Discharge planning, self-management, and community support: Strategies to avoid psychiatric rehospitalisation from a service user perspective.

OBJECTIVE: Psychiatric rehospitalisation is often seen as a negative outcome in terms of healthcare quality and cost, as well as potentially hindering the process of recovery. The purpose of our study was to explore psychiatric rehospitalisation from a service-user perspective, paying attention to how rehospitalisation can be avoided. METHOD: Eight focus groups, including a total of 55 mental health service users, were conducted in six European countries (Austria, Finland, Italy, Norway, Romania, and Slovenia). The results were analysed using systematic text condensation. RESULTS: All participants had been in touch with mental health services for at least one year, and had experienced more than one psychiatric hospitalisation. Participants emphasised the importance of discharge planning and psychoeducation both during and after the hospital stay, as well as the benefits of structured plans, coping strategies, self-monitoring techniques, and close contact with local community services.Social contacts and meaningful activities were also considered to be critical, as was support from peers and family members. CONCLUSION: Efforts to avoid psychiatric rehospitalisation should include actions that support a functional day-to-day life, improve coping strategies, and build on cross-sectoral collaboration. PRACTICE IMPLICATIONS: The study emphasises the need for psychoeducational and psychosocial interventions, starting already during the inpatient stay.

Birth size is not associated with depressive symptoms from adolescence to middle-age: results from the Northern Swedish Cohort study.

Low birth weight has been shown to be related to increased risk of depression later in life - but the evidence is not conclusive. We examined the association of size at birth with repeatedly measured depressive symptoms in 947 individuals from the Northern Swedish Cohort, a community-based age-homogeneous cohort born in 1965, and followed with questionnaires between ages 16 and 43 (participation rate above 90% in all the surveys). Information on birth size was retrieved from archived birth records. Length of gestation was known for a subsample of 512 individuals (54%). We studied the association of birth weight and ponderal index with self-reported depressive symptoms at ages 16, 21, 30 and 43; with the life-course average of depressive symptoms score and with longitudinal trajectories of depressive symptoms retrieved by latent class growth analysis. Socioeconomic background, mental illness or alcohol problems of a parent, exposure to social adversities in adolescence and prematurity were accounted for in the analyses. We did not find any relationship between weight or ponderal index at birth and our measure of depressive symptoms between ages 16 and 43 in a series of different analyses. Adjustment for length of gestation did not alter the results. We conclude that size at birth is not associated with later-life depressive symptoms score in this cohort born in the mid-1960s in Sweden. The time and context need to be taken into consideration in future studies.

Mental health service users' experiences of psychiatric re-hospitalisation - an explorative focus group study in six European countries.

BACKGROUND: Psychiatric re-hospitalisation is considered costly and disruptive to individuals. The perspective of the mental health service user is largely unexplored in literature. The purpose of our study was to explore service users' experiences of psychiatric re-hospitalisation across six countries in Europe. METHOD: Eight focus groups were conducted in Romania, Slovenia, Finland, Italy, Austria and Norway. RESULTS: A total of 55 service users participated in the study. All participants had been in receipt of mental health services for at least 1 year, and had experienced more than one psychiatric hospitalisation. The experience of re-hospitalisation was considered: (1) less traumatising than the first hospitalisation, (2) to be necessary, and a relief, (3) occurring by default and without progress, (4) part of the recovery process. CONCLUSIONS: Psychiatric re-hospitalisation was considered inevitable by the study participants, in both positive and negative terms. Striking similarities in service user experiences were found across all of the six countries, the first experience of psychiatric hospitalisation emerging as especially significant. Findings indicate the need for further action in order to develop more recovery and person-centred approaches within hospital care. For psychiatric inpatient care to be a positive part of the recovery process, further knowledge on what therapeutic action during the hospital stay would be beneficial, such as therapy, activities and integration with other services.

Informal caregiving as a risk factor for type 2 diabetes in individuals with favourable and unfavourable psychosocial work environments: A longitudinal multi-cohort study.

AIM: To examine whether informal caregiving is associated with increased risk of type 2 diabetes (T2D), and whether job strain and social support at work modify the association. METHODS: Individual participant's data were pooled from three cohort studies-the French GAZEL study, the Swedish Longitudinal Occupational Survey of Health (SLOSH) and the British Whitehall II study-a total of 21,243 study subjects. Informal caregiving was defined as unpaid care for a closely related person. Job strain was assessed using the demand-control model, and questions on co-worker and supervisor support were combined in a measure of social support at work. Incident T2D was ascertained using registry-based, clinically assessed and self-reported data. RESULTS: A total of 1058 participants developed T2D during the up to 10 years of follow-up. Neither informal caregiving (OR: 1.09, 95% CI: 0.92-1.30) nor high job strain (OR: 1.04, 95% CI: 0.86-1.26) were associated with T2D risk, whereas low social support at work was a risk factor for T2D (OR: 1.18, 95% CI: 1.02-1.37). Also, informal caregivers who were also exposed to low social support at work were at higher risk of T2D (OR: 1.40, 95% CI: 1.08-1.82) compared with those who were not informal caregivers and had high social support at work (multiplicative test for interaction, P=0.04; additive test for interaction, synergy index=10). CONCLUSION: Informal caregiving was not independently associated with T2D risk. However, low social support at work was a risk factor, and informal caregivers with low social support at work had even higher risks of T2D.

Body mass index as a predictor of healthy and disease-free life expectancy between ages 50 and 75: a multicohort study.

BACKGROUND: While many studies have shown associations between obesity and increased risk of morbidity and mortality, little comparable information is available on how body mass index (BMI) impacts health expectancy. We examined associations of BMI with healthy and chronic disease-free life expectancy in four European cohort studies. METHODS: Data were drawn from repeated waves of cohort studies in England, Finland, France and Sweden. BMI was categorized into four groups from normal weight (18.5-24.9 kg m-2) to obesity class II (⩾35 kg m-2). Health expectancy was estimated with two health indicators: sub-optimal self-rated health and having a chronic disease (cardiovascular disease, cancer, respiratory disease and diabetes). Multistate life table models were used to estimate sex-specific healthy life expectancy and chronic disease-free life expectancy from ages 50 to 75 years for each BMI category. RESULTS: The proportion of life spent in good perceived health between ages 50 and 75 progressively decreased with increasing BMI from 81% in normal weight men and women to 53% in men and women with class II obesity which corresponds to an average 7-year difference in absolute terms. The proportion of life between ages 50 and 75 years without chronic diseases decreased from 62 and 65% in normal weight men and women and to 29 and 36% in men and women with class II obesity, respectively. This corresponds to an average 9 more years without chronic diseases in normal weight men and 7 more years in normal weight women between ages 50 and 75 years compared to class II obese men and women. No consistent differences were observed between cohorts. CONCLUSIONS: Excess BMI is associated with substantially shorter healthy and chronic disease-free life expectancy, suggesting that tackling obesity would increase years lived in good health in populations.

Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data.

BACKGROUND: Adverse psychosocial working environments characterized by job strain (the combination of high demands and low control at work) are associated with an increased risk of depressive symptoms among employees, but evidence on clinically diagnosed depression is scarce. We examined job strain as a risk factor for clinical depression. METHOD: We identified published cohort studies from a systematic literature search in PubMed and PsycNET and obtained 14 cohort studies with unpublished individual-level data from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium. Summary estimates of the association were obtained using random-effects models. Individual-level data analyses were based on a pre-published study protocol. RESULTS: We included six published studies with a total of 27 461 individuals and 914 incident cases of clinical depression. From unpublished datasets we included 120 221 individuals and 982 first episodes of hospital-treated clinical depression. Job strain was associated with an increased risk of clinical depression in both published [relative risk (RR) = 1.77, 95% confidence interval (CI) 1.47-2.13] and unpublished datasets (RR = 1.27, 95% CI 1.04-1.55). Further individual participant analyses showed a similar association across sociodemographic subgroups and after excluding individuals with baseline somatic disease. The association was unchanged when excluding individuals with baseline depressive symptoms (RR = 1.25, 95% CI 0.94-1.65), but attenuated on adjustment for a continuous depressive symptoms score (RR = 1.03, 95% CI 0.81-1.32). CONCLUSIONS: Job strain may precipitate clinical depression among employees. Future intervention studies should test whether job strain is a modifiable risk factor for depression.

Job strain and the risk of severe asthma exacerbations: a meta-analysis of individual-participant data from 100 000 European men and women.

BACKGROUND: Many patients and healthcare professionals believe that work-related psychosocial stress, such as job strain, can make asthma worse, but this is not corroborated by empirical evidence. We investigated the associations between job strain and the incidence of severe asthma exacerbations in working-age European men and women. METHODS: We analysed individual-level data, collected between 1985 and 2010, from 102 175 working-age men and women in 11 prospective European studies. Job strain (a combination of high demands and low control at work) was self-reported at baseline. Incident severe asthma exacerbations were ascertained from national hospitalization and death registries. Associations between job strain and asthma exacerbations were modelled using Cox regression and the study-specific findings combined using random-effects meta-analyses. RESULTS: During a median follow-up of 10 years, 1 109 individuals experienced a severe asthma exacerbation (430 with asthma as the primary diagnostic code). In the age- and sex-adjusted analyses, job strain was associated with an increased risk of severe asthma exacerbations defined using the primary diagnostic code (hazard ratio, HR: 1.27, 95% confidence interval, CI: 1.00, 1.61). This association attenuated towards the null after adjustment for potential confounders (HR: 1.22, 95% CI: 0.96, 1.55). No association was observed in the analyses with asthma defined using any diagnostic code (HR: 1.01, 95% CI: 0.86, 1.19). CONCLUSIONS: Our findings suggest that job strain is probably not an important risk factor for severe asthma exacerbations leading to hospitalization or death.

Is transition to disability pension in young people associated with changes in risk of attempted suicide?

BACKGROUND: The aim of the present study was to investigate trajectories of suicide attempt risks before and after granting of disability pension in young people. METHOD: The analytic sample consisted of all persons 16-30 years old and living in Sweden who were granted a disability pension in the years 1995-1997; 2000-2002 as well as 2005-2006 (n = 26,624). Crude risks and adjusted odds ratios for suicide attempt were computed for the 9-year window around the year of disability pension receipt by repeated-measures logistic regressions. RESULTS: The risk of suicide attempt was found to increase continuously up to the year preceding the granting of disability pension in young people, after which the risk declined. These trajectories were similar for women and men and for disability pension due to mental and somatic diagnoses. Still, the multivariate odds ratios for suicide attempts for women and for disability pension due to mental disorders were 2.5- and 3.8-fold increased compared with the odds ratios for men and disability pension due to somatic disorders, respectively. Trajectories of suicide attempts differed for young individuals granted a disability pension during 2005-2006 compared with those granted during 1995-1997 and 2000-2002. CONCLUSIONS: We found an increasing risk of suicide attempt up until the granting of a disability pension in young individuals, after which the risk decreased. It is of clinical importance to monitor suicide attempt risk among young people waiting for the granting of a disability pension.

Hospital organizational factors influence work-family conflict in registered nurses: Multilevel modeling of a nation-wide cross-sectional survey in Sweden.

BACKGROUND: The present shortage of registered nurses (RNs) in many European countries is expected to continue and worsen, which poses a substantial threat to the maintenance of healthcare in this region. Work-family conflict is a known risk factor for turnover and sickness absence. OBJECTIVE: This paper empirically examines whether the nurse practice environment is associated with experienced work-family conflict. DESIGN: A multilevel model was fit with the individual RN at the 1st, and the hospital department at the 2nd level using cross-sectional RN survey data from the Swedish part of RN4CAST, an EU 7th framework project. The data analyzed here is based on a national sample of 8356 female and 592 male RNs from 369 hospital departments. RESULTS: We found that 6% of the variability in work-family conflict experienced by RNs was at the department level. Organizational level factors significantly accounted for most of the variability at this level with two of the work practice environment factors examined, staffing adequacy and nurse involvement in hospital affairs, significantly related to work-family conflict. Due to the design of the study, factors on ward and work group levels could not be analyzed, but are likely to account for additional variance which in the present analysis appears to be on the individual level, with private life factors likely explaining another major part. CONCLUSION: These results suggest that higher level organizational factors in health care have a significant impact on the risk of work-family conflict among RNs through their impact on the nurse practice environment. Lower level organizational factors should be investigated in future studies using hierarchical multilevel sampling.

Diagnosis-specific sick leave as a long-term predictor of disability pension: a 13-year follow-up of the GAZEL cohort study.

BACKGROUND: Factors that increase the risk of labour market exclusion are poorly understood. In this study, we examined the extent to which all-cause and diagnosis-specific sick leave predict subsequent disability pension (DP). METHODS: Prospective cohort study of 20 434 persons employed by the French national gas and electric company (the GAZEL study). New sick-leave spells >7 days in 1990-1992 were obtained from company records. Follow-up for DP was from 1994 to 2007. RESULTS: The HR, adjusted for age and occupational position, for DP was 3.5 (95% CI 2.7 to 4.5) in men and 2.6 (95% CI 1.9 to 3.5) in women with one or more sick-leave spells >7 days compared with those with no sick leave. The strongest predictor of DP was sick leave with a psychiatric diagnosis, HR 7.6 (95% CI 5.2 to 10.9) for men and 4.1 (95% CI 2.9 to 5.9) for women. Corresponding HRs for sick leave due to circulatory diagnoses in men and women were 5.6 (95% CI 3.7 to 8.6) and 3.1 (95% CI 1.8 to 5.3), for respiratory diagnoses 3.9 (95% CI 2.6 to 5.8) and 2.6 (95% CI 1.7 to 4.0), and musculoskeletal diagnoses 4.6 (95% CI 3.4 to 6.4) and 3.3 (95% CI 2.2 to 4.8), respectively. CONCLUSIONS: Sick leave with a psychiatric diagnosis is a major risk factor for subsequent DP, especially among men. Sick leave due to musculoskeletal or circulatory disorders was also a strong predictor of DP. Diagnosis-specific sick leave should be recognised as an early risk marker for future exclusion from the labour market.

Job strain in relation to body mass index: pooled analysis of 160 000 adults from 13 cohort studies.

BACKGROUND: Evidence of an association between job strain and obesity is inconsistent, mostly limited to small-scale studies, and does not distinguish between categories of underweight or obesity subclasses. OBJECTIVES: To examine the association between job strain and body mass index (BMI) in a large adult population. METHODS: We performed a pooled cross-sectional analysis based on individual-level data from 13 European studies resulting in a total of 161 746 participants (49% men, mean age, 43.7 years). Longitudinal analysis with a median follow-up of 4 years was possible for four cohort studies (n = 42 222). RESULTS: A total of 86 429 participants were of normal weight (BMI 18.5-24.9 kg m(-2) ), 2149 were underweight (BMI < 18.5 kg m(-2) ), 56 572 overweight (BMI 25.0-29.9 kg m(-2) ) and 13 523 class I (BMI 30-34.9 kg m(-2) ) and 3073 classes II/III (BMI ≥ 35 kg m(-2) ) obese. In addition, 27 010 (17%) participants reported job strain. In cross-sectional analyses, we found increased odds of job strain amongst underweight [odds ratio 1.12, 95% confidence interval (CI) 1.00-1.25], obese class I (odds ratio 1.07, 95% CI 1.02-1.12) and obese classes II/III participants (odds ratio 1.14, 95% CI 1.01-1.28) as compared with participants of normal weight. In longitudinal analysis, both weight gain and weight loss were related to the onset of job strain during follow-up. CONCLUSIONS: In an analysis of European data, we found both weight gain and weight loss to be associated with the onset of job strain, consistent with a 'U'-shaped cross-sectional association between job strain and BMI. These associations were relatively modest; therefore, it is unlikely that intervention to reduce job strain would be effective in combating obesity at a population level.

Covert coping with unfair treatment at work and risk of incident myocardial infarction and cardiac death among men: prospective cohort study.

BACKGROUND: Covert coping with unfair treatment at work--occurring when an employee does not show the "aggressor" that he/she feels unfairly treated--has been found to be associated with cardiovascular risk factors. This study examined whether covert coping also predicts incident coronary heart disease. METHODS: A prospective cohort study (the WOLF Stockholm study) of workplaces in the Stockholm area, Sweden. The participants were 2755 men with no history of myocardial infarction at baseline screening in 1992-1995. The main outcome measure was hospitalisation due to myocardial infarction or death from ischaemic heart disease until 2003 obtained from national registers (mean follow-up 9.8 ± 0.9 years). RESULTS: Forty-seven participants had myocardial infarction or died from ischaemic heart disease during follow-up. After adjustment for age, socioeconomic factors, risk behaviours, job strain and biological risk factors at baseline, there was a dose-response relationship between covert coping and risk of incident myocardial infarction or cardiac death (p for trend=0.10). Men who frequently used covert coping had a 2.29 (95% CI 1.00 to 5.29) times higher risk than those who did not use coping. Restricting the analysis to direct coping behaviours only strengthened this association (p for trend=0.02). CONCLUSIONS: In this study, covert coping is strongly related to increased risk of hard-endpoint cardiovascular disease.

Prevalence and characteristics of hearing problems in a working and non-working Swedish population.

BACKGROUND: Hearing problems are among the top 10 most common burdens of disease and are projected to be become even more common by the year 2030. The aim of the present study was to give a current assessment of the prevalence of communication difficulties because of hearing loss and tinnitus, in the general Swedish working and non-working populations in relation to sex, age, socioeconomic status (SES) and noise exposure. How prevalence is affected by SES has not been previously established. METHODS: A total of 18 734 individuals were invited to participate in the study, of which 11 441 (61%) enrolled. Of the participants, 9756 answered the questionnaire for those who work and 1685 answered the version for non-workers. FINDINGS: The most important findings are that 31% in the working population and 36% in the non-working population report either hearing loss or tinnitus or both. The prevalence of hearing problems increases with age, is higher among men and persons with low self-rated SES, and covaries with exposure to noise at work. Severe hearing problems are already present in men and women under 40 years of age who are exposed to work-related noise. INTERPRETATION: Prevalence of hearing problems is far more common than previously estimated and is associated with SES and noise exposure history. Hearing problems have a gradual onset that can take years to become recognised. In order to proactively intervene and prevent this deleterious, yet avoidable handicap, statistics need to be regularly updated.

Diagnosis-specific sickness absence and all-cause mortality in the GAZEL study.

BACKGROUND: This study aims to examine diagnosis-specific sickness absence as a risk marker for all-cause mortality. METHODS: Prospective occupational cohort (the GAZEL study). Medically certified sickness absence spells >7 days for 15 diagnostic categories, 1990-1992, were examined in relation to all-cause mortality, January 1993-February 2007. The reference group for each diagnostic category was participants with no spell >7 days for that diagnosis. The participants were French public utility workers (5271 women and 13 964 men) aged 37-51 years in 1990, forming the GAZEL study. Over the follow-up period, there were 144 deaths in women and 758 in men. RESULTS: 7875 employees (41.0%) had at least one spell of sickness absence >7 days over the 3-year period. The commonest diagnoses were mental disorders, musculoskeletal diseases, respiratory diseases and external causes in both sexes; genitourinary diseases in women, and digestive and circulatory diseases in men. Of these common diagnoses, mental disorders in women, hazard ratio (95% confidence intervals) 1.24 (1.1 to 1.4), and mental disorders 1.35 (1.3 to 1.5), digestive diseases 1.29 (1.1 to 1.6) and circulatory diseases 1.35 (1.2 to 1.6) in men were associated with mortality after adjustment for age, employment grade and sickness absence in all other diagnostic categories. CONCLUSIONS: Employees with medically certified absence spells of 1 week or more over a 3-year period had a 60% excess risk of early death. In women and men this excess risk was associated with some of the commonest diagnoses of sickness absence, in particular mental disorders. Sickness absence for mental disorders may be a useful early indicator of groups at increased risk of fatal disease.

Managerial leadership and ischaemic heart disease among employees: the Swedish WOLF study.

OBJECTIVE: To investigate the association between managerial leadership and ischaemic heart disease (IHD) among employees. METHODS: Data on 3122 Swedish male employees were drawn from a prospective cohort study (WOLF). Baseline screening was carried out in 1992-1995. Managerial leadership behaviours (consideration for individual employees, provision of clarity in goals and role expectations, supplying information and feedback, ability to carry out changes at work successfully, and promotion of employee participation and control) were rated by subordinates. Records of employee hospital admissions with a diagnosis of acute myocardial infarction or unstable angina and deaths from IHD or cardiac arrest to the end of 2003 were used to ascertain IHD. Cox proportional-hazards analyses were used to calculate hazard ratios for incident IHD per 1 standard deviation increase in standardised leadership score. RESULTS: 74 incident IHD events occurred during the mean follow-up period of 9.7 years. Higher leadership score was associated with lower IHD risk. The inverse association was stronger the longer the participant had worked in the same workplace (age-adjusted hazard ratio 0.76 (95% CI 0.61 to 0.96) for employment for 1 year, 0.77 (0.61 to 0.97) for 2 years, 0.69 (0.54 to 0.88) for 3 years, and 0.61 (0.47 to 0.80) for 4 years); this association was robust to adjustments for education, social class, income, supervisory status, perceived physical load at work, smoking, physical exercise, BMI, blood pressure, lipids, fibrinogen and diabetes. The dose-response association between perceived leadership behaviours and IHD was also evident in subsidiary analyses with only acute myocardial infarction and cardiac death as the outcome. CONCLUSION: If the observed associations were causal then workplace interventions should focus on concrete managerial behaviours in order to prevent IHD in employees.

Sickness absence as a prognostic marker for common chronic conditions: analysis of mortality in the GAZEL study.

OBJECTIVES: To determine whether sickness absence is a prognostic marker in terms of mortality among people with common chronic conditions. METHODS: Prospective occupational cohort study of 13,077 men and 4871 women aged 37-51 from the National Gas and Electricity Company, France. Records of physician-certified sickness absences over a 3-year period were obtained from employers' registers. Chronic conditions were assessed in annual surveys over the same period. The main outcome measure was all-cause mortality (803 deaths, mean follow-up after assessment of sickness absence: 13.9 years). RESULTS: In Cox proportional hazard models adjusted for age, sex, socioeconomic position and co-morbidity, >28 annual sickness-absence days versus no absence days was associated with an excess mortality risk among those with cancer (hazard ratio 5.4, 95% CI 2.2 to 13.1), depression (1.7, 1.1 to 2.8), chronic bronchitis or asthma (2.7, 1.6 to 4.6) and hypertension (1.6, 1.0 to 2.6). The corresponding hazard ratios for more than five long (>14 days) sickness-absence episodes per 10 person-years versus no such episodes were 5.4 (2.2 to 13.1), 1.8 (1.3 to 2.7), 2.0 (1.3 to 3.2) and 1.8 (1.2 to 2.7), respectively. Areas under receiver operating characteristics curves for these absence measures varied between 0.56 and 0.73, indicating the potential of these measures to distinguish groups at high risk of mortality. The findings were consistent across sex, age and socioeconomic groups and in those with and without co-morbid conditions. CONCLUSION: Data on sickness absence may provide useful prognostic information for common chronic conditions at the population level.

Job strain and ischaemic disease: does the inclusion of older employees in the cohort dilute the association? The WOLF Stockholm Study.

OBJECTIVE: Evidence on the association between job strain and ischaemic disease is mixed. This study examined whether including older age individuals in a cohort used to assess job strain attenuates findings towards the null. DESIGN: A prospective cohort study with baseline screening in 1992-5. A follow-up for ischaemic disease until 2003 was based on linkages to national registries. Ischaemic disease was corroborated by objective criteria (hospitalisation as a result of acute myocardial infarction, unstable angina or ischaemic stroke; or death from ischaemic heart disease, cardiac arrest or ischaemic stroke). PARTICIPANTS: 3160 male employees aged 19-65 years without pre-existing or current ischaemic disease. RESULTS: 93 cases of incident ischaemic disease were recorded. In the 19-55 year age group, the participants with job strain had a 1.76 (95% CI 1.05 to 2.95) times higher age-adjusted risk of incident ischaemic disease than those free of strain. Further adjustment for conventional cardiovascular risk factors had little effect on this association, but the impact of job strain was reduced by 70% to non-significant after the inclusion of employees older than 55 years in the cohort (hazard ratio 1.22, 95% CI 0.75 to 1.96). CONCLUSIONS: Including older employees in a cohort may dilute the effect of job strain on cardiovascular disease and is a potential reason for inconsistent findings in previous studies.

Downsizing of staff is associated with lowered medically certified sick leave in female employees.

AIM: To determine whether changes in number of staff in work sites are associated with medically certified sick leave among employees with an increased risk of developing cardiovascular disease. METHODS: The 5720 employees (aged 18-65) were from the WOLF study of cardiovascular risk factors in working men and women in greater Stockholm during the years 1992-95. From the medical examination a cardiovascular score was calculated for each participant. The WOLF study base was linked to a Statistics Sweden registry of economic and administrative activities. Sick leave spells lasting for at least 15 days during the calendar year following downsizing/expansion were identified for each subject. RESULTS: In multiple logistic regression an increased likelihood of having no medically certified sick leave (15 days or more) was found in women during the year following both downsizing and expansion. These analyses were adjusted for age and cardiovascular score. A high cardiovascular risk score reduced the likelihood of having no medically certified sick leave. The inclusion of psychosocial work environment variables did not change the results markedly. Separate analyses of women with and without high cardiovascular score showed that downsizing had a more pronounced effect on reduced long term sick leave among those with high than among those without low cardiovascular score. There were no consistent findings in men. CONCLUSIONS: There is evidence of a reduction of long term sick leave in women after downsizing and this is particularly evident among those with high cardiovascular score.

Psychophysiological effects of temporary alternative employment.

Twenty-one participants in a mobilising labour market project offering temporary, alternative employment in Sweden were followed longitudinally for one year, including a six month post-participation follow-up period. Earlier analyses of self-rated psychosocial data have indicated consistent improvements in mental health and quality of life. In the present study, however, a significant rise in serum prolactin, plus decreased dehydro-epiandro-sterone sulphate levels and tendencies towards increased alanine aminotransferase, gamma-glutamyl transferase and diastolic blood pressure, seem to disconfirm the hypothesis that biological markers of psychosocial health would improve in a similar fashion. It is speculated that this apparent inconsistency could be part of a protective adaptation to long-term unemployment similar to the cocooning tendencies in maternal behaviour. Specifically, we argue that this could protect against the stress of being in an uncontrollable and 'helpless' situation by facilitating a re-focusing on more private matters as opposed to 'hopeless' job seeking. While being potentially detrimental for people with fair chances on the labour market, it is possible that such an adaptation may be helpful for more vulnerable groups.

Unemployment, labour market policy and health in Sweden during years of crisis in the 1990's.

OBJECTIVE: To give an overview of an economic crisis in Sweden and its health consequences for employed and unemployed groups together with some health-related data from participants in labour market programmes. OUTCOME AND CONCLUSIONS: During the first half of the 1990's, Sweden was hit by a pervasive crises characterised by steeply increasing unemployment and growing job insecurity. Long-term survey data show that somatic well-being continued to improve in the population, while psychological well-being deteriorated, and this deterioration was of a similar magnitude among unemployed and employed groups. Two non-traditional labour market programmes for unemployed individuals are briefly described. Both programmes resulted in some positive effects on subjective health, which, however, were not corroborated by psychophysiological data. It is argued that the employment-unemployment dichotomy can be replaced by a dimensional view on labour market connection, as insecure jobs may have as detrimental health effects as open unemployment. Impediments to empowerment in the labour market programmes are discussed.