Mental health service diversity and work disability: associations of mental health service system characteristics and mood disorder disability pensioning in Finland

PURPOSE

Public mental health services (MHS) are crucial in preventing psychiatric disability pensions (DP). We studied the associations between mood disorder DP risk and the characteristics of Finnish municipalities' MHS provision using the ESMS-R mapping tool and Finnish population registers, based on first-time granted mood disorder DPs between 2010 and 2015.

METHODS

The final data set included 13,783 first-time mood disorder DP recipients and 1088 mental health service units in 104 municipalities. We focused on five different MHS types: all MHS, outpatient care provision, local services without and with gatekeeping, and centralized services. Three factors for each MHS type were studied: service resources, richness, and diversity index. Negative binomial regression models were used in the analysis.

RESULTS

In all the municipalities, higher service richness and diversity regarding all MHS, outpatient care and local services with gatekeeping were associated with a lower DP risk. In urban municipalities, service richness was mainly associated with lower DP risk, and in semi-urban municipalities service diversity and resources were primarily associated with lower DP risk in outpatient care and local services with gatekeeping. In rural municipalities, DP risk indicated no association with MHS factors.

CONCLUSION

The organization and structure of MHS play a role in psychiatric disability pensioning. MHS richness and diversity are associated with lower mood disorder DP in specific societal contexts indicating their role as quality indicators for regional MHS. The diversity of service provision should be accounted for in MHS planning to offer services matching population needs.

Patterns of mental health services and mood disorder disability pensions: a standard comparison of Finland's three largest hospital districts

INTRODUCTION

Mental disorders are one of the most common and disabling health conditions worldwide. There is however no consensus on the best practice of system level mental health services (MHS) provision, in order to prevent e.g. mood disorder disability pensions (DPs). We analyzed the MHS provision between Finland's three largest hospital districts Helsinki and Uusimaa (HUS), Southwest Finland and Pirkanmaa, with known differences in mood disorder DP risk but presumably equal rates of mood disorder prevalence.

METHODS

We used public MHS data analyzed with the standardized DEscription and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) mapping tool, focusing on all MHS, outpatient care provision, local services without and with gatekeeping, and centralized services. We also collected demographic data based on the European Socio-Demographic Schedule (ESDS). As a novel approach, the Gini-Simpson Diversity Index (GSDI) was calculated for the districts.

RESULTS

Evident differences were observed regarding the districts' MHS factors. As the hospital district with lower DP risk, HUS was characterized by the highest level of regional socioeconomic prosperity as well as high service richness and diversity. With a nationally average DP risk, Southwest Finland had the highest number of MHS personnel in full-time equivalents (FTE) per 100 000 inhabitants. Pirkanmaa, with a higher DP risk, had overall the lowest service richness and the lowest FTE of the three districts in all MHS, outpatient care and local services with gatekeeping.

CONCLUSIONS

Our findings indicate that greater richness and diversity of MHS, especially in outpatient and community-based settings, may serve as indicators of a balanced, high-quality service system that is more effective in preventing mood disorder DP and meeting the different needs of the population. In addition, the need for sufficient resourcing in all MHS and outpatient services is indicated. We suggest using diversity indices to complement the measuring and reporting of regional service variation.

Socioeconomic status, psychotherapy duration, and return to work from disability due to common mental disorders

OBJECTIVE

Low socioeconomic status (SES) is a risk factor for work disability due to common mental disorders (CMDs), one possible reason being inequal use of services. Psychotherapy is an evidence-based treatment for CMDs. This study examines socioeconomic and sociodemographic differences in psychotherapy attendance and an association of psychotherapy duration with return to work (RTW).

METHODS

The study subjects (N = 12,263) were all Finnish citizens granted a disability pension (DP) due to CMDs in 2010-2012. Numbers of psychotherapy sessions (maximum 200) were collected from the nine-year interval around the DP grant. Socioeconomic and sociodemographic differences in psychotherapy duration (dependent variable) among DP recipients were studied using multinomial logistic regression models, likewise, the association between psychotherapy duration and RTW (dependent variable) among temporary DP recipients was examined.

RESULTS

Higher SES, female gender, and younger age were positively associated with attending longer psychotherapies and surpassing the early treatment termination level (>10 sessions). Attending 11-60 psychotherapy sessions was positively associated with full RTW and partial RTW, whereas longer psychotherapies were not. Early termination was positively associated with partial RTW only.

CONCLUSION

This study demonstrates varying tendencies among CMD patients from different backgrounds to attend long rehabilitative psychotherapies, which may create inequalities in RTW.

Socioeconomic factors and use of psychotherapy in common mental disorders predisposing to disability pension

Background

Research in high-income countries has identified low socioeconomic status as a risk factor for disability pension (DP) due to common mental disorders (CMDs). Psychotherapy is an evidence-based treatment for the majority of CMDs along with medication and it is often targeted to prevent work disability. This study examines socioeconomic differences in the use of rehabilitative psychotherapy in Finland, where citizens have universal health coverage, but psychotherapy is partly dependent on personal finance.

Methods

The study subjects (N = 22,501) were all the Finnish citizens granted a DP due to CMD between 2010 and 2015 and a comparison group (N = 57,732) matched based on age, gender, and hospital district. Socioeconomic differences in psychotherapy use were studied using logistic regression models. Socioeconomic status was defined by education, income, and occupation. Age, gender, and family status were also examined.

Results

A lower level of education, lower occupational status (blue-collar worker), male gender, and older age, were associated with less frequent psychotherapy use, in both groups. Education was the strongest component of socioeconomic status associated with psychotherapy use, but the role of income was not straightforward. Unemployment when approaching DP, but not otherwise, was a risk factor for not receiving rehabilitative psychotherapy. Socioeconomic disparities were not any smaller among CMD patients approaching DP than in the comparison group.

Conclusion

This study demonstrates the disparity in the provision of psychotherapy for CMD patients, even on the verge of DP with an acute need for services. This disparity is partly related to a complex interplay of socioeconomic factors and the service system characteristics. Factors predisposing to unequal access to mental health services are presumably diverse and should be studied further.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08389-1.

Socioeconomic factors and regional differences in mental disorder-based disability pensioning in Finland

Introduction

Prior literature has indicated low socioeconomic status (SES) and regional differences as epidemiological risk factors for disability pension (DP) due to mental disorders.

Objectives

Our studies aimed to examine these associations and differences in greater detail, with separate consideration of the risk factors for mood disorders (F30–39) and non-affective psychotic disorder (F20–29) DP.

Methods

Subjects (N = 36 879) were all those granted DP due to a mental disorder for the first time between 2010 and 2015 in Finland. All the subjects were matched with three controls. Education, income and occupational status were used as measures of SES. Conditional logistic regression models were used to study SES differences. Negative binomial regression analysis was used to study the levels of DP risk in the Finnish hospital districts.

Results

DP recipients had low educational and income levels and often lived alone. The risk of DP was greater in white-collar occupational groups compared with blue-collar workers. Students had the greatest risk of DP for all mental and mood disorders. Significant differences in the regional mental disorder DP risks did not appear to follow the traditional Finnish health differences.

Conclusions

We found evidence of SES factors and regional variation associating with mental disorder-related severe loss of working and studying ability in a disorder-specific way. The increased risk of white-collar worker DP could be related to the psychosocially demanding contemporary working life. Regional variation in DP may at least partly relate to differences in regional mental health service systems.

Disclosure

No significant relationships.

Contextual and mental health service factors in mental disorder-based disability pensioning in Finland - a regional comparison

Background

We investigated the regional differences in all mental disorder disability pensions (DP) between 2010 and 2015 in Finland, and separately in mood disorders and non-affective psychotic disorder DP. We also studied the contribution of several district-level contextual and mental health service factors to mental disorder DP.

Methods

Subjects were all those granted mental disorder DP for the first time between 2010 and 2015 in Finland (N = 36,879). Associations between the district-level contextual and mental health service factors and regional DP risks collected from the year 2015 were studied with negative binomial regression analysis in the Finnish hospital districts. The population number on the age (18 to 65 years), gender, occupational status and residential hospital district of the Finnish population from 2015 was used as exposure in the model.

Results

Significant differences in the regional mental disorder DP risks between and within hospital districts did not appear to follow the traditional Finnish health differences. A lower risk of DP was associated with contextual indicators of higher regional socioeconomic level. Furthermore, population density as a proxy for access to mental health services indicated a higher regional DP risk for lower density in all mental (IRR 1.10; 95% CI 1.06–1.14) and mood disorder (IRR 1.12; 95% CI 1.08–1.16) DP. Both the highest and the lowest regional numbers of all mental health outpatient visits were associated with a higher DP risk in all mental and mood disorder DP, whereas particularly low regional numbers of inpatient treatment periods and of patients were associated with a lower risk of DP.

Conclusions

In this comprehensive population-level study, we found evidence of significant regional variation in mental disorder DP and related district-level factors. This variation may at least partly relate to differences in regional mental health service systems and treatment practices. Adapting to the needs of the local population appears to be indicated for both regional mental health service systems and treatment practices to achieve optimal performance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07099-4.

Effects of primary- and secondary-treated bleached kraft mill effluents on the immune system and physiological parameters of roach

The present study was designed to examine, whether, effluents from a modern pulp and paper mill using elemental chlorine-free/total chlorine-free (ECF/TCF) bleaching, exert effects on the immune system of fish and, in addition, to relate these findings to physiological parameters known to be affected by bleached kraft-mill effluents (BKME). Roach (Rutilus rutilus) were exposed in laboratory conditions to primary- or secondary-treated effluent from a pulp and paper mill. In order to study their capability to respond to foreign antigens they were immunised with bovine gamma-globulin (BGG) prior to exposure. The number of anti-BGG antibody-secreting cells (ASC) and the number of immunoglobulin-secreting cells (ISC) in the spleen and blood as well as the level of anti-BGG specific antibodies and concentration of plasma immunoglobulin (IgM) were studied. Phagocytosis and migration of granulocytes of the head kidney were also determined. In addition to the immunological parameters, the activity of hepatic biotransformation enzymes, the carbohydrate metabolism and osmoregulation were examined. Exposure of roach for 21 days to BKME affected several immunological parameters. Both effluents, primary- and secondary-treated, impaired the immunoreactivity of the fish. Sex-related differences in the immune responses were evident in many parameters e.g. in the number of blood ISC and splenic ASC. Sex also had effects on cortisol levels and in the induction of 7-ethoxyresorufin O-deethylase (EROD). These results demonstrate that both primary- and secondary-treated effluent from a pulp and paper mill using ECF/TCF bleaching have effects on fish immune functions. Further, these findings suggest that steroids may contribute to immunomodulation in fish.

Iliac crest donor site morbidity following open and closed methods of bone harvest for alveolar cleft osteoplasty

Donor site morbidity after bone harvesting still remains a crucial problem in alveolar cleft osteoplasty. This study focuses on ilium donor site morbidity comparing two different techniques. A series of 52 consecutive patients was divided in half. All had anterior iliac crest bone grafts. In the study group the harvesting was performed with a closed osteotomy using a cylindrical Shepard osteotome. The control group underwent the traditional open osteotomy. In the open osteotomy group the short-term morbidity at the donor site was slightly greater than in the closed harvesting group. The low short-term morbidity in the closed harvesting group was reflected in the analgesic consumption which was three times higher in the open osteotomy group (p < 0.008). The most striking difference occurred in the appearance of the mature scar: a length of 24.2 mm (mean) in the closed harvesting group against 60.3 mm in the open osteotomy group (p < 0.0001), and a width of 4.9 mm (mean) versus 7.7 mm, respectively (p < 0.003). The long-term morbidity was negligible in both groups. Based on these findings we suggest that bone harvesting from the anterior iliac crest remains the preferred method, provided that closed harvesting is undertaken.

Biomarker responses in whitefish (Coregonus lavaretus L. s.l.) experimentally exposed in a large lake receiving effluents from pulp and paper industry

Physiological and biochemical biomarker responses were studied in juvenile whitefish (Coregonus lavaretus L. s.l.) exposed experimentally to effluent from the forest industry. The large study area (609 km2), Southern Lake Saimaa, in Southeast Finland, receives 330,000 m3 d-1 of biologically and 55,000 m3 d-1 of chemically treated effluents, discharged from two integrated elementary chlorine free (ECF) bleached kraft pulp and paper mills, from one ECF pulp mill, and from one mill producing unbleached pulp and cardboard. The assessment of exposure to effluent discharged from the mills was based on lake water chlorophenolics (CPs) and resin acids (RAs) measured in samples collected from the 22 experimental sites along the area. Despite the low levels of effluent constituents in the lake, they were still accumulated in detectable levels in fish bile, indicating an exposure to the bioactive compounds of effluents. In comparison to the reference area, a two- to four-fold increase in ethoxyresorufin O-deethylase (EROD) activity was observed in whitefish exposed in the vicinity (1-6 km) of all the mills. However, cytochrome P450 1A1 (CYP1A1) gene expression was increased in only one of the receiving areas, indicating higher sensitivity of the EROD activity in the present study. There were no statistically significant correlations between EROD activity and the ambient water concentrations of the CPs, the RAs, or effluent dilution expressed by water sodium concentration. Neither bile chlorophenolics nor bile resin acids showed a significant correlation with EROD. No significant changes in circulating reproductive steroids, 17beta-estradiol and testosterone, in juvenile whitefish were observed. The vitellogenin gene was expressed in the vicinity of the pulp mill discharging the most wood-derived compounds, i.e. resin acids and wood-sterols, including beta-sitosterol. No differences were observed in plasma immunoglobulin M, glucose, or lactate concentrations between the effluent sources.

Blood flow increase in the orofacial area of humans induced by painful stimulation

The purpose of this study was to investigate if painful stimulation produces blood flow changes in the tooth pulp and the facial skin in humans. Also, we attempted to find out if the possible blood flow changes induced by painful stimulation could be explained by central sympathetic and parasympathetic reflex mechanisms, by an antidromic activation of nociceptive axons (axon reflex), or by a change in central cardiovascular parameters. Laser Doppler flowmeter was used to assess the blood flow changes. Electrical tooth pulp stimulation at painful intensities induced a blood flow increase in the ipsilateral lip adjacent to the stimulus site, and vice versa. Nonpainful stimulation had no effects. Painful thermal stimulation of the upper lip also produced an increase in the blood flow of the ipsilateral upper incisor. The blood flow changes in the lip produced by dental stimulation were not correlated with changes in systemic blood pressure or heart rate. Painful electrical stimulation of the hand did not induce any changes in the pulpal blood flow, whereas painful dental stimulation produced a blood flow decrease in the finger but no change in the contralateral lip or cheek. In monkey experiments a regional block of the central conduction of the inferior alveolar nerve at the level of the mandibular foramen produced varying results: the blood flow increase in the lower incisor produced by noxious thermal stimulation of the ipsilateral lower lip was not abolished in two experiments but was abolished in other two experiments. It is concluded that painful stimulation can induce significant increases in the blood flow of the orofacial regions in humans. This increase is predominantly restricted to the region adjacent to the stimulus site and cannot be explained by changes in the central cardiovascular parameters. Central neuronal reflex mechanisms and an axon reflex may both underlie these blood flow increases.

Effects of jaw clenching, jaw movement and static jaw position on facial skin sensitivity to non-painful electrical stimulation in man

The effects of isometric jaw clenching, static jaw position and jaw movement on electrically evoked perception thresholds of the facial skin of the mental region were studied in healthy human subjects. Exercise consisted of brief (1 s) isometric contractions of jaw-closing muscles against a static load (30% of the maximum force), or continuous jaw movements at two different frequencies (1 and 3 Hz). A visual cue was used to indicate the start and end of the isometric exercise (duration 1 s.). Isometric jaw clenching induced a significant elevation of perception thresholds in the skin of the lower jaw just before and during the early electromyographic response of the jaw-closing muscles. This elevation was attenuated before the end of the exercise. Corresponding thresholds evoked by electrical stimulation applied to the dorsum of the hand were not changed by isometric jaw clenching. Changes in static jaw position did not have any effect on detection thresholds. Continuous 'masticatory-like' jaw movements produced a velocity-dependent reduction of sensitivity in the facial skin. The suppression was significantly stronger than that produced by isometric jaw exercise. An imagined isometric biting exercise, which presumably activated the supplementary motor cortex, did not cause any threshold elevations. The results indicate that isometric jaw clenching as well as cyclical jaw movements produce segmentally a phasic, rapidly attenuating masking of facial skin sensitivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Lowered cutaneous sensitivity to nonpainful electrical stimulation during isometric exercise in humans

The effect of isometric exercise on cutaneous sensitivity to nonpainful electric stimulation was studied in human subjects. The exercises consisted of brief (duration: 1-10 s) palmar flexions of the hand or foot against varying loads (10-30% of the maximal force). A visual "go" cue was used to indicate the start and end of the exercise. Isometric hand exercise produced a load-dependent increase of electrotactile thresholds of the fingers. The threshold elevation was rapidly attenuated with prolonged duration of the exercise. The hand exercise-induced threshold elevation was of equal magnitude in the glabrous and hairy skin of the fingers. Thresholds were not changed for the hand contralateral to the exercising hand. Passive static pressure of the hand did not produce threshold changes, whereas activation of afferent inhibition by a vibrotactile stimulus (100 Hz, 0.1 mm) did produce a significant threshold elevation. Exercise-induced threshold elevation was also significant immediately prior to the EMG response of the arm but not at the time of the visual "go" signal, or before it. The threshold increase found during the EMG response was not significantly stronger than that found prior to the EMG response. These results suggest that isometric exercise load-dependently produces a phasic, rapidly attenuating increase in cutaneous tactile thresholds in the exercising limb but not multisegmentally. Corollary efferent barrage from motor to sensory structures of the brain could be underlying the threshold changes produced by isometric exercise, whereas afferent inhibitory mechanisms seem to have only a minor role.

Maxillofacial and dental ice hockey injuries

Maxillofacial and dental ice hockey injuries in Finland were studied during 1979 to 1985. A total of 6,885 accidents occurred to registered players between 1979 and 1982, and 791 (11.5%) of them affected the maxillofacial and dental regions. There were 1,401 separate injuries during the same period, 1,184 of which (84.5%) affected the teeth. The most common cause of accidents (in 54.1% of cases) was a blow received from a stick. Maxillofacial and dental injuries accounted for 38.0% of the total cost of all ice hockey injuries. The mean cost of maxillofacial and dental injuries was over 3 times as high as that for ice hockey injuries as a whole. The use of a mandatory full-cage face mask greatly reduced the number of maxillofacial and dental injuries and hence the cost of treatment.