Trends in Life Expectancy in Residential Long-Term Care by Sociodemographic Position in 1999-2018: A Multistate Life Table Study of Finnish Older Adults.

OBJECTIVES: Residential long-term care (LTC) use has declined in many countries over the past years. This study quantifies how changing rates of entry, exit, and mortality have contributed to trends in life expectancy in LTC (i.e., average time spent in LTC after age 65) across sociodemographic groups. METHODS: We analyzed population-register data of all Finns aged ≥65 during 1999-2018 (n = 2,016,987) with dates of LTC and death and sociodemographic characteristics. We estimated transition rates between home, LTC, and death using Poisson generalized additive models, and calculated multistate life tables across 1999-2003, 2004-2008, 2009-2013, and 2014-2018. RESULTS: Between 1999-2003 and 2004-2008, life expectancy in LTC increased from 0.75 (95% CI: 0.74-0.76) to 0.89 (95% CI: 0.88-0.90) years among men and from 1.61 (95% CI: 1.59-1.62) to 1.83 (95% CI: 1.81-1.85) years among women, mainly due to declining exit rates from LTC. Thereafter, life expectancy in LTC decreased, reaching 0.80 (95% CI: 0.79-0.81) and 1.51 (95% CI: 1.50-1.53) years among men and women, respectively, in 2014-2018. Especially among women and nonmarried men, the decline was largely due to increasing death rates in LTC. Admission rates declined throughout the study period, which offset the increase in life expectancy in LTC attributable to declining mortality in the community. Marital status differences in life expectancy in LTC narrowed over time. DISCUSSION: Recent declines in LTC use were driven by postponed LTC admission closer to death. The results suggest that across sociodemographic strata older adults enter LTC in even worse health and spend a shorter time in care than before.

Does having siblings really protect against childhood atopic diseases? A total population and within-family analysis.

The association between having older siblings and decreased risk for atopic symptoms is well-established. This has been interpreted as evidence for the microbiota hypothesis, i.e. that increased early-childhood microbial exposure caused by siblings protects from immune hypersensitivities. However, possible confounders of the association have received little attention. We used register data on Finnish cohorts born in 1995-2004 (N = 559,077) to assess medication purchases for atopic diseases: antihistamines, eczema medication, asthma medication and Epinephrine. We modelled the probability of atopic medication purchases at ages 0-15 by birth order controlling for important observed confounders and all unobserved genetic and environmental characteristics shared by siblings in a within-family fixed effects model. We further studied medication purchases among first-borns according to the age difference with younger siblings to assess whether having younger siblings in early childhood is beneficial. Having older siblings was associated with a lower probability of atopic medication purchases. Compared to first-borns, the probability was 10-20% lower among second-borns, 20-40% lower among third-borns, and 30-70% lower among subsequent children, depending on medication type. Confounding accounted for up to 75% of these differences, particularly for asthma and eczema medication, but significant differences by birth order remained across all medication types. Among first-borns, a smaller age difference with younger siblings was related to a lower likelihood of atopic medication use. Our results, based on designs that account for unobserved confounding, show that exposure to siblings in early childhood, protects from atopic diseases, and thus strongly support the microbiota hypothesis.

Association between genetic risk of alcohol consumption and alcohol-related morbidity and mortality under different alcohol policy conditions: Evidence from the Finnish alcohol price reduction of 2004.

AIMS: Harmful alcohol consumption is influenced by both genetic susceptibility and the price of alcohol. Many previous studies have observed that genetic susceptibility to consumption of alcohol is more predictive in less restrictive drinking conditions. We assess whether such a pattern applies when the prices of alcoholic beverages are decreased. DESIGN: Data consist of genetically informed population-representative surveys (FINRISK 1992, 1997, 2002 and Health 2000) linked to administrative registers. We analysed the interaction between a polygenic score (PGS) for alcoholic drinks per week consumed and price reduction in predicting the incidence of alcohol-related hospitalizations and deaths in difference-in-difference and interrupted time-series frameworks. SETTING: Individuals in Finland were followed quarter-yearly from 1 March 2000 to 31 May 2008. PARTICIPANTS: A total of 22 152 individuals (607 132-person quarter-years, 1399 outcome events) aged 30-79 years. INTERVENTION: A natural experiment stemming from the alcohol tax reduction in March 2004 and import deregulation in May 2004. MEASUREMENTS: Outcome was quarter-yearly-measured alcohol-related death or hospitalization. The independent variables of main interest were PGS and a price reform indicator. We adjusted for gender, age, age squared, season, 10 first principal components of the genome, data collection round and genotyping batch. FINDINGS: Both alcohol price reduction and one standard deviation change in PGS were associated with alcohol-related health outcomes; odds ratios (ORs) were 1.32, 95% confidence interval (CI) = 1.13, 1.53 and 1.26, 95% CI = 1.12, 1.42 in the 8-year follow-up, respectively. The association between PGS and alcohol-related morbidity was similar before and after the alcohol price reform (PGS × price reform interaction OR = 0.96, 95% CI = 0.81, 1.14). These results were robust across different follow-up periods and measurement and analysis strategies. CONCLUSIONS: Although the decrease of alcohol price in Finland in 2004 substantially increased overall alcohol-related morbidity and mortality, the genetic susceptibility to alcohol consumption did not become more manifest in predicting them.

Income differences in COVID-19 incidence and severity in Finland among people with foreign and native background: A population-based cohort study of individuals nested within households.

BACKGROUND: Although intrahousehold transmission is a key source of Coronavirus Disease 2019 (COVID-19) infections, studies to date have not analysed socioeconomic risk factors on the household level or household clustering of severe COVID-19. We quantify household income differences and household clustering of COVID-19 incidence and severity. METHODS AND FINDINGS: We used register-based cohort data with individual-level linkage across various administrative registers for the total Finnish population living in working-age private households (N = 4,315,342). Incident COVID-19 cases (N = 38,467) were identified from the National Infectious Diseases Register from 1 July 2020 to 22 February 2021. Severe cases (N = 625) were defined as having at least 3 consecutive days of inpatient care with a COVID-19 diagnosis and identified from the Care Register for Health Care between 1 July 2020 and 31 December 2020. We used 2-level logistic regression with individuals nested within households to estimate COVID-19 incidence and case severity among those infected. Adjusted for age, sex, and regional characteristics, the incidence of COVID-19 was higher (odds ratio [OR] 1.67, 95% CI 1.58 to 1.77, p < 0.001, 28.4% of infections) among individuals in the lowest household income quintile than among those in the highest quintile (18.9%). The difference attenuated (OR 1.23, 1.16 to 1.30, p < 0.001) when controlling for foreign background but not when controlling for other household-level risk factors. In fact, we found a clear income gradient in incidence only among people with foreign background but none among those with native background. The odds of severe illness among those infected were also higher in the lowest income quintile (OR 1.97, 1.52 to 2.56, p < 0.001, 28.0% versus 21.6% in the highest quintile), but this difference was fully attenuated (OR 1.08, 0.77 to 1.52, p = 0.64) when controlling for other individual-level risk factors-comorbidities, occupational status, and foreign background. Both incidence and severity were strongly clustered within households: Around 77% of the variation in incidence and 20% in severity were attributable to differences between households. The main limitation of our study was that the test uptake for COVID-19 may have differed between population subgroups. CONCLUSIONS: Low household income appears to be a strong risk factor for both COVID-19 incidence and case severity, but the income differences are largely driven by having foreign background. The strong household clustering of incidence and severity highlights the importance of household context in the prevention and mitigation of COVID-19 outcomes.

The contribution of alcohol-related deaths to the life-expectancy gap between people with and without depression - a cross-country comparison.

BACKGROUND: Alcohol-related deaths may be among the most important reasons for the shorter life expectancy of people with depression, yet no study has quantified their contribution. We quantify the contribution of alcohol-related deaths to the life-expectancy gap in depression in four European countries with differing levels of alcohol-related mortality. METHODS: We used cohort data linking population registers with health-care and death records from Denmark, Finland, Sweden and Turin, Italy, in 1993-2007 (210,412,097 person years, 3046,754 deaths). We identified psychiatric inpatients with depression from hospital discharge registers in Denmark, Finland, and Sweden and outpatients with antidepressant prescriptions from prescription registers in Finland and Turin. We assessed alcohol-related and non-alcohol-related deaths using both underlying and contributory causes of death, stratified by sex, age and depression status. We quantified the contribution of alcohol-related deaths by cause-of-death decomposition of the life-expectancy gap at age 25 between people with and without depression. RESULTS: The gap in life expectancy was 13.1-18.6 years between people with and without inpatient treatment for depression and 6.7-9.1 years between those with and without antidepressant treatment. The contribution of alcohol-related deaths to the life-expectancy gap was larger in Denmark (33.6%) and Finland (18.1-30.5%) - i.e., countries with high overall alcohol-related mortality - than in Sweden (11.9%) and Turin (3.2%), and larger among men in all countries. The life-expectancy gap due to other than alcohol-related deaths varied little across countries. CONCLUSIONS: Alcohol contributes heavily to the lower life expectancy in depression particularly among men and in countries with high overall alcohol-related mortality.

Current Unemployment, Unemployment History, and Mental Health: A Fixed-Effects Model Approach.

Poor mental health among the unemployed-the long-term unemployed in particular-is established, but these associations may be driven by confounding from unobserved, time-invariant characteristics such as past experiences and personality. Using longitudinal register data on 2,720,431 residents aged 30-60 years, we assessed how current unemployment and unemployment history predict visits to specialized care due to psychiatric conditions and self-harm in Finland in 2008-2018. We used linear ordinary-least-squares and fixed-effects models. Prior to adjusting for time-invariant characteristics, current unemployment was associated with poor mental health, and the risk increased with longer unemployment histories. Accounting for all time-invariant characteristics with the fixed-effects models, these associations attenuated by approximately 70%, yet current unemployment was still associated with a 0.51 (95% confidence interval: 0.48, 0.53) percentage-point increase in the probability of poor mental health among men and women. Longer unemployment histories increased the probability among men in their 30s but not among older men or among women. The results indicate that selection by stable characteristics may explain a major part of the worse mental health among the unemployed and especially the long-term unemployed. However, even when controlling for this selection, current unemployment remains associated with mental health.

Health-related selection into employment among the unemployed.

BACKGROUND: Successful transitions from unemployment to employment are an important concern, yet little is known about health-related selection into employment. We assessed the association of various physical and psychiatric conditions with finding employment, and employment stability. METHODS: Using total population register data, we followed Finnish residents aged 30-60 with an unemployment spell during 2009-2018 (n = 814,085) for two years from the onset of unemployment. We predicted any, stable, and unstable employment by health status using Cox proportional hazards models. The data on specialized health care and prescription reimbursement were used to identify any alcohol-related conditions and poisonings, psychiatric conditions and self-harm, injuries, and physical conditions. We further separated physical conditions into cancer, diabetes, heart disease, and neurological conditions, and psychiatric conditions into depression, anxiety disorders and substance use disorders. RESULTS: The likelihood of any employment was lower among those who had any of the assessed health conditions. It was lowest among those with alcohol-related or psychiatric conditions with an age-adjusted hazard ratio of 0.45 (95% confidence interval 0.44, 0.46) among men and 0.39 (0.38, 0.41) among women for alcohol-related and 0.64 (0.63, 0.65) and 0.66 (0.65, 0.67) for psychiatric conditions, respectively. These results were not driven by differences in socioeconomic characteristics or comorbidities. All the included conditions were detrimental to both stable and unstable employment, however alcohol-related and psychiatric conditions were more harmful for stable than for unstable employment. CONCLUSIONS: The prospects of the unemployed finding employment are reduced by poor health, particularly alcohol-related and psychiatric conditions. These two conditions may also lead to unstable career trajectories. The selection process contributes to the health differentials between employed and unemployed people. Unemployed people with health problems may therefore need additional support to improve their chances of employment.

Contributions of specific causes of death by age to the shorter life expectancy in depression: a register-based observational study from Denmark, Finland, Sweden and Italy.

BACKGROUND: The reasons for the shorter life expectancy of people with depression may vary by age. We quantified the contributions of specific causes of death by age to the life-expectancy gap in four European countries. METHODS: Using register-based cohort data, we calculated annual mortality rates in between 1993 and 2007 for psychiatric inpatients with depression identified from hospital-care registers in Denmark, Finland and Sweden, and between 2000 and 2007 for antidepressant-treated outpatients identified from medication registers in Finland and Turin, Italy. We decomposed the life-expectancy gap at age 15 years by age and cause of death. RESULTS: The life-expectancy gap was especially large for psychiatric inpatients (12.1 to 21.0 years) but substantial also for antidepressant-treated outpatients (6.3 to 14.2 years). Among psychiatric inpatients, the gap was largely attributable to unnatural deaths below age 55 years. The overall contribution was largest for suicide in Sweden (43 to 45%) and Finland (37 to 40%). In Denmark, 'other diseases' (25 to 34%) and alcohol-attributable causes (10 to 18%) had especially large contributions. Among antidepressant-treated outpatients, largest contributions were observed for suicide (18% for men) and circulatory deaths (23% for women) in Finland, and cancer deaths in Turin (29 to 36%). Natural deaths were concentrated at ages above 65 years. LIMITATIONS: The indication of antidepressant prescription could not be ascertained from the medication registers. CONCLUSIONS: Interventions should be directed to self-harm and substance use problems among younger psychiatric inpatients and antidepressant-treated young men. Rigorous monitoring and treatment of comorbid somatic conditions and disease risk factors may increase life expectancy for antidepressant-treated outpatients, especially women.

Health of Immigrant Children: The Role of Immigrant Generation, Exogamous Family Setting, and Family Material and Social Resources.

Although the children of first-generation immigrants tend to have better health than the native population, the health advantage of the children of immigrant families deteriorates over generations. It is, however, poorly understood where on the generational health assimilation spectrum children with one immigrant and one native parent (i.e., exogamous families) lie, to what extent family resources explain health assimilation, and whether the process of assimilation varies across health conditions. We seek to extend our understanding of the process of health assimilation by analyzing the physical and mental health of immigrant generations, assessing the role of exogamous family arrangements, and testing the contributions of family material and social resources to children's outcomes. We use register-based longitudinal data on all children residing in Finland, born in 1986-2000, and alive in 2000; these data are free of reporting bias and loss to follow-up. We estimate the risk of receiving inpatient and outpatient care for somatic conditions, psychopathological disorders, and injuries by immigrant generation status. Our results show evidence of a negative health assimilation process, with both first- and second-generation immigrant children having a higher prevalence of physical problems and particularly mental health problems than native children that is only partially explained by family resources. We find that the children of exogamous families are at especially high risk of developing psychopathological disorders. These results provide strong support for the hypothesis that children of exogamous families constitute a specific health risk group and that the impact on children's health of family social and material resources seems to be secondary to other unobserved factors.

Association between neighbourhood characteristics and antidepressant use at older ages: a register-based study of urban areas in three European countries.

BACKGROUND: Research evidence on the association between neighbourhood characteristics and individual mental health at older ages is inconsistent, possibly due to heterogeneity in the measurement of mental-health outcomes, neighbourhood characteristics and confounders. Register-based data enabled us to avoid these problems in this longitudinal study on the associations between socioeconomic and physical neighbourhood characteristics and individual antidepressant use in three national contexts. METHODS: We used register-based longitudinal data on the population aged 50+ from Turin (Italy), Stockholm (Sweden), and the nine largest cities in Finland linked to satellite-based land-cover data. This included individual-level information on sociodemographic factors and antidepressant use, and on neighbourhood socioeconomic characteristics, levels of urbanicity, green space and land-use mix (LUM). We assessed individual-level antidepressant use over 6 years in 2001-2017 using mixed-effects logistic regression. RESULTS: A higher neighbourhood proportion of low-educated individuals predicted lower odds for antidepressant use in Turin and Stockholm when individual-level sociodemographic factors were controlled for. Urbanicity predicted increased antidepressant use in Stockholm (OR=1.02; 95% CI 1.01 to 1.03) together with more LUM (OR=1.03; 1.01-1.05) and population density (OR=1.08; 1.05-1.10). The two latter characteristics also predicted increased antidepressant use in the Finnish cities (OR=1.05; 1.02-1.08 and OR=1.14; 1.02-1.28, respectively). After accounting for all studied neighbourhood and individual characteristics of the residents, the neighbourhoods still varied by odds of antidepressant use. CONCLUSIONS: Overall, the associations of neighbourhood socioeconomic and physical characteristics with older people's antidepressant use were small and inconsistent. However, we found modest evidence that dense physical urban environments predicted higher antidepressant use among older people in Stockholm and the Finnish cities.

Unemployment from stable, downsized and closed workplaces and alcohol-related mortality.

AIMS: To assess the importance of health selection in the association between unemployment and alcohol-related mortality by comparing mortalities of those unemployed from workplaces experiencing different levels of downsizing. The more severe the downsizing, the less dependent unemployment would be on personal characteristics and the weaker the role of health selection. DESIGN: We estimated hazards models of unemployment on alcohol-related diseases and poisonings and external causes with alcohol as a contributing cause over follow-ups of 0-5, 6-10 and 11-20 years and at different levels of downsizing (stable, downsized or closed). SETTING: Finland, 1990 to 2009. PARTICIPANTS: A register-based random sample of employees aged 25-63 in privately owned workplaces (n = 275 738). MEASUREMENTS: The outcome was alcohol-related death and the exposure was unemployment. We adjusted for age, sex, year, education, marital status, health status, workplace tenure, industry, region and unemployment rate. FINDINGS: Alcohol-disease mortality was elevated among the unemployed throughout the follow-up, regardless of the level of downsizing. At 11-20 years after baseline, those unemployed from stable workplaces had a 2.46 hazard ratio (HR) (95% confidence interval [CI] = 2.14-2.82), those from downsized workplaces 1.94 (95% CI = 1.64-2.30) and those from closed workplaces 2.13 (95% CI = 1.75-2.59), when compared with the controls. Alcohol-related external-cause mortality at 0-5 years follow-up was only associated with unemployment from stable workplaces (HR = 1.39, 95% CI = 1.22-1.58), but over time, an association emerged among those unemployed following downsizing and closure. At 11-20-year follow-up, the HR following downsizing was 1.83 (CI 95% = 1.37-2.45) and 1.54 (95% CI = 1.03-2.28) following closure. CONCLUSIONS: There is some indication that alcohol-related ill-health may lead to unemployment in Finland. However, the persistent long-term association between unemployment and alcohol-related mortality even after workplace closure may imply a causal relation.

Evaluating the Role of Parental Education and Adolescent Health Problems in Educational Attainment.

This article reconsiders the role of social origin in health selection by examining whether parental education moderates the association between early health and educational attainment and whether health problems mediate the intergenerational transmission of education. We used longitudinal register data on Finns born in 1986-1991 (n = 352,899). We measured the completion of secondary and tertiary education until age 27 and used data on hospital care and medication reimbursements to assess chronic somatic conditions, frequent infections, and mental disorders at ages 10-16. We employed linear probability models to estimate the associations between different types of health problems and educational outcomes and to examine moderation by parental education, both overall in the population and comparing siblings with and without health problems. Finally, we performed a mediation analysis with g-computation to simulate whether a hypothetical eradication of health problems would weaken the association between parental and offspring education. All types of health problems reduced the likelihood of secondary education, but mental disorders were associated with the largest reductions. Among those with secondary education, there was further evidence of selection to tertiary education. High parental education buffered against the negative impact of mental disorders on completing secondary education but exacerbated it in the case of tertiary education. The simulated eradication of health problems slightly reduced disparities by parental education in secondary education (up to 10%) but increased disparities in tertiary education (up to 2%). Adolescent health problems and parental education are strong but chiefly independent predictors of educational attainment.

The changing contribution of childhood social characteristics to mortality: a comparison of Finnish cohorts born in 1936-50 and 1961-75.

BACKGROUND: Life course epidemiology suggests that early life circumstances affect adult mortality, but most of the evidence is based on cohorts born in the beginning of the 20th century. It remains unclear whether and how the influences of early life circumstances on mortality have changed in later birth cohorts. METHODS: Analyses rely on 10% register-based samples of households drawn from the 1950 and the 1975 Finnish censuses, with consistent follow-up of socioeconomic and housing-related characteristics and early mid-life mortality (at ages 30-55 years). We estimate survival models for the associations between childhood circumstances and all-cause, internal and external mortality for cohorts born in 1936-50 and 1961-75 adjusting for attained social characteristics. We estimate sibling intraclass correlations as summary measures of all early life and familial influences. RESULTS: Adverse childhood social circumstances were typically associated with about 10-30% excess cause-specific mortality. These associations were almost fully attenuated by adjustment for achieved later life social characteristics. Early life influences have grown over time for mortality from external causes, particularly as related to home ownership and family type. Differentials have remained stable for internal causes. The intraclass correlations further confirmed the increasing association of early life circumstances on external-cause mortality. CONCLUSIONS: Our analyses show that the associations between childhood characteristics and mid-life mortality are substantial and almost fully mediated by achieved adult social characteristics. The increase in the contribution of childhood circumstances to mid-life mortality is driven by ever stronger associations with external causes of death.

Time patterns of external and alcohol-related mortality after marital and non-marital separation: the contribution of psychiatric morbidity.

BACKGROUND: External and alcohol-related mortality is elevated postseparation, but the role of poor mental health in explaining this excess is unclear. We assess postseparation excess mortality by union type and over time since separation and examine how psychiatric morbidity present already before separation, during the separation process and after separation attenuates this excess. METHODS: Using individual-level register data from 1995 to 2012, we followed 311 751 Finns in long-term unions. Psychiatric morbidity was identified from dates of prescription medication purchases and hospital admissions, separations from dates of moving out of joint households and mortality from the Death Register. Cox regression was used to analyse postseparation mortality controlling for psychiatric morbidity before, during and after separation. RESULTS: External and alcohol-related excess mortality is most pronounced immediately after separation, particularly among men, and is much larger following marital than non-marital separation. After sociodemographic factors are adjusted for, further adjustment for psychiatric morbidity attenuates the excess by about 25%. Psychiatric morbidity poorly explains alcohol-related postseparation excess mortality, but for suicide mortality, adjustment for psychiatric morbidity reduces the excess by about 40% among men and 50% among women. Among women, this is largely due to psychiatric morbidity present already before separation, whereas among men the attenuation is also due to psychiatric morbidity during the separation process and after it. CONCLUSION: Separation may exacerbate the problems of people already in poor mental health, and relationship dynamics should thus be considered during treatment. Particularly among men separation is a risk factor for suicide even without pre-existing mental health problems.

The Association Between Unemployment and Mortality: A Cohort Study of Workplace Downsizing and Closure.

Workplace downsizing and closure have been considered natural experiments that strengthen causal inference when assessing the association between unemployment and health. Selection into unemployment plays a lesser role among those exposed to severe workplace downsizing. This study compared mortality for individuals unemployed from stable, downsized, and closed workplaces with a reference group unexposed to unemployment. We examined nationally representative register data of residents of Finland aged 25-63 years in 1990-2009 (n = 275,738). Compared with the control group, the hazard ratio for substance use-related mortality among men unemployed from stable workplaces was 2.43 (95% confidence interval (CI): 2.22, 2.67), from downsized workplaces 1.85 (CI: 1.65, 2.08), and from closed workplaces 2.16 (CI: 1.84, 2.53). Among women, the corresponding estimates were 3.01 (CI: 2.42, 3.74), 2.39 (CI: 1.75, 3.27), and 1.47 (CI: 1.09, 1.99). Unemployment from stable workplaces was associated with mortality from psychiatric and self-harm-related conditions. However, mortality due to ischemic heart disease and other somatic diseases decreased for those unemployed following closure. The results indicate that selection mechanisms partially explain the excess mortality among the unemployed. However, substance-use outcomes among men and women, and fatal accidents and violence among men, might be causally associated with unemployment.

The Association Between Income and Psychotropic Drug Purchases: Individual Fixed Effects Analysis of Annual Longitudinal Data in 2003-2013.

BACKGROUND: Previous cross-sectional studies show that low income is associated with poor mental health. However, longitudinal research has produced varying results. We assess whether low income is associated with increased psychotropic drug use after accounting for confounding by observed time-varying, and unobserved stable individual differences. METHODS: The longitudinal register-based data comprises an 11% nationally representative random sample of Finnish residents aged 30-62 years between the years 2003 and 2013. The analytic sample includes 337,456 individuals (2,825,589 person-years). We estimate the association between annual income and psychotropic purchasing using ordinary-least-squares and fixed effects models, the latter controlling for all unobserved time-invariant individual characteristics. RESULTS: The annual prevalence of psychotropic purchasing was 15%; 13% among men and 18% among women. Adjusted for age squared, sex and calendar year, the doubling of income decreased the probability of purchases by 4 percentage points (95% confidence interval: 4,4) in the ordinary-least-squares model. We observed no association after further adjusting for observed sociodemographic characteristics and unobserved individual differences in the fixed effects specification. CONCLUSIONS: Following adjustment for an extensive set of confounders, no contemporaneous association between variations in annual individual income and psychotropic drug purchasing was observed. Similar results were obtained irrespective of baseline income level and sex. The results imply that indirect selection based on preexisting individual characteristics plays a major role in explaining the association between variations in income measured over the short term, and psychotropic drug purchases. The association appears largely attributable to unobserved, stable individual characteristics. See video abstract at, http://links.lww.com/EDE/B463.

Parental education and adolescent health problems due to violence, self-harm and substance use: what is the role of parental health problems?

BACKGROUND: Adolescent health problems are more prevalent in families with low socioeconomic position, but few studies have assessed the role of parental health in this association. This study examines the extent to which parental health problems, particularly those related to high-risk health behaviour, might explain the association between parental education and adolescent health problems due to violence, self-harm and substance use. METHODS: We used longitudinal register data on a 20% representative sample of all families with children aged 0-14 years in 2000 in Finland with information on parental social background and parental and offspring health problems based on hospital discharge data. We estimated discrete-time survival models with the Karlson-Holm-Breen method on hospital admissions due to violence, self-harm and substance use among adolescents aged 13-19 years in 2001-2011 (n=145 404). RESULTS: Hospital admissions were 2-3 times more common among offspring of basic educated parents than tertiary educated parents. Similar excess risks were observed among those with parental mental health problems and parental health problems due to violence, self-harm and substance use. The OR for offspring of basic educated parents was attenuated from OR 2.73 (95% CI 2.34 to 3.18) to OR 2.38 (2.04 to2.77) with adjustment for parental health problems, particularly those due to violence, self-harm and substance use. Having both low parental education and parental health problems showed simple cumulative effects. CONCLUSIONS: The excess risks of hospital admissions due to violence, self-harm and substance use among adolescents with lower educated parents are largely independent of severe parental health problems.

Substance abuse in parents and subsequent risk of offspring psychiatric morbidity in late adolescence and early adulthood: A longitudinal analysis of siblings and their parents.

The effects of substance abuse on other family members are not fully established. We estimate the contribution of parental substance abuse on offspring psychiatric morbidity in late adolescence and early adulthood, with emphasis on the timing and persistency of exposure. We used a nationally representative 20% sample of Finnish families with children born in 1986-1996 (n = 136,604) followed up in 1986-2011. We identified parental substance abuse and offspring psychiatric morbidity from hospital discharge records, death records and medication registers. The effects of parental substance abuse at ages 0-4, 5-9 and 10-14 on psychiatric morbidity after age 15 were estimated using population averaged and sibling fixed effects models; the latter controlling for unobserved factors shared by siblings. Parental substance abuse at ages 0-14 was associated with almost 2-fold increase in offspring psychiatric morbidity (HR = 1.86, 95% CI 1.78-1.95). Adjustment for childhood parental education, income, social class and family type reduced these effects by about 50%, with some further attenuation after adjustment for time-varying offspring characteristics. In the sibling fixed effects models those exposed at 0-4 or 5-9 years had 20% (HR = 1.20, 95% CI 0.90-1.60) and 33% (HR = 1.33, 95% CI 1.01-1.74) excess morbidity respectively. Also in sibling models those with early exposure at ages 0-4 combined with repeated exposure in later childhood had about 80-90% higher psychiatric morbidity as compared to never exposed siblings (e.g. for those exposed throughout childhood HR = 1.81, 95% CI 1.01-3.25). Childhood exposure to parental substance abuse is strongly associated with subsequent psychiatric morbidity. Although these effects are to a large extent due to other characteristics shared within the parental home, repeated exposure to parental substance abuse is independently associated with later psychiatric morbidity.

Cohabitation and mental health: Is psychotropic medication use more common in cohabitation than marriage?

Marriage is associated with better mental health. While research on the mental health of cohabiting individuals has increased in recent years, it has yielded mixed results thus far. We assessed whether the mental health of cohabiters is comparable to that of married individuals or those living alone using longitudinal data on psychotropic medication purchases. Panel data from an 11% random sample of the population residing in Finland for the years 1995 to 2007, with annual measurements of all covariates, were used. Ordinary least squares (OLS) models were applied to disentangle the relation between cohabitation and psychotropic medication purchases while controlling for relevant time-varying factors (age, education, economic activity, and number of children), and individual fixed effects (FE) models to further account for unobserved time-invariant individual factors. Our sample consisted of 63,077 men and 61,101 women aged 25 to 39 years in 1995. Descriptive results and the OLS model indicated that the likelihood of purchasing psychotropic medication was lowest for married individuals, higher for cohabiters, and highest for individuals living alone. This difference between cohabiting and married individuals disappeared after controlling for time-varying covariates (percent difference [% diff] for men: 0.3, 95% confidence interval [CI]: -0.0, 0.6; % diff for women: -0.2, 95% CI: -0.6, 0.2). Further controlling for unobserved confounders in the FE models did not change this non-significant difference between cohabiting and married individuals. The excess purchases of psychotropic medication among individuals living alone compared to those cohabiting decreased to 1.2 (95% CI: 1.0, 1.4) and 1.4 (95% CI: 1.1, 1.6) percentage-points in the fully-adjusted FE model for men and women, respectively. Similar results were found for all subcategories of psychotropic medication. In summary, these findings suggested that the mental health difference between cohabiting and married individuals, but not the difference between cohabiting individuals and those living alone, was largely due to selection.

Partner resources and incidence and survival in two major causes of death.

Because people tend to marry social equals - and possibly also because partners affect each other's health - the social position of one partner is associated with the other partner's health and mortality. Although this link is fairly well established, the underlying mechanisms are not fully identified. Analyzing disease incidence and survival separately may help us to assess when in the course of the disease a partner's resources are of most significance. This article addresses the importance of partner's education, income, employment status, and health for incidence and survival in two major causes of death: cancer and cardiovascular diseases (CVD). Based on a sample of Finnish middle-aged and older couples (around 200,000 individuals) we show that a partner's education is more often connected to incidence than to survival, in particular for CVD. Once ill, any direct effect of partner's education seems to decline: The survival chances after being hospitalized for cancer or CVD are rather associated with partner's employment status and/or income level when other individual and partner factors are adjusted for. In addition, a partner's history of poor health predicted higher CVD incidence and, for women, lower cancer survival. The findings suggest that various partner's characteristics may have different implications for disease and survival, respectively. A wider focus on social determinants of health at the household level, including partner's social resources, is needed.