD (aHR: 8.40, 95% CI 6.16-11.47) and accompanied refugees had a nearly 3-fold risk of PTSD (aHR: 2.78, 95% CI 2.29-3.37). Rates of PTSD decreased with years spent in Sweden. The risk of CMDs decreased with increasing education.

Conclusions

Young refugees had a lower risk of treated depressive and anxiety disorders, but a higher risk for PTSD. In refugees, the rates of anxiety disorders increased slightly over time, whereas the rates of PTSD decreased. Last, low education was an important predictor for CMDs.

Key messages

Our study highlights the need to specifically focus on stress-related mental disorders in studies on refugees as risk estimates might differ. Moreover, providing scalable low-intensity interventions to address CMDs including posttraumatic stress are an important first step in order to prevent prolonged suffering and persistence of PTSD in refugee youth.

Prevalence and predictors of low future expectations among Syrian refugees resettled in Sweden

Background

Future Expectation is important for motivation and wellbeing, however drastic life events such as in refugee situations may result in low expectations. This study aims to investigate the prevalence and determinants of low future expectations among Syrian refugees resettled in Sweden.

Methods

A random sample of 1215 Syrian refugees resettled in Sweden responded to questionnaire. Weighted analyses and adjusted relative risks were conducted to determine the prevalences and predictors of low future expectations. Synergy index was calculated for low social support and depression in relation to low expectations.

Results

The prevalences of low future expectations for labour market, social and economic intergration were 10.9%, 13.4% and 14.1% respectively. Longer stay in Sweden, being older, low social support and depression were associated with low future expectations. The simultaneous presence of depression and low social support had a synergistic effect on low social expectation.

Discussions

Understanding and addressing factors related to low future expectations among refugees may be useful for facilitating their labour market, social and economic integration.

Work disability patterns before and after incident acute myocardial infarction and subsequent risk of common mental disorders: A Swedish cohort study

This study investigated the extent to which work disability patterns including sickness absence and disability pension (SA/DP) before and after acute myocardial infarction (AMI) were associated with subsequent common mental disorders (CMDs) such as depression and anxiety in AMI patients without previous CMD. Total 11,493 patients 26–64 years with incident AMI during 2008–10 were followed up for CMD (measured as antidepressant prescription) through 2013. Four SA/DP trajectory groups during the 3-years pre-AMI and 1-year post-AMI were identified. Hazard ratios (HRs) with 95% confidence intervals for subsequent CMD were estimated in Cox models. Higher pre-AMI SA/DP annual levels (>1–12 months/year) were associated with 40–60% increased CMD rate than the majority (78%) with low increasing levels (increasing up to 1 month/year). Regarding post-AMI findings, constant high (~25–30 days/month) SA/DP levels within the first 3 months was associated with a 76% higher CMD rate, compared to constant low (0 days/month). A gradually decreasing post-AMI SA/DP pattern over a 12-month period suggested protective influences for CMD (HR = 0.80). This is the first study to demonstrate that pre- and post-AMI work disability patterns are associated with subsequent CMD risk in AMI patients. Work disability patterns should be considered as an indicator of AMI prognosis in terms of CMD risk.

Work disability before and after incident myocardial infarction and subsequent common mental disorder

Background

This study investigated the extent to which work-disability patterns including sickness absence and disability pension (SA/DP) before and after acute myocardial infarction (AMI) were associated with subsequent common mental disorders (CMDs) such as depression and anxiety in AMI patients without previous CMD.

Methods

A cohort of 11,493 patients aged 26-64 years without previous CMD with incident AMI during 2008-2010 were followed up for CMD measured as antidepressant prescription through 2013. Four SA/DP trajectory groups during the 3 years pre-AMI and 1 year post-AMI were identified. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated in Cox models.

Results

Higher pre-AMI SA/DP levels (>1-12 months/year), compared to the majority of patients (78%) following low increasing annual levels (increasing up to 1 month/year) of pre-AMI SA/DP, were associated with a 40-60% increased CMD rate. Regarding post-AMI findings, constant high (∼25-30 days/month) and steeply decreasing SA/DP levels within the first 3 months were associated with a 76% and 35% higher CMD rate, respectively, compared to constant low (<1 days/month) levels. Conversely, a gradually decreasing pattern of post-AMI SA/DP over a 12-month period suggested protective influences for CMD (HR = 0.80), even after adjusting for sociodemographic and medical factors.

Conclusions

This is the first study to demonstrate that pre- and post-AMI work disability patterns are associated with subsequent CMD risk in AMI patients. Work disability patterns should be considered in clinical practice as an indicator of AMI prognosis in terms of CMD risk.

Key messages

Increasing and high persistent levels of pre-AMI work disability are associated with higher risk of subsequent CMD, while gradually decreasing post-AMI work disability has a favourable CMD prognosis. Pre- and post-AMI patterns of work disability (sickness absence and disability pension) can be a useful marker in terms of CMD prognosis.

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.

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

PURPOSE

This 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.

METHODS

Prospective 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.

RESULTS

Compared 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.

CONCLUSIONS

Migrant 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.