Effect of Pharmacological Treatment of Attention-Deficit/Hyperactivity Disorder on Criminality.

OBJECTIVE: Criminality rates are higher among persons with attention-deficit/hyperactivity disorder (ADHD), and evidence that medication reduces crime is limited. Medication rates between clinics vary widely even within universal health care systems, partly because of providers' treatment preferences. We used this variation to estimate causal effects of pharmacological treatment of ADHD on 4-year criminal outcomes. METHOD: We used Norwegian population-level registry data to identify all unique patients aged 10 to 18 years diagnosed with ADHD between 2009 and 2011 (n = 5,624), their use of ADHD medication, and subsequent criminal charges. An instrumental variable design, exploiting variation in provider preference for ADHD medication between clinics, was used to identify causal effects of ADHD medication on crime among patients on the margin of treatment, that is, patients who receive treatment because of their provider's preference. RESULTS: Criminality was higher in patients with ADHD relative to the general population. Medication preference varied between clinics and strongly affected patients' treatment. Instrumental variable analyses supported a protective effect of pharmacological treatment on violence-related and public-order-related charges with numbers needed to treat of 14 and 8, respectively. There was no evidence for effects on drug-, traffic-, sexual-, or property-related charges. CONCLUSION: This is the first study to demonstrate causal effects of pharmacological treatment of ADHD on some types of crimes in a population-based natural experiment. Pharmacological treatment of ADHD reduced crime related to impulsive-reactive behavior in patients with ADHD on the margin of treatment. No effects were found on crimes requiring criminal intent, conspiracy, and planning. STUDY PREREGISTRATION INFORMATION: The ADHD controversy project: Long-term effects of ADHD medication; https://www.isrctn.com/; 11891971.

Effect of ADHD medication on risk of injuries: a preference-based instrumental variable analysis.

ADHD is associated with an increased risk of injury. Causal evidence for effects of pharmacological treatment on injuries is scarce. We estimated effects of ADHD medication on injuries using variation in provider preference as an instrumental variable (IV). Using Norwegian registry data, we followed 8051 patients who were diagnosed with ADHD aged 5 to 18 between 2009 and 2011 and recorded their ADHD medication and injuries treated in emergency rooms and emergency wards up to 4 years after diagnosis. Persons with ADHD had an increased risk of injuries compared to the general population (RR 1.35; 95% CI: 1.30-1.39), with higher risk in females (RR 1.47; 95% CI: 1.38-1.56) than males (RR 1.23; 95% CI: 1.18-1.28). The between-clinics variation in provider preference for ADHD medication was large and had a considerable impact on patients' treatment status. There was no causal evidence for protective effects of pharmacological treatment on injuries overall for young individuals with ADHD characterized by milder or atypical symptoms. However, there was an apparent effect of pharmacological treatment over time on the risk of injuries treated at emergency wards in this patient group.

When health trumps money: Economic incentives and health equity in the public provision of nursing homes in Norway.

The allocation of public care services should be determined by individual needs, but can be influenced by economic factors. This paper examines the impact of economic incentives on the allocation of public nursing home care in the Norwegian long-term care system. In Norway, municipalities and city districts have economic incentives for choosing nursing home care for high-income individuals in need of care and home-based care in sheltered housing for low-income individuals. The study uses a theoretical model and empirical data from the municipality of Oslo to determine if nursing home spots are allocated based on income, which would be financially advantageous for the city districts. We do not find evidence that the economic incentives of the care provider play a role in the allocation of nursing homes. Thus, in this setting, needs seem to be the dominant factor for allocation of nursing home care, while economic incentives seem to play no significant role. The clear legal mandate to provide services based on needs only is likely an important factor in this.

Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: Protocol for a controversies in psychiatry research project.

OBJECTIVES: Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency. METHODS: By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories. CONCLUSIONS: This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group.

Geographical variation in ADHD: do diagnoses reflect symptom levels?

Rates of ADHD diagnosis vary across regions in many countries. However, no prior study has investigated how much within-country geographic variation in ADHD diagnoses is explained by variation in ADHD symptom levels. We examine whether ADHD symptom levels explain variation in ADHD diagnoses among children and adolescents using nationwide survey and register data in Norway. Geographical variation in incidence of ADHD diagnosis was measured using Norwegian registry data from the child and adolescent mental health services for 2011-2016. Geographical variation in ADHD symptom levels in clinics' catchment areas was measured using data from the Norwegian mother, father and child cohort study for 2011-2016 (n = 39,850). Cross-sectional associations between ADHD symptom levels and the incidence of ADHD diagnoses were assessed with fractional response models. Geographical variation in ADHD diagnosis rates is much larger than what can be explained by geographical variation in ADHD symptoms levels. Treatment in the Norwegian child and adolescent mental health services is free, universally available upon referral, and practically without competition from the private sector. Factors beyond health care access and unequal symptom levels seem responsible for the geographical variation in ADHD diagnosis.

Effects of dialogue meetings on sickness absence-Evidence from a large field experiment.

Sickness absence entails large individual and societal costs. Dialogue Meetings (DMs) where the absentee, the employer, and the physician discuss arrangements for full or partial work resumption have been in place in Norway since 2007. In collaboration with the Labour and Welfare Administration, we conducted a large-scale, pre-registered, randomized field experiment to evaluate aspects of the Norwegian DMs policy. We do not find statistically significant effects of summoning to a meeting and we can reject even small threat (notification) effects of sending out letters. We also conduct an extensive search for heterogeneous treatment effects but find no evidence of these.

Preference-based instrumental variables in health research rely on important and underreported assumptions: a systematic review.

OBJECTIVE: Preference-based instrumental variables (PP IV) designs can identify causal effects when patients receive treatment due to variation in providers' treatment preference. We offer a systematic review and methodological assessment of PP IV applications in health research. STUDY DESIGN AND SETTING: We included studies that applied PP IV for evaluation of any treatment in any population in health research (PROSPERO: CRD42020165014). We searched within four databases (Medline, Web of Science, ScienceDirect, SpringerLink) and four journals (including full-text and title and abstract sources) between January 1, 1998, and March 5, 2020. We extracted data on areas of applications and methodology, including assumptions using Swanson and Hernan's (2013) guideline. RESULTS: We included 185 of 1087 identified studies. The use of PP IV has increased, being predominantly used for treatment effects in cancer, cardiovascular disease, and mental health. The most common PP IV was treatment variation at the facility-level, followed by physician- and regional-level. Only 12 percent of applications report the four main assumptions for PP IV. Selection on treatment may be a potential issue in 46 percent of studies. CONCLUSION: The assumptions of PP IV are not sufficiently reported in existing work. PP IV-studies should use reporting guidelines.

Causal modelling of variation in clinical practice and long-term outcomes of ADHD using Norwegian registry data: the ADHD controversy project.

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) is among the most common mental disorders in children and adolescents, and it is a strong risk factor for several adverse psychosocial outcomes over the lifespan. There are large between-country and within-country variations in diagnosis and medication rates. Due to ethical and practical considerations, a few studies have examined the effects of receiving a diagnosis, and there is a lack of research on effects of medication on long-term outcomes.Our project has four aims organised in four work packages: (WP1) To examine the prognosis of ADHD (with and without medication) compared with patients with other psychiatric diagnoses, patients in contact with public sector child and adolescent psychiatric outpatient clinics (without diagnosis) and the general population; (WP2) Examine within-country variation in ADHD diagnoses and medication rates by clinics' catchment area; and(WP3) Identify causal effects of being diagnosed with ADHD and (WP4) ADHD medication on long-term outcomes. METHOD AND ANALYSIS: Our project links several nationwide Norwegian registries. The patient sample is all persons aged 5-18 years that were in contact with public sector child and adolescent psychiatric outpatient clinics in 2009-2011. Our comparative analysis of prognosis will be based on survival analysis and mixed-effects models. Our analysis of variation will apply mixed-effects models and generalised linear models. We have two identification strategies for the effect of being diagnosed with ADHD and of receiving medication on long-term outcomes. Both strategies rely on using preference-based instrumental variables, which in our project are based on provider preferences for ADHD diagnosis and medication. ETHICS AND DISSEMINATION: The project is approved by the Regional Ethics Committee, Norway (REC number 2017/2150/REC south-east D). All papers will be published in open-access journals and results will be presented in national and international conferences. TRIAL REGISTRATION NUMBERS: ISRCTN11573246 and ISRCTN11891971.

Children and Careers: How Family Size Affects Parents' Labor Market Outcomes in the Long Run.

We estimate the effect of family size on various measures of labor market outcomes over the whole career until retirement, using instrumental variables estimation in data from Norwegian administrative registers. Parents' number of children is instrumented with the sex mix of their first two children. We find that having additional children causes sizable reductions in labor supply for women, which fade as children mature and even turn positive for women without a college degree. Among women with a college degree, there is evidence of persistent and even increasing career penalties of family size. Having additional children reduces these women's probability of being employed by higher-paying firms, their earnings rank within the employing firm, and their probability of being the top earner at the workplace. Some of the career effects persist long after labor supply is restored. We find no effect of family size on any of men's labor market outcomes in either the short or long run.

The market for paid sick leave.

In many countries, general practitioners (GPs) are assigned the task of controlling the validity of their own patients' insurance claims. At the same time, they operate in a market where patients are customers free to choose their GP. Are these roles compatible? Can we trust that the gatekeeping decisions are untainted by private economic interests? Based on administrative registers from Norway with records on sick pay certification and GP-patient relationships, we present evidence to the contrary: GPs are more lenient gatekeepers the more competitive is the physician market, and a reputation for lenient gatekeeping increases the demand for their services.

Daylight and absenteeism--evidence from Norway.

Based on administrative register data from Norway, we examine the impact of hours of daylight on sick-leave absences among workers. Our preferred estimates imply that an additional hour of daylight increases the daily entry rate to absenteeism by 0.5 percent and the corresponding recovery rate by 0.8 percent, ceteris paribus. The overall relationship between absenteeism and daylight hours is negative. Absenteeism is also sensitive to weather conditions. Heavy snowfall raises the incidence of absence during the winter, while warm weather reduces the probability of returning to work during the summer.

The changing of the guards: can family doctors contain worker absenteeism?

Using administrative data from Norway, we examine the extent to which family doctors influence their clients' propensity to claim sick-pay. The analysis exploits exogenous switches of family doctors occurring when physicians quit, retire, or for other reasons sell their patient lists. We find that family doctors have significant influence on their clients' absence behavior, particularly on absence duration. Their influence is stronger in geographical areas with weaker competition between physicians. We conclude that it is possible for family doctors to contain sick-pay expenditures to some extent, and that there is a considerable variation in the way they perform this task.

Does retirement age impact mortality?

The relationship between retirement and mortality is studied with a unique administrative data set covering the full population of Norway. A series of retirement policy changes in Norway reduced the retirement age for a group of workers but not for others. Difference-in-differences estimation based on monthly birth cohorts and treatment group status show that the early retirement programme significantly reduced the retirement age; this holds true also when we account for programme substitution, for example into the disability pension. Instrumental variables estimation results show no effect on mortality of retirement age; neither do estimation results from a hazard rate model.

[Sickness absence associated with major life events]. / Sykefravær rundt større livshendelser.

BACKGROUND: Sickness absence in the Norwegian workplace doubled in the period 1993-2003. However, the extent to which the driving factors were medical or non-medical remains unclear, as does the extent to which the cause may be found in the composition of the workforce. MATERIAL AND METHODS: A differences-in-differences regression model was used to estimate the added sickness absence associated with major life events such as separation, death of spouse and pregnancy in the period 1993-2005. The data were obtained from administrative registers covering the entire Norwegian population, and include all absence periods of 16 days' duration or more reported by a doctor's medical certificate. The primary outcome measures were incidence (the proportion of absentees in a given time window) and absence (the proportion of sick days in a given time window). The level of absence among employees exposed to the specified life events was compared to control groups matched for gender, age, education and income. RESULTS: In 1993, people in each of the three groups exposed to major life events had more frequent and longer periods of absence than people in the control groups. This added sickness absence increased between 1993 and 2005. The changes in added sickness absence were at times significant, particularly for pregnant women. While sickness absence among pregnant women in 1993 was 15.4 percentage points higher than in the control group, the difference had increased to 24.8 percentage points in 2005. INTERPRETATION: We find it improbable for the increase in added sickness absence to be caused by changes in the medical impact of life events or alterations in the workforce composition. We believe the increase is caused by changing attitudes among the working population and in the medical profession towards sickness absence on grounds that are not strictly medical, combined with improved social acceptance and diagnosis of mental health issues, and/or a medicalisation of natural health variations (pregnancy) and emotional distress (grief).

The anatomy of absenteeism.

Based on comprehensive administrative register data from Norway, we examine the determinants of sickness absence behavior; in terms of employee characteristics, workplace characteristics, panel doctor characteristics, and economic conditions. The analysis is based on a novel concept of a worker's steady state sickness absence propensity, computed from a multivariate hazard rate model designed to predict the incidence and duration of sickness absence for all workers. Key conclusions are that (i) most of the cross-sectional variation in absenteeism is caused by genuine employee heterogeneity; (ii) the identity of a person's panel doctor has a significant impact on absence propensity; (iii) sickness absence insurance is frequently certified for reasons other than sickness; and (iv) the recovery rate rises enormously just prior to the exhaustion of sickness insurance benefits.