The importance of clinical and labour market histories in psychiatric disability retirement: analysis of the comprehensive Finnish national-level RETIRE data.

OBJECTIVES: Despite the stable incidence of mental disorders in Finland and Europe, mental health-related occupational disability has been increasing. We unveiled the paths to permanent psychiatric disability, recovery, or death, by analysing sequences of labour market participation. METHODS: The RETIRE register database includes information regarding all persons (n = 42,170) awarded an ICD-10 psychiatric disability pension between 2010 and 2015 in Finland. We identified clusters of typical paths of pre-retirement labour market history. Controlling for major mental disorders, age, and sex, we evaluated factors associated with returning to work (RTW), or death, over a 5-year follow-up period. RESULTS: Only 10.5% of the disabled subjects returned to work within the follow-up. Half of them ended up with a permanent disability pension. Seven distinguishable paths to disability were identified. Subjects in the cluster characterized by steady employment were relatively often females, lost their work ability due to affective disorders, and had the highest rate of returning to work (16.3%). Mortality was highest (9%) among the cluster characterized by long-term unemployment. Distributions of major diagnostic groups, as well as age and sex, differed between clusters. After their adjustment in the analysis of RTW or death, the identified labour market history paths prior to losing work ability remained as important independent prognostic factors for both outcomes. CONCLUSIONS: The complex retirement process involves identifiable clinical and contextual associating factors. Labour market history patterns associate with varying prognoses after psychiatric retirement. Prolonged unemployment appears as a predictor of relatively poor prognoses, whereas employment indicates the opposite.

Mental disorders and long-term labour market outcomes: nationwide cohort study of 2 055 720 individuals.

OBJECTIVE: To examine the associations between an onset of serious mental disorders before the age of 25 with subsequent employment, income and education outcomes. METHODS: Nationwide cohort study including individuals (n = 2 055 720) living in Finland between 1988-2015, who were alive at the end of the year they turned 25. Mental disorder diagnosis between ages 15 and 25 was used as the exposure. The level of education, employment status, annual wage or self-employment earnings, and annual total income between ages 25 and 52 (measurement years 1988-2015) were used as the outcomes. RESULTS: All serious mental disorders were associated with increased risk of not being employed and not having any secondary or higher education between ages 25 and 52. The earnings for individuals with serious mental disorders were considerably low, and the annual median total income remained rather stable between ages 25 and 52 for most of the mental disorder groups. CONCLUSIONS: Serious mental disorders are associated with low employment rates and poor educational outcomes, leading to a substantial loss of total earnings over the life course.

Risk factors for suicide in depression in Finland: first-hospitalized patients followed up to 24 years.

OBJECTIVE: To examine longitudinally risk factors for suicide in depression, and gender differences in risk factors and suicide methods. METHOD: We linked data from (i) The Finnish Hospital Discharge Register, (ii) the Census Register of Statistics Finland, and (iii) Statistics Finland's register on causes of deaths. All 56 826 first-hospitalized patients (25 188 men, 31 638 women) in Finland in 1991-2011 with a principal diagnosis of depressive disorder were followed up until death (2587 suicides) or end of the year 2014 (maximum 24 years). RESULTS: Clinical characteristics (severe depression adjusted hazard ratio [AHR] 1.19 [95% CI 1.08-1.30]; psychotic depression AHR 1.45 [1.30-1.62]; and comorbid alcohol dependence AHR 1.26 [1.13-1.41]), male gender (AHR 2.07 [1.91-2.24]), higher socioeconomic status and living alone at first hospitalization were long-term predictors of suicide deaths. Highest risk was associated with previous suicide attempts (cumulative probability 15.4% [13.7-17.3%] in men, 8.5% [7.3-9.7%] in women). Gender differences in risk factors were modest, but in lethal methods prominent. CONCLUSION: Sociodemographic and clinical characteristics at first hospitalization predict suicide in the long term. Inpatients with previous suicide attempts constitute a high-risk group. Despite some gender differences in risk factors, those in lethal methods may better explain gender disparity in risk.

An evaluation of the absolute and relative stability of alexithymia over 11years in a Finnish general population.

OBJECTIVE: We investigated if alexithymia, a personality construct with difficulties in emotional processing, is stable in the general population. METHODS: Altogether 3083 unselected subjects aged 30 and older in Finland completed the 20-item Toronto Alexithymia Scale (TAS-20) in the longitudinal Health 2000 and Health 2011 general population surveys (BRIF8901). The stability of alexithymia at the 11-year follow-up was assessed with t-tests, correlations, and separate linear regression models with base-line and follow-up age, gender, marital status, education, and 12-month depressive and anxiety disorders as confounders. RESULTS: The mean score (SD) of the TAS-20 for the whole sample was 44.2 (10.4) in 2000 and 44.2 (10.9) in 2011 (p=0.731). The mean score of the TAS-20 subscale Difficulty Identifying Feelings increased by 0.3 points, Difficulty Describing Feelings decreased by 0.6 points and Externally Oriented Thinking increased by 0.3 points. The effect sizes of the changes varied from negligible to small. Age had little effect except for the group of the oldest subjects (75-97years): the TAS-20 mean (SD) score was 49.1 (10.1) in 2000 and 53.1 (10.3) in 2011 (p<0.001), the effect size for the increase was medium. TAS-20 score in 2000 explained a significant proportion of variance in TAS-20 score in 2011. Controlling for all baseline confounders improved the model incrementally; the same applied to controlling for confounders at follow-up. Baseline depression or anxiety disorders were not associated with the TAS-20 scores in 2011, whereas current diagnoses were. CONCLUSIONS: According to our large longitudinal study both the absolute and relative stability of alexithymia assessed with the TAS-20 are high in the adult general population.

Total and cause-specific mortality of Finnish military personnel following service in international peacekeeping operations 1990-2010: a comprehensive register-based cohort study.

OBJECTIVES: To estimate total and cause-specific mortality after international peacekeeping deployments among the Finnish military peacekeeping personnel in comparison to the general population of similar age and sex. DESIGN: A register-based study of a cohort of military peacekeeping personnel in 1990-2010 followed for mortality until the end of 2013. Causes of death were obtained from the national Causes of Death Register. The standardised mortality ratio (SMR) for total and cause-specific mortality was calculated as the ratio of observed and expected number of deaths. SETTING: Finland (peacekeeping operations in different countries in Africa, Asia and in an area of former Yugoslavia in Europe). PARTICIPANTS: 14 584 men and 418 women who had participated in international military peacekeeping operations ending between 1990 and 2010. INTERVENTIONS: Participation in military peacekeeping operations. MAIN OUTCOME: Total and cause-specific mortality. RESULTS: 209 men and 3 women died after their peacekeeping service. The SMR for all-cause mortality was 0.55 (95% CI 0.48 to 0.62). For the male peacekeeping personnel, the SMR for all diseases was 0.44 (95% CI 0.35 to 0.53) and for accidental and violent deaths 0.69 (95% CI 0.57 to 0.82). The SMR for suicides was 0.71 (95% CI 0.53 to 0.92). CONCLUSIONS: Even though military peacekeeping personnel are working in unique and often stressful conditions, their mortality after their service is lower compared with the general population. Military peacekeeping personnel appear to be a selected population group with low general mortality and no excess risk of any cause of death after peacekeeping service.

Common mental disorders in young adults born late-preterm.

BACKGROUND: Results of adulthood mental health of those born late-preterm (34 + 0-36 + 6 weeks + days of gestation) are mixed and based on national registers. We examined if late-preterm birth was associated with a higher risk for common mental disorders in young adulthood when using a diagnostic interview, and if this risk decreased as gestational age increased. METHOD: A total of 800 young adults (mean = 25.3, s.d. = 0.62 years), born 1985-1986, participated in a follow-up of the Arvo Ylppö Longitudinal Study. Common mental disorders (mood, anxiety and substance use disorders) during the past 12 months were defined using the Composite International Diagnostic Interview (Munich version). Gestational age was extracted from hospital birth records and categorized into early-preterm (<34 + 0, n = 37), late-preterm (34 + 0-36 + 6, n = 106), term (37 + 0-41 + 6, n = 617) and post-term (⩾42 + 0, n = 40). RESULTS: Those born late-preterm and at term were at a similar risk for any common mental disorder [odds ratio (OR) 1.11, 95% confidence interval (CI) 0.67-1.84], for mood (OR 1.11, 95% CI 0.54-2.25), anxiety (OR 1.00, 95% CI 0.40-2.50) and substance use (OR 1.31, 95% CI 0.74-2.32) disorders, and co-morbidity of these disorders (p = 0.38). While the mental disorder risk decreased significantly as gestational age increased, the trend was driven by a higher risk in those born early-preterm. CONCLUSIONS: Using a cohort born during the advanced neonatal and early childhood care, we found that not all individuals born preterm are at risk for common mental disorders in young adulthood - those born late-preterm are not, while those born early-preterm are at a higher risk. Available resources for prevention and intervention should be targeted towards the preterm group born the earliest.

The characteristics and outcomes of hospitalised and outpatient-treated first-onset schizophrenia patients: a 5-year register linkage study.

AIM: We compared the course and outcome of schizophrenia in two groups: (i) hospitalised patients (HP) (n = 5980) who were identified based on their first hospital admission for schizophrenia and (ii) outpatient-treated patients (OTP) who received disability pension because of schizophrenia but who had no hospital admissions for schizophrenia or other psychotic disorder before having been granted a disability pension for schizophrenia (n = 1220). Outcomes were compared using data on mortality, psychiatric hospital utilisation, relapse rate and occupational functioning. METHODS: A nationwide register-based 5-year follow-up study of all first-onset schizophrenia cases between 1998 and 2003 in Finland. The data were linked with the register information of hospital admissions, disability pensions and National Causes of Death Registers. RESULTS: When outcome of treatment was evaluated using mortality rate, relapses, hospital treatment and involuntary admissions as outcome measures, results indicated that OTP group had got along better with their illnesses than HP group. The mortality rates, number of psychiatric treatment days and relapse rate during the 5-year follow up were significantly lower in OTP group. Within the OTP group, there was a notable subgroup of never HP (n = 737, 60.4%), who did not require any psychiatric hospitalisation during the 5-year follow up. CONCLUSIONS: Patients first identified as outpatients had better outcomes than patients first identified following a hospitalisation. Future studies are required to establish whether outpatient treatment is associated with more favourable prognosis, even after fully adjusting for severity of initial symptoms. The higher suicide mortality of hospital-treated patients suggests that hospital treatment of first-onset patients does not protect from suicide.

Use of mental health services and complementary and alternative medicine in persons with common mental disorders.

OBJECTIVE: Few studies investigated the use of complementary and alternative medicine (CAM) by subjects with mental disorders. We examined the relationship between depressive, anxiety and alcohol-use disorders and their comorbidity, as well as the relationship between use of CAM and use of mental health services. METHOD: The Finnish adult (> or =30 years) population-based Health 2000 Study (n = 5987) collected information on use of CAM plus health and mental health care services. RESULTS: Generalised anxiety disorder and panic disorder were positively associated and alcohol abuse was negatively associated with use of CAM. The prevalence was highest in persons with comorbidity of anxiety and depressive disorders. The use or perceived usefulness of mental health services did not differ between CAM users and other participants. CONCLUSION: The relationship between the use of CAM and mental disorders appears to vary depending on the type of mental disorder. Use of CAM seems unrelated to the use and the perceived usefulness of mental health services.

Use of health services for major depressive and anxiety disorders in Finland.

Factors associated with people suffering from major depressive disorder (MDD) or anxiety disorders seeking or receiving treatment are not well known. In the Health 2000 Study, a representative sample (n=6005) of Finland's general adult (> or =30 years) population was interviewed with the M-CIDI for mental disorders and health service use for mental problems during the last 12 months. Predictors for service use among those with DSM-IV MDD (n=298) or anxiety disorders (n=242) were assessed. Of subjects with MDD, anxiety disorders, or both, 34%, 36%, and 59% used health services, respectively. Greater severity and perceived disability, psychiatric comorbidity, and living alone predicted health care use for MDD subjects, and greater perceived disability, psychiatric comorbidity, younger age, and parent's psychiatric problems for anxiety disorder subjects. The use of specialist-level mental health services was predicted by psychiatric comorbidity, but not characteristics of the disorders per se. Perceived disability and comorbidity are factors influencing the use of mental health services by both anxiety disorder and MDD subjects. However, still only approximately one-half of those suffering from even severe and comorbid disorders use health services for them.

Time patterns and seasonal mismatch in suicide.

OBJECTIVE: Physical time-givers may have a modifying effect on the time patterns of death from suicide. METHOD: Data on a total of 1397 suicides in Finland over a year were collected using the method of psychological autopsy. We linked versatile information on each individual to meteorological data adjusted for local weather conditions, and to the universal astronomic data. RESULTS: The number of suicides with seasonal mismatch was greater than the expected in the northernmost region of the country (P = 0.03). The northern location was the most significant predictor of such suicides (P = 0.001). They were associated with the changes in ambient temperature during the preceding day (P < 0.00001), the changes to colder preceding suicides in the spring. CONCLUSION: Our findings show that mismatch between the changes in ambient temperature and those in the length of day may precede death from suicide in some individuals.

Suicides of alcohol misusers and non-misusers in a nationwide population.

Alcohol dependence is a risk factor for suicide, and in the general population alcohol consumption and suicide rates are known to be associated. We investigated victims with and without alcohol misuse among unselected completed suicides to explore the role of alcohol misuse in the suicidal process and final act. In a total 1-year (1987-1988) population of suicides in the National Suicide Prevention Project in Finland, alcohol-misusing and -non-misusing victims were compared. On the basis of informant interviews, 35% (n = 349) of included victims were classified as alcohol misusers and 65% (n = 648) as non-misusers. The misusers were more often younger, male, divorced or separated and had more often worked, but were recently unemployed. They had experienced more often recent adverse life events possibly dependent on their own behaviour, were far more likely to be alcohol-intoxicated at the time of suicide, and tended to die from drug overdose. Several characteristics of these predominantly male alcohol misusers indicated better earlier lifetime psychosocial adjustment compared to the non-misusers, but more adverse life events close to suicide. Alcohol misuse is likely to have a deteriorating influence on the life course of those who eventually succumb to suicide, and its adverse consequences are common in misusers during the final months.

Alcohol-related problems among adolescent suicides in Finland.

We studied 106 adolescent suicides out of a total nationwide population of 1397 suicides. Forty-four (42%) of these 13-22-year-old victims were classified as having suffered either a DSM-III-R alcohol use disorder or diagnostically subthreshold alcohol misuse according to retrospective evaluation using the Michigan Alcoholism Screening Test (MAST). These victims were found to differ from the other adolescent suicides in several characteristics: they were more likely to have comorbid categorical DSM-III-R disorders, antisocial behaviour, disturbed family backgrounds, precipitating life-events as stressors and severe psychosocial impairment. In addition, they also had a greater tendency to be alcohol-intoxicated at the time of the suicidal act, which tended to occur during weekends, suggesting that drinking in itself, and its weekly pattern, each contributed to the completion of their suicides.

The treatment received by substance-dependent male and female suicide victims.

Within a nation-wide psychological autopsy study we investigated use of treatment services and recognition of substance abuse problems among male and female substance-dependent suicide victims. Although during their final month half of the male subjects and two-thirds of the female subjects contacted health care services, in only one-sixth and one-third of cases, respectively, were substance abuse problems currently recognized. During their final year, 37% of the males and 67% of the females received psychiatric care. This was associated with Axis-I comorbid disorders among males, with lower socio-economic status and abuse of prescribed drugs among females, and with previous suicide attempts among both sexes. Due to their high psychiatric morbidity and tendency to have contacts with psychiatric services, the recognition, treatment and follow-up of subjects with substance use disorders in psychiatric care would appear to be of major importance for suicide prevention.

Female psychoactive substance-dependent suicide victims differ from male--results from a nationwide psychological autopsy study.

Suicides involving alcohol or other substance dependence have been studied in male-dominated populations. We studied male and female suicide victims with DSM-III-R psychoactive substance dependence (PSD) separately in a nationwide psychological autopsy study in Finland. The subjects were substance-dependent males from a systematic random sample and all substance-dependent female suicide victims from the total population of suicides committed over a 1-year period in Finland. Comparisons by sex and age were made, and two logistic models were created predicting sex. Females were more likely to have abused or been dependent on prescribed medication. Female victims aged 40 years or less had a relatively high frequency of borderline personality disorder (BPD), frequent previous suicide attempts, and suicidal communication, whereas older females were more like older males. The onset of a comorbid axis I disorder preceded substance dependence more often among females. Male and female substance-dependent suicide victims differ in a number of characteristics, including previous suicidality, age-related variation in personality disorders, and type of substance used. Findings from studies of predominantly male substance-dependent suicide victims cannot necessarily be generalized to females.

Employment status influences the weekly patterns of suicide among alcohol misusers.

As part of the National Suicide Prevention Project in Finland, a nationwide psychological autopsy study, all suicide victims (n = 1397) over a 12-month period were investigated concerning factors associated with any variation in suicide frequency between weekdays and weekends. In particular, employment status was expected to have influenced the weekly pattern of alcohol misuse, and thereby to have caused clustering of suicides at weekends among the employed. Among suicide victims who had misused alcohol, those in employment were significantly more likely to have committed suicide during the weekend that those without work (52% vs. 34%, p < 0.001). In logistic regression analysis, employment was the only independent variable significantly associated with suicide at the weekend. According to forensic chemical analysis, those classified as misusers had frequently used alcohol at the time of suicide, regardless of the weekday, and slightly more often if employed. The clustering of suicides at weekends among employed alcohol misusers is probably explained by a weekly pattern in the use of alcohol, which suggests that besides the established risk factors for suicide among alcohol misusers, the act of using alcohol per se also contributes to the suicidal act.