Time is money: general practitioners' reflections on the fee-for-service system.

BACKGROUND: Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions. METHODS: We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis. RESULTS: We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees. CONCLUSIONS: GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification.

BACKGROUND: General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. METHODS: Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach. RESULTS: Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. CONCLUSION: Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.

The societal impact of individual placement and support implementation on employment outcomes for young adults receiving temporary health-related welfare benefits: a difference-in-differences study.

BACKGROUND: Individual placement and support (IPS) is an evidence-based practice that helps individuals with mental illness gain and retain employment. IPS was implemented for young adults at a municipality level through a cross-sectoral collaboration between specialist mental healthcare, primary mental healthcare, and the government funded employment service (NAV). We investigated whether IPS implementation had a causal effect on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation (work assessment allowance, WAA) welfare benefit, measured at the societal level compared to municipalities that did not implement IPS. METHOD: We used a difference in differences design to estimate the effects of IPS implementation on the outcome of workdays per year using longitudinal registry data. We estimate the average effect of being exposed to IPS implementation during four-years of implementation compared to ten control municipalities without IPS for all WAA recipients. RESULTS: We found a significant, positive, causal effect on societal level employment outcomes of 5.6 (p = 0.001, 95% CI 2.7-8.4) increased workdays per year per individual, equivalent to 12.7 years of increased work in the municipality where IPS was implemented compared to municipalities without IPS. Three years after initial exposure to IPS implementation individuals worked, on average, 10.5 more days per year equating to 23.8 years of increased work. CONCLUSIONS: Implementing IPS as a cross sectoral collaboration at a municipality level has a significant, positive, causal, societal impact on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation welfare benefit.

Economic analyses of supported employment programmes for people with mental health conditions: A systematic review.

BACKGROUND: Employment is intrinsic to recovery from mental health conditions, helping people live independently. Systematic reviews indicate supported employment (SE) focused on competitive employment, including individual placement and support (IPS), is effective in helping people with mental health conditions into work. Evidence is limited on cost-effectiveness. We comprehensively reviewed evidence on the economic case for SE/IPS programmes. METHODS: We searched PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, IBSS, Business Source Complete, and EconLit for economic and return on investment analyses of SE/IPS programmes for mental health conditions. Traditional vocational rehabilitation, sheltered work, and return to work initiatives after sickness absence of less than 1 year were excluded. Studies were independently screened by two reviewers. We assessed quality using the Consolidate Health Economic Evaluation Reporting Standards checklist. The protocol was preregistered with PROSPERO-CRD42020184359. RESULTS: From 40,015 references, 28 studies examined the economic case for IPS, four IPS augmented by another intervention, and 24 other forms of SE. Studies were very heterogenous, quality was variable. Of 41 studies with quality scores over 50%, 10 reported cost per quality-adjusted life year gained, (8 favourable to SE/IPS), 14 net monetary benefits (12 positive), 5 return on investment (4 positive), and 20 cost per employment outcome (14 favorable, 5 inconclusive, 1 negative). Totally, 24 of these 41 studies had monetary benefits that more than outweighed the additional costs of SE/IPS programmes. CONCLUSIONS: There is a strong economic case for the implementation of SE/IPS programmes. The economic case is conservative as evidence on long-term impacts of programmes is limited.

Disability pension dynamics in early adulthood: A two-decade longitudinal study of educational, work and welfare-state trajectories in Norway.

Background: Since the 1990's, structural transformations in the Norwegian economy have decreased employment opportunities for low-skilled young people lacking formal education credentials. In parallel with these economic changes, there has been a strong increase in the proportion of young disability pensioners. Preventing labour market exit requires a thorough understanding of the disability process. We aim to 1) identify the most typical trajectories into disability pension for young Norwegian inhabitants between 1993 and 2014 and 2) investigate if the trajectories and composition of young disability pensioners changed over time. Methods: Using high-quality Norwegian registry data, we established two population-based cohorts of Norwegian inhabitants aged 29-39 years in either 2003 (cohort 1) or 2014 (cohort 2) who were not disability pensioners during the first month of their cohort period but had been granted a disability pension by the cohort end-date. Cohort 1 was followed from the beginning of 1993 through 2003, cohort 2 from 2004 through 2014. We used sequence and cluster analyses to identify typical disability pension trajectories and investigate how they changed overtime. Results: The majority follow trajectories characterised by little or no previous work participation. Both the trajectories and composition of young disability pensioners changed overtime. Between the two cohorts there was 1) a doubling in the probability of following 'precarious income trajectories', 2) a decrease in the probability of following 'work and/or education trajectories' and 3) an increase in the proportion of early school leavers. Conclusion: Current initiatives such as the Norwegian Inclusive Workplace Agreement (IA) focus on preventing transitions from employment to disability benefits. However, such initiatives have little relevance for young disability pensioners as the majority have weak labour market attachment. Policymakers should therefore consider placing more emphasis on non-workplace interventions.

Effectiveness of training workplace managers to understand and support the mental health needs of employees: a systematic review and meta-analysis.

Managers are in an influential position to make decisions that can impact on the mental health and well-being of their employees. As a result, there is an increasing trend for organisations to provide managers with training in how to reduce work-based mental health risk factors for their employees. A systematic search of the literature was conducted to identify workplace interventions for managers with an emphasis on the mental health of employees reporting directing to them. A meta-analysis was performed to calculate pooled effect sizes using the random effects model for both manager and employee outcomes. Ten controlled trials were identified as relevant for this review. Outcomes evaluating managers' mental health knowledge (standardised mean difference (SMD)=0.73; 95% CI 0.43 to 1.03; p<0.001), non-stigmatising attitudes towards mental health (SMD=0.36; 95% CI 0.18 to 0.53; p<0.001) and improving behaviour in supporting employees experiencing mental health problems (SMD=0.59; 95% CI 0.14 to 1.03; p=0.01) were found to have significant pooled effect sizes favouring the intervention. A significant pooled effect was not found for the small number of studies evaluating psychological symptoms in employees (p=0.28). Our meta-analysis indicates that training managers in workplace mental health can improve their knowledge, attitudes and self-reported behaviour in supporting employees experiencing mental health problems. At present, any findings regarding the impact of manager training on levels of psychological distress among employees remain preliminary as only a very limited amount of research evaluating employee outcomes is available. Our review suggests that in order to understand the effectiveness of manager training on employees, an increase in collection of employee level data is required.

Exercise and the Prevention of Depression: Results of the HUNT Cohort Study.

OBJECTIVE: The purpose of the present study was to address 1) whether exercise provides protection against new-onset depression and anxiety and 2) if so, the intensity and amount of exercise required to gain protection and, lastly, 3) the mechanisms that underlie any association. METHOD: A "healthy" cohort of 33,908 adults, selected on the basis of having no symptoms of common mental disorder or limiting physical health conditions, was prospectively followed for 11 years. Validated measures of exercise, depression, anxiety, and a range of potential confounding and mediating factors were collected. RESULTS: Undertaking regular leisure-time exercise was associated with reduced incidence of future depression but not anxiety. The majority of this protective effect occurred at low levels of exercise and was observed regardless of intensity. After adjustment for confounders, the population attributable fraction suggests that, assuming the relationship is causal, 12% of future cases of depression could have been prevented if all participants had engaged in at least 1 hour of physical activity each week. The social and physical health benefits of exercise explained a small proportion of the protective effect. Previously proposed biological mechanisms, such as alterations in parasympathetic vagal tone, did not appear to have a role in explaining the protection against depression. CONCLUSIONS: Regular leisure-time exercise of any intensity provides protection against future depression but not anxiety. Relatively modest changes in population levels of exercise may have important public mental health benefits and prevent a substantial number of new cases of depression.

Is the prevalence of mental illness increasing in Australia? Evidence from national health surveys and administrative data, 2001-2014.

OBJECTIVES: To assess changes in the prevalence rates of probable common mental disorders (CMDs) and in rates of disability support pensions (DSPs) for people with psychiatric disorders in Australia between 2001 and 2014. DESIGN, SETTING AND PARTICIPANTS: Secondary analysis of data from five successive Australian national health surveys of representative samples of the working age population (18-65 years of age) and national data on DSP recipients. MAIN OUTCOME MEASURES: Prevalence of probable CMDs with very high symptom level (defined by a Kessler Psychological Distress Scale [K10] score of 30 or more) or with high symptom level (K10 score of 22 or more); the proportion of working age Australians receiving DSPs for psychiatric conditions. RESULTS: There was no change in the prevalence rate of probable CMDs with very high symptom levels between 2001 and 2014, but a slight decrease in the prevalence of probable CMDs with high symptoms levels, particularly among those under 45 years of age. Over the same period, the proportion of working age individuals receiving DSPs for psychiatric conditions increased by 51% (for trend, P < 0.001), equivalent to one additional DSP for every 182 working age Australians. CONCLUSIONS: Contrary to popular belief, the prevalence of probable CMDs in Australia was stable between 2001 and 2014. However, the proportion of the working age population receiving DSPs for psychiatric conditions increased dramatically over the same period. This conundrum is a major public health problem that should be further examined.

Adolescent mental health and earnings inequalities in adulthood: evidence from the Young-HUNT Study.

BACKGROUND: Previous studies have shown that adolescent mental health problems are associated with lower employment probabilities and risk of unemployment. The evidence on how earnings are affected is much weaker, and few have addressed whether any association reflects unobserved characteristics and whether the consequences of mental health problems vary across the earnings distribution. METHODS: A population-based Norwegian health survey linked to administrative registry data (N=7885) was used to estimate how adolescents' mental health problems (separate indicators of internalising, conduct, and attention problems and total sum scores) affect earnings (≥30 years) in young adulthood. We used linear regression with fixed-effects models comparing either students within schools or siblings within families. Unconditional quantile regressions were used to explore differentials across the earnings distribution. RESULTS: Mental health problems in adolescence reduce average earnings in adulthood, and associations are robust to control for observed family background and school fixed effects. For some, but not all mental health problems, associations are also robust in sibling fixed-effects models, where all stable family factors are controlled. Further, we found much larger earnings loss below the 25th centile. CONCLUSIONS: Adolescent mental health problems reduce adult earnings, especially among individuals in the lower tail of the earnings distribution. Preventing mental health problems in adolescence may increase future earnings.

Cross-language consistency of the Comprehensive Assessment of Psychopathic Personality (CAPP) model.

This study is the first to our knowledge to examine the cross-language consistency across the original version of the Comprehensive Assessment of Psychopathy (CAPP) and a translated version. The CAPP is a lexically based construct map of psychopathy comprising 33 symptoms from 6 broad domains of personality functioning. English-language CAPP prototypicality ratings from 124 mental health workers were compared with ratings from 211 Norwegian mental health workers using the Norwegian translation. High agreement was found across languages in regard to which symptoms where perceived as central to psychopathy or not. Multigroup confirmatory factor analyses (MGCFA) indicated that, overall, the symptoms had similar associations with the 6 proposed underlying dimensions across the 2 language versions. Finally, in general, the probability for a given prototypicality rating on an individual symptom was similar across language version samples at the same level of the underlying trait, as analyzed with Item Response Theory (IRT). Together these findings lend support to the validity of the construct of psychopathy, the validity of the CAPP as a concept map of psychopathy, and the validity of the Norwegian translation of the CAPP.

A prototypicality validation of the Comprehensive Assessment of Psychopathic Personality model (CAPP).

Cooke and colleagues recently developed the lexically based model of psychopathy named the Comprehensive Assessment of Psychopathic Personality (CAPP, Cooke, Hart, Logan, & Michie, 2004). The current study was the first to evaluate aspects of the validity of a translated version of the CAPP model, which comprises 33 symptoms from six domains of personality functioning. Prototypicality ratings from 796 Norwegian community residents, forensic mental health professionals, and corrections professionals were obtained. Most CAPP symptoms were evaluated as highly prototypical of psychopathy by all three groups. Symptoms from the Self, Dominance, and Attachment domains were perceived as more prototypical than those from the Behavioral domain. Confirmatory Factor Analysis (CFA) indicated that two CAPP domains were unidimensional whereas evidence of unidimensionality was somewhat weaker for the other domains, but improved substantially after removal of problematic symptoms. Overall, the findings support the content validity of the CAPP model. This may have relevance to the current considerations regarding reformulation of the criteria for Antisocial Personality Disorder in DSM-V.

Alcohol consumption, problem drinking, abstention and disability pension award. The Nord-Trøndelag Health Study (HUNT).

AIMS: To examine associations of abstention, alcohol consumption and problem drinking with subsequent disability pensioning (DP), and whether previous excessive consumption ('sick-quitting') could explain some of the increased risk for DP among abstainers. DESIGN: Prospective population-based study. SETTING AND PARTICIPANTS: Data were from two waves of the Nord-Trøndelag Health Study (HUNT) linked with the national insurance database. The two main analyses included 37,729 (alcohol consumption) and 34,666 (problem drinking) participants. MEASUREMENTS: Alcohol consumption was measured by self-reported consumption, while problem drinking was assessed by the Cut down, Annoyed, Guilt, Eye-opener (CAGE) questionnaire. Information on subsequent DP, including diagnosis for which the DP was awarded, was gathered from the national insurance database. Covariates included somatic illness and symptoms, mental health, health-related behaviour, socio-economic status and social activity. FINDINGS: Those reporting the highest level of alcohol consumption were not at increased risk for DP [hazard ratio (HR) 1.12, 95% confidence interval (CI): 0.92-1.38], whereas problem drinking was a strong predictor (HR 2.79, 95% CI: 2.08-3.75) compared to their corresponding reference groups. Alcohol abstainers were also at increased risk for DP, but among them, the previous consumers (HR 1.95, 95% CI: 1.48-2.57) and previous excessive consumers (HR 1.67, 95% CI: 1.01-2.74) were at higher risk for DP than constant abstainers. CONCLUSIONS: Problem drinking is linked to subsequent requirement for a disability pension but mere alcohol consumption is not. This is partly explained by 'sick-quitting'.

The association between habitual diet quality and the common mental disorders in community-dwelling adults: the Hordaland Health study.

OBJECTIVE: Recent evidence suggests a role for diet quality in the common mental disorders depression and anxiety. We aimed to investigate the association between diet quality, dietary patterns, and the common mental disorders in Norwegian adults. METHODS: This cross-sectional study included 5731 population-based men and women aged 46 to 49 and 70 to 74 years. Habitual diet was assessed using a validated food frequency questionnaire, and mental health was measured using the Hospital Anxiety and Depression Scale. RESULTS: After adjustments for variables including age, education, income, physical activity, smoking, and alcohol consumption, an a priori healthy diet quality score was inversely related to depression (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.59-0.84) and anxiety (OR = 0.77, 95% CI = 0.68-0.87) in women and to depression (OR = 0.83, 95% CI = 0.70-0.99) in men. Women scoring higher on a healthy dietary pattern were less likely to be depressed (OR = 0.68, 95% CI = 0.57-0.82) or anxious (OR = 0.87, 95% CI = 0.77-0.98), whereas men were more likely to be anxious (OR = 1.19, 95% CI = 1.03-1.38). A traditional Norwegian dietary pattern was also associated with reduced depression in women (OR = 0.77, 95% CI = 0.64-0.92) and anxiety in men (OR = 0.77, 95% CI = 0.61-0.96). A western-type diet was associated with increased anxiety in men (OR = 1.27, 95% CI = 1.14-1.42) and women (OR = 1.29, 95% CI = 1.17-1.43) before final adjustment for energy intake. CONCLUSIONS: In this study, those with better quality diets were less likely to be depressed, whereas a higher intake of processed and unhealthy foods was associated with increased anxiety.

Health problems account for a small part of the association between socioeconomic status and disability pension award. Results from the Hordaland Health Study.

BACKGROUND: Low socioeconomic status is a known risk factor for disability pension, and is also associated with health problems. To what degree health problems can explain the increased risk of disability pension award associated with low socioeconomic status is not known. METHODS: Information on 15,067 participants in the Hordaland Health Study was linked to a comprehensive national registry on disability pension awards. Level of education was used as a proxy for socioeconomic status. Logistic regression analyses were employed to examine the association between socioeconomic status and rates of disability pension award, before and after adjusting for a wide range of somatic and mental health factors. The proportion of the difference in disability pension between socioeconomic groups explained by health was then calculated. RESULTS: Unadjusted odds ratios for disability pension was 4.60 (95% CI: 3.34-6.33) for the group with elementary school only (9 years of education) and 2.03 (95% CI 1.49-2.77) for the group with high school (12 years of education) when compared to the group with higher education (more than 12 years). When adjusting for somatic and mental health, odds ratios were reduced to 3.87 (2.73-5.47) and 1.81 (1.31-2.52). This corresponds to health explaining only a marginal proportion of the increased level of disability pension in the groups with lower socioeconomic status. CONCLUSION: There is a socioeconomic gradient in disability pension similar to the well known socioeconomic gradient in health. However, health accounts for little of the socioeconomic gradient in disability pension. Future studies of socioeconomic gradients in disability pension should focus on explanatory factors beyond health.

Physical activity and common mental disorders.

BACKGROUND: Previous studies have suggested that physical activity may have antidepressant and/or anti-anxiety effects. AIMS: To examine the bidirectional relationship between physical activity and common mental disorders and establish the importance of context, type and intensity of activity undertaken. METHOD: A clinical examination of 40 401 residents of Norway was undertaken. Participants answered questions relating to the frequency and intensity of both leisure-time and workplace activity. Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS). Biological and social data were also collected. RESULTS: There was an inverse relationship between the amount of leisure-time physical activity and case-level symptoms of depression. This cross-sectional association was only present with leisure-time (as opposed to workplace) activity and was not dependent on the intensity of activities undertaken. Higher levels of social support and social engagement were important in explaining the relationship between leisure activity and depression. Biological changes such as alterations to parasympathetic vagal tone (resting pulse) and changes to metabolic markers had a less important role. CONCLUSIONS: Individuals who engage in regular leisure-time activity of any intensity are less likely to have symptoms of depression. The context and social benefits of exercise are important in explaining this relationship.

The health status of nonparticipants in a population-based health study: the Hordaland Health Study.

The authors aimed to examine whether nonparticipation in a population-based health study was associated with poorer health status; to determine whether specific health problems were overrepresented among nonparticipants; and to explore potential consequences of participation bias on associations between exposures and outcomes. They used data from the Hordaland Health Study (HUSK), conducted in western Norway in 1997-1999. Of 29,400 persons invited, 63.1% participated in the study. Information from HUSK was linked with the Norwegian national registry of disability pensions (DPs), including information about DP diagnosis. The risk of DP receipt was almost twice as high among nonparticipants as participants (relative risk = 1.88, 95% confidence interval: 1.81, 1.95). The association was strongest for DPs received for mental disorders, with a 3-fold increased risk for nonparticipation. Substance abuse, psychotic disorders, and personality disorders were especially overrepresented among nonparticipants. The authors simulated the impact of nonparticipation on associations between exposures and outcomes by excluding HUSK participants with higher symptoms of common mental disorders (exposure) and examining the impact on DP (outcome). This selective exclusion modestly reduced associations between common mental disorders and DP. The authors conclude that nonparticipants have poorer health, but this is disorder-dependent. Participation bias is probably a greater threat to the validity of prevalence studies than to studies of associations between exposures and outcomes.

Common mental disorders and disability pension award: seven year follow-up of the HUSK study.

OBJECTIVE: Rates of disability pension (DP) awards remain high in most developed countries. We aimed to estimate the impact of anxiety and depression on DPs awarded both for mental and for physical diagnoses and to estimate the relative contribution of sub case-level anxiety and depression compared with case-level symptom loads. METHODS: Information from a large cohort study on mental and physical health in individuals aged 40-46 (N=15,288) was linked to a comprehensive national database of disability benefits. Case-level and sub case-level anxiety and depression were defined as scores on the Hospital Anxiety and Depression Scale of >or=8 and 5-7, respectively. The outcome was incident award of a DP (including ICD-10 diagnosis) during 1-7-year follow-up. RESULTS: DP awards for all diagnoses were predicted both from case-level anxiety [HR 1.90 (95% CI 1.50-2.41)], case-level depression [HR 2.44 (95% CI 1.65-3.59] and comorbid anxiety and depression [HR 4.92 (95% CI 3.94-6.15)] at baseline. These effects were only partly accounted for by adjusting for baseline somatic symptoms and diagnoses. Anxiety and depression also predicted awards for physical diagnoses [HR 3.26 (95% CI 2.46-4.32)]. The population attributable fractions (PAF) of sub case-level anxiety and depression symptom loads were comparable to those from case-level symptom loads (PAF anxiety 0.07 versus 0.11, PAF depression 0.05 versus 0.06). CONCLUSION: The long-term occupational impact of symptoms of anxiety and depression is currently being underestimated. Sub case-level symptom loads of anxiety and depression make an important and previously unmeasured contribution to DP awards.

Insomnia symptoms and use of health care services and medications: the HUNT-2 study.

This study investigated how symptoms of insomnia are related to use of health care services and medications. Data on insomnia symptoms, use of a range of health care services, and potential confounders were gathered from 47,700 individuals aged 20 to 89. The prevalence of insomnia symptoms was higher among health care users across a range of health professionals. The frequency of medication use, alcohol overuse, and hospitalization was also higher among individuals with insomnia symptoms. Overall, much of these associations were explained by medical or mental conditions, but the effects largely remained significant in the fully adjusted analyses. This study concludes that insomnia symptoms represent a significant public health concern, being independently associated with substantially elevated use of health care services, medications, and alcohol overuse.

Health anxiety and disability pension award: The HUSK Study.

OBJECTIVE: To examine the hypothesized effect of health anxiety on subsequent disability pension award. Mental disorders are consistently underrecognized in general health care, leading to underestimation of its effects on related social security expenditures. According to medicolegal diagnoses for disability pension award, there are almost no awards of disability benefits for health anxiety or hypochondriasis. There are no empirical longitudinal population-based studies on occupational disability in health anxiety or the extreme of hypochondriasis. METHODS: Using a historical cohort design, we utilized a unique link between a large epidemiological cohort study (n = 6819) and a comprehensive national database of disability benefits to examine the effect of health anxiety on subsequent disability pension award (n = 277) during 1.0 to 6.6 years of follow-up. The data sources were merged after informed consent, using the national personal identification number. RESULTS: Health anxiety was a strong predictor of disability pension award, exceeding the effect of general anxiety, and comparable to the effect of depression. This effect was partly accounted for by adjustment for income and level of education, and comorbid mental, psychosomatic, or physical conditions. The effect was not limited to high symptom levels, but followed a dose-response association. Despite the robust effect in this prospective study, health anxiety or hypochondriasis was not recognized as medicolegal diagnosis for any awards of disability pension, and was not accounted for by other mental disorders. CONCLUSIONS: Health anxiety is a strong, independent, and yet underrecognized risk factor for disability pension award.

Insomnia and long sleep duration are risk factors for later work disability. The Hordaland Health Study.

Both insomnia and sleep duration have previously been linked with a range of adverse outcomes, but no studies have explored their relative effect on subsequent work disability. The aim of the present study was to investigate the contribution of insomnia versus sleep duration to later long-term work disability. Using a historical cohort design with 4-year follow-up, data on insomnia, sleep duration and potential confounders were gathered from 6599 working persons (40-45 years). The outcome was award of disability pension, as registered in the National Insurance Administration. After controlling for baseline exposure to disability and sick leave, insomnia was a strong predictor of permanent work disability [odds ratio (OR) = 4.56], and this effect remained significant after controlling for sleep duration, as well as for other possible confounders (OR = 1.88). Short sleep duration was not significantly associated with subsequent work disability, while long sleep duration (>8.5 h) did predict work disability (OR = 2.96), also in the fully adjusted model (OR = 2.14).The present study demonstrates that both insomnia and long sleep duration are strong and independent risk factors for subsequent work disability.