Identification of alcohol abuse and transition from long-term unemployment to disability pension

Real-world effectiveness of pharmacological treatments of alcohol use disorders in a Swedish nation-wide cohort of 125 556 patients

BACKGROUND AND AIM

Pharmacotherapy for alcohol use disorder (AUD) is recommendable, but under-used, possibly due to deficient knowledge of medications. This study aimed to investigate the real-world effectiveness of approved pharmacological treatments (disulfiram, acamprosate, naltrexone and nalmefene) of AUD.

DESIGN

A nation-wide, register-based cohort study.

SETTING

Sweden.

PARTICIPANTS

All residents aged 16-64 years living in Sweden with registered first-time treatment contact due to AUD from July 2006 to December 2016 (n = 125 556, 62.5% men) were identified from nation-wide registers.

MEASUREMENTS

The main outcome was hospitalization due to AUD. The secondary outcomes were hospitalization due to any cause, alcohol-related somatic causes, as well as work disability (sickness absence or disability pension), and death. Mortality was analysed with between-individual analysis using a traditional multivariate-adjusted Cox hazards regression model. Recurrent outcomes, such as hospitalization-based events and work disability, were analysed with within-individual analyses to eliminate selection bias.

FINDINGS

Naltrexone combined with acamprosate [hazard ratio (HR) = 0.74; 95% confidence interval (CI) = 0.61-0.89], combined with disulfiram (HR = 0.76, 95% CI = 0.60-0.96) and as monotherapy (HR = 0.89, 95% CI = 0.81-0.97) was associated with a significantly lower risk of AUD-hospitalization compared with no use of AUD medication. Similar results were found for risk of hospitalization due to any cause. Benzodiazepine use and acamprosate monotherapy were associated with an increased risk of AUD-hospitalization (HR = 1.18, 95% CI = 1.14-1.22 and HR = 1.10, 95% CI = 1.04-1.17, respectively). No statistically significant effects were found for work disability or mortality.

CONCLUSIONS

Naltrexone as monotherapy and when combined with disulfiram and acamprosate appears to be associated with lower risk of hospitalization due to any and alcohol-related causes, compared with no use of alcohol use disorder (AUD) medication. Acamprosate monotherapy and benzodiazepine use appear to be associated with increased risk of AUD-associated hospitalization.

Healthcare attendance styles among long-term unemployed people with substance-related and mood disorders

BACKGROUND

Both increased and decreased health service usage and unmet care needs are more prevalent among unemployed people than in the general population.

STUDY DESIGN

This study investigates the associations of substance-related and mood disorders among long-term unemployed people with styles of healthcare attendance in Finland.

METHODS

The study material consisted of the health register information on 498 long-term unemployed people in a project screening for work disabilities. The data were analysed by mixed methods: qualitative typological analysis was applied to identify differential healthcare attendance styles, and the associations of the obtained styles with mental health disorders were analysed quantitatively by multinomial logistic regression.

RESULTS

Three styles, characterized as smooth, faltering and marginalized, were identified. Compared with participants with the smooth attendance style without mental disorders, those with the faltering style had tenfold relative risk for substance-related disorder and fourfold relative risk for mood disorder. Those with the marginalized style had fivefold relative risk for substance-related disorder and twofold relative risk for mood disorder. Adjusting for background characteristics did not alter the statistical significance of substance-related disorder. In the case of mood disorders, the statistical significance persisted throughout the adjustments in the faltering style.

CONCLUSION

Dysfunctional use of health services is more common among people with substance-related or mood disorders, who are at risk of drifting towards long-term unemployment and work disabilities. The early detection of those with faltering or marginalized healthcare attendance style may prevent prolonged unemployment, enable rehabilitation measures and reduce the risk of disability pensions.

Association between good work ability and health behaviours among unemployed: A cross-sectional survey

BACKGROUND

There has been relatively little research on the possible factors promoting good work ability among unemployed people. Consequently, the role of health behaviours in good work ability among the unemployed is unknown.

PURPOSE

To explore the work ability and health behaviours of unemployed people through sociodemographic factors and examine the association between good work ability and health behaviours.

DESIGN

A cross-sectional survey.

METHODS

The study is based on the Finnish nationwide Regional Health and Well-being Study using mailed and online questionnaires in 2014-2015. A total of 1973 unemployed or laid-off people between the ages of 20 and 65 responded to the survey. The associations of work ability with sociodemographic factors - gender, age, marital status, minors (i.e. under-18s) living in the household, education, living environment, and duration of unemployment - and health behaviours with sociodemographic factors were first explored using cross-tabulations. Health behaviours included body mass index, daily smoking, alcohol consumption, vegetable consumption, health promotion groups, physical exercise, and sitting in one's leisure time. Health behaviours were then examined using logistic regression analyses, in association with good work ability; the latter was measured with the Work Ability Score.

RESULTS

Being aged below 45, being married or cohabiting, having a high level of education, and short-term unemployment were associated with good work ability. A quarter of participants were daily smokers. A proportion of women with risk level alcohol use (79%) was higher than that of men (59.9%). A third of unemployed people participated in high-intensity physical activity. In regression analyses, high-intensity physical activity (OR 2.25, 95% CI 1.06-4.78) was associated with good work ability.

CONCLUSIONS

Unemployed women and men widely exhibited unhealthy behaviours such as daily smoking and a risk level use of alcohol. Health promotion actions for enhancing a healthy lifestyle and good work ability among unemployed people, particularly in emphasizing the importance of physical activity, are highly recommended.

Identification of Depression and Screening for Work Disabilities among Long-Term Unemployed People

The study explores whether clinical screening targeted at work disabilities among long-term unemployed people reveals eligible individuals for a disability pension and the importance of depression in granting the disability pensions. A total of 364 participants of the screening project were considered as eligible to apply for disability pension. Among them, 188 were diagnosed as clinically depressed. They were classified into those with earlier depression diagnosis (n = 85), those whose depression had not been diagnosed earlier (n = 103), and those without diagnosed depression (n = 176). The association of this ‘Depression identification pattern’ with being granted a disability pension was explored by logistic regression analyses. Compared to those with earlier diagnosis, those whose depression had not been diagnosed earlier were granted disability pension more commonly (72% vs. 54% OR 2.2, p = 0.012). Corresponding figures of the undepressed were 73%, OR 2.3, p = 0.002. The adjustments did not affect the results. Clinical examination of the long-term unemployed people in terms of work disability seems to be worthwhile. In particular, the examination reveals new depression diagnoses, which contribute more to the award of disability pension than depression diagnosed earlier by regular health care. Novel ways to detect depression among the unemployed should be implemented in the health and employment services.

Identification of major depressive disorder among the long-term unemployed

PURPOSE

Depression is a common mental health disorder among the unemployed, but research on identifying their depression in health care is scarce. The present study aimed to explore the identification of major depressive disorder (MDD) in health care on long-term unemployed and find out if the duration of unemployment correlates with the risk for unidentified MDD.

METHODS

The study sample consisted the patient files of long-term unemployed people (duration of unemployment 1-35 years, median 11 years), who in a screening project diagnosed with MDD (n = 243). The MDD diagnosis was found in the health care records of 101. Binomial logistic regression models were used to explore the effect of the duration of unemployment, as a discrete variable, to the identification of MDD in health care.

RESULTS

MDD was appropriately identified in health care for 42% (n = 101) of the participants with MDD. The odds ratio for unidentified MDD in health care was 1.060 (95% confidence interval 1.011; 1.111, p = 0.016) per unemployment year. When unemployment had continued, for example, for five years the odds ratio for having unidentified MDD was 1.336. The association remained significant throughout adjustments for the set of background factors (gender, age, occupational status, marital status, homelessness, criminal record, suicide attempts, number of health care visits).

CONCLUSIONS

This study among depressed long-term unemployed people indicates that the longer the unemployment period has lasted, the more commonly these people suffer from unidentified MDD. Health services should be developed with respect to sensitivity to detect signs of depression among the long-term unemployed.