Educational inequalities in major depressive disorder prevalence, timing and duration among adults over the life course: a microsimulation analysis based on the Lifelines Cohort Study.

BACKGROUND: Educational inequalities in major depressive disorder (MDD) pose a major challenge. Tackling this issue requires evidence on the long-term impact of intervening on modifiable factors, for example lifestyle and psychosocial factors. For this reason, we aimed to simulate the development of educational inequalities in MDD across the life course, and to estimate the potential impact of intervening on modifiable factors. METHODS: We used data from the prospective Dutch Lifelines Cohort Study to estimate the required input for a continuous-time microsimulation. The microsimulation allowed us to project the development of educational inequalities in MDD between ages 18 and 65, and to assess the potential benefit of intervening on quality of social contacts, health literacy and smoking. RESULTS: On average, an additional 19.1% of individuals with low education will ever experience MDD between ages 18 and 65 compared with those with high education. Additionally, individuals with low education generally will develop MDD 0.9 years earlier and spend 1.2 years more with MDD, than individuals with high education. Improving the quality of social contacts in individuals with low education produced the largest effect; it would reduce the inequalities in the prevalence, onset and duration of MDD by an average of 18.4%, 18.3% and 28.6%, respectively. CONCLUSIONS: Intervening on modifiable factors, particularly quality of social contacts, in individuals with low education could help reduce the estimated educational inequalities in MDD over the life course.

Work- and mental health-related events and body mass index trajectories during the Covid-19 lockdown. Evidence from the lifelines cohort study in the Netherlands.

BACKGROUND: The aim of this study was to identify heterogeneity in trajectories of body mass index (BMI) during the Covid-19 pandemic in the Netherlands. Moreover, we aimed to investigate whether work- and mental health-related disruptive events experienced during the pandemic, such as job insecurity or depression, were associated with such BMI trajectories. METHODS: Longitudinal data from the Lifelines Covid Questionnaire was used (21 waves between April 2020 and July 2021; n = 64,630). Different trajectories were identified using group-based trajectory models. Multinomial regression models were fitted to analyse the main determinants of experiencing changes in BMI during the pandemic. RESULTS: Trajectories of increased BMI, and, to a lesser extent also trajectories of decreased BMI, were more common among those who experienced disruptive work-related events (e.g., being laid-off or having a temporary contract) and mental health-related events (e.g., anxiety or depression) during the pandemic. Those experiencing multiple events were particularly likely to show trajectories of increased or decreased BMI. CONCLUSIONS: During the Covid-19 pandemic, strong heterogeneity was observed in BMI trajectories. This was partially related to work- and mental health-related events.

Life-course insecurity among young adults: Evidence for variation by employment status?

Previous research suggests that lack of employment security can lead young adults to experience a higher degree of insecurity with regard to their future life. We test the relationship between life-course insecurity, i.e. worrisome feelings with regard to one's own future, and young adults' employment status using a newly developed measurement instrument. Furthermore, we examine whether, in terms of life-course insecurity, specific groups of young people are more affected by insecure employment conditions based on their structural position. Survey data (n = 1087) were collected within a Dutch representative panel among those aged 18-35. Structural equation modelling is used to construct latent dependent variables for experienced insecurity in four life domains, namely 'work', 'finances', 'partner and family' and 'leisure and personal development'. Results show that, while controlling for gender, life phase, education level and level of neuroticism, lack of employment is associated with higher insecurity in all four domains of life. Precarious employment based on a flexible contract is associated with higher insecurity regarding 'work', 'finances' and 'partner and family'. Moreover, we find the relationship between lack of employment and life-course insecurity to be stronger for young people in the 26-35 age bracket. However, higher educational attainment does not attenuate the positive relationship between precarious employment and life-course insecurity. The findings of this study inform our theoretical understanding of agency within the life course of young adults by signaling insecure labour market attachment as a potential constraint to formulating plans for the future.

Educational inequalities in metabolic syndrome prevalence, timing, and duration amongst adults over the life course: a microsimulation analysis based on the lifelines cohort study.

BACKGROUND: Educational inequalities in metabolic syndrome (MetS) are a growing public health concern. Intervening on modifiable factors may help reduce these inequalities, but there is a need for evidence on the long-term impact of intervening on these factors. Thus, we simulate the development of educational inequalities in MetS across the life course and assess the impact of intervening on the modifiable factors that contribute to these inequalities. METHODS: We used data from the prospective multigenerational Dutch Lifelines Cohort Study to estimate the required input for a continuous-time microsimulation. The microsimulation projects the development of educational inequalities in MetS between ages 18 and 65, and assesses the potential benefit of intervening on smoking, alcohol use, diet quality, and health literacy. FINDINGS: The likelihood of ever experiencing MetS between ages 18 and 65 varies from 32.5% among high educated women to 71.5% among low educated men. On average, 27.6% more individuals with low education will ever experience MetS between ages 18 and 65 compared to those with high education. Additionally, individuals with low education generally will develop MetS 2.3 years earlier, and will spend an extra 2.6 years with MetS, compared to individuals with high education. Changes to smoking behaviours in individuals with low education produced the largest effect; it would reduce inequalities in prevalence, timing and duration by an average of 7.5%, 9.5%, and 6.9%, respectively. CONCLUSIONS: Interventions targeting the modifiable factors included in this study, especially smoking, could help reduce the estimated educational inequalities in MetS over the life course.

Understanding trends in loneliness during the COVID-19 pandemic in The Netherlands: the moderating role of gender, age, and living arrangement.

Objectives: Evidence suggests that the COVID-19 pandemic and the preventive lockdown measures increased loneliness levels. However, most studies are cross-sectional or rely on a pre-post (pandemic) design. This study relies on multiple observations to analyze the impact of the lockdown on loneliness levels in the Netherlands, and test whether it differed by gender, age, and living arrangement.Methods: Longitudinal data from the Covid-Questionnaire within the Lifelines Cohort Study from the northern Netherlands was used. Data was gathered between March 2020 and July 2021 with a total of 21 waves and 769,526 observations nested in 74,844 individuals. The outcome was a multi-dimensional Loneliness Index. The association between the lockdown period and loneliness levels was estimated using fixed-effects linear regression. Moderation effects were tested by means of two-way interactions.Results: Loneliness levels increased during stricter lockdown periods, and decreased when preventive measures were relaxed. Women and young adults experienced stronger fluctuations in their loneliness levels, whereas living arrangement did not play a notable moderating role.Conclusion: This study calls for special attention to be paid to the public issue of loneliness during periods of lockdown. Women and young adults appear as particularly vulnerable groups during the Covid-19 pandemic.

Sickness absence around contact with outpatient mental health care services - differences between migrants and non-migrants: a Norwegian register study.

BACKGROUND: Mental disorders are a leading cause of sickness absence. Some groups of migrants are at higher risk of both mental disorder and sickness absence. Yet, research on sickness absence in relation to mental disorders among migrants is limited. This study investigates differences in sickness absence in the twelve-month period around contact with outpatient mental health services between non-migrants and various migrant groups with different length of stays. It also considers whether these differences are similar for men and women. METHODS: Using linked Norwegian register data, we followed 146,785 individuals, aged 18-66 years, who had attended outpatient mental health services and who had, or had recently had, a stable workforce attachment. The number of days of sickness absence was calculated for the 12-month period surrounding contact with outpatient mental health services. We applied logistic regression and zero-truncated negative binomial regression to assess differences in any sickness absence and number of days of absence between non-migrants and migrants, including refugees and non-refugees. We included interaction terms between migrant category and sex. RESULTS: Refugee men and other migrant men from countries outside the European Economic Area (EEA) had a higher probability of any sickness absence in the period surrounding contact with outpatient mental health services than their non-migrant counterparts. Women from EEA countries with stays of less than 15 years had a lower probability than non-migrant women. Additionally, refugees, both men and women, with 6-14 years in Norway had more days of absence while EEA migrants had fewer days than their non-migrant counterparts. CONCLUSIONS: Refugee men and other non-EEA migrant men appear to have higher sickness absence than non-migrant men around the time of contact with services. This finding does not apply to women. Several probable reasons for this are discussed, though further research is required to understand why. Targeted strategies to reduce sickness absence and support the return to work for refugees and other non-EEA migrant men are needed. Barriers to timely help-seeking should also be addressed.

Changes in anxiety and depression symptoms during the Covid-19 lockdown in the Netherlands. The moderating role of pre-existing mental health, employment situation and alcohol consumption.

PURPOSE: Evidence suggests an increase of depression and anxiety symptoms during the Covid-19 pandemic but most studies relied on cross-sectional designs and/or small samples, and they often overlooked subgroup effects in the impact of the lockdown. We investigated the effect of the pandemic on depression and anxiety symptoms, and whether it differed by employment situation and alcohol consumption. METHODS: This longitudinal study used 23 waves of the Covid-Questionnaire (April 2020-July 2021), within the Lifelines cohort from the Netherlands (n = 76,254). Depression and anxiety symptoms were combined in a "mental health score". Linear fixed-effects models were fitted to analyse trends in mental health throughout the observation period. The moderating role of pre-existing mental health, employment situation, and alcohol consumption was tested. RESULTS: Depression and anxiety symptoms fluctuated considerably during the observation period, with clear peaks in winter 2021, during the strictest lockdown period. Moreover, temporal patterns differed by employment situation and alcohol consumption patterns, suggesting that various subgroups reacted to the pandemic and the lockdown in different ways. CONCLUSION: Lockdowns increased depression and anxiety symptoms in the Netherlands. The effect was particularly strong for unemployed individuals, those with risky alcohol consumption patterns and those with pre-existing mental health disorders.

Mental disorder and subsequent marital separation among migrant and non-migrant women.

Using national register data between 2006-2014, we investigated the relationship between outpatient mental health service use (a proxy for mental disorder) and subsequent marital separation among women in Norway and whether the strength of the association differed for migrant and non-migrant women. Our sample population included 679,928 married women aged 18-60 years. Service use was strongly associated with marital separation among all women. The relationship was stronger for Filipinas but weaker for Somalis and Russians, compared with non-migrant women. Migration-related factors may influence marital separation among migrant women and barriers to care are likely to exist.

Relationship Between Childhood Abuse and Body Mass Index in Young Adulthood: Mediated by Depression and Anxiety?

We examined whether childhood abuse is related to body mass index (BMI) in young adults and whether this relationship is mediated by depression and anxiety. Data are from the Dutch longitudinal cohort study TRAILS (nfemales = 836, nmales = 719). At wave 4, childhood sexual, physical and verbal abuse, and lifetime major depressive disorder (MDD) and generalized anxiety disorder (GAD) were assessed. BMI was measured at wave 4 and 5 (mean age = 19.2/22.4 years). Sex-stratified structural equation models were estimated. Females who had experienced sexual abuse had a higher BMI at wave 4 (B = 0.97, 95%CI = [-0.01,1.96]) and a higher increase in BMI between wave 4 and 5 (B = 0.52, 95%CI = [0.04,1.01]) than females who had not experienced sexual abuse. Additionally, MDD and BMI at wave 4 were related in females (B = 1.35, 95%CI = [0.52,2.18]). MDD mediated the relationship between sexual abuse and BMI at wave 4 in females. In addition, sexual abuse moderated the relationship between MDD and BMI at wave 4. The relationship was stronger among females who had experienced sexual abuse than among females who had not. Prevention of BMI changes among females who experienced sexual abuse may thus be warranted, particularly when they developed MDD. MDD treatment, such as abuse-focused psychotherapy, may aid this prevention.

Disentangling the association between alcohol consumption and employment status: causation, selection or confounding?

BACKGROUND: Alcohol use constitutes a major health risk and is related to unemployment. However, the direction of this relationship is unclear: unemployment may change drinking patterns (causation), but heavy drinkers may also be more prone to lose their job (selection). We simultaneously examined selection and causation, and assessed the role of residual confounding. Moreover, we paid attention to the subgroup of abstainers and occupationally disabled, often disregarded in the literature. METHODS: Longitudinal data (three waves collected between 2006 and 2018) of the Lifelines Cohort study from the Netherlands were used (138 875 observations of 55 415 individuals, aged 18-60 at baseline). Alcohol use was categorized as 'abstaining', 'moderate drinking' and 'binge drinking' (≥5 drinks/occasion for male; ≥4 for women). Employment status included occupational disability, short (<6 months) and long-term (≥6 months) unemployment. Random- and fixed-effects multinomial regression models were fitted in order to account for residual confounding. Reciprocal causality was assessed through generalized structural equation modelling with fixed-effects. RESULTS: Long unemployment spells increase the risk for both binge drinking (ß = 0.23; 95% CI 0.04-0.42) and abstinence (ß = 0.27; 95% CI 0.11-0.44), and the effects hold after accounting for reciprocal causality and time-constant confounding. Contrarily, the effect of binge drinking on unemployment is weak (ß = 0.14; 95% CI -0.03 to 0.31). Abstinence is strongly associated with occupational disability (ß = 0.40; 95% CI 0.24-0.57). CONCLUSIONS: We find evidence supporting the causation hypothesis (unemployment altering drinking patterns), whereas evidence for the selection hypothesis is weak and mostly confounded by unobserved variables, such as poor health prior to baseline.

Economic Precariousness and the Transition to Parenthood: A Dynamic and Multidimensional Approach.

Economic precariousness has taken on a central role in explanations of the postponement of childbearing in developed societies. However, most studies conceptualize and operationalize precariousness as being static and one-dimensional, which provides only a partial perspective on the links between precariousness and fertility. In this paper, we study precariousness as a dynamic and multidimensional concept, distinguishing between past and current precariousness as well as between precariousness relating to income and to employment. Analyses are based on Dutch full-population register data. We select all inhabitants of the Netherlands who left education in 2006 and follow them until 2018. Event history analyses show that current and past income and employment precariousness all have independent negative effects on the first birth rate for men. Current and past employment precariousness and past income precariousness also reduce the first birth rate for women, but current income precariousness increases women's probability of first conception. When precariousness is both persistent and multidimensional, it is associated with a threefold decrease in the monthly probability of conceiving a first child for men and almost a halving of the probability for women. Our analyses show the need for going beyond static and one-dimensional analyses in order to understand how economic precariousness may affect fertility behaviour. Supplementary Information: The online version contains supplementary material available at 10.1007/s10680-022-09617-4.

Socioeconomic differences in metabolic syndrome development among males and females, and the mediating role of health literacy and self-management skills.

BACKGROUND: Our aim was to investigate sex differences in the associations between socioeconomic position (SEP) and metabolic syndrome (MetS) development, and to what extent these associations are mediated by health literacy and self-management skills. METHODS: A subsample (n = 88,384, 59.5% female) of the adult Lifelines Cohort Study was used. MetS development according to NCEP-ATPIII criteria was assessed on average 3.8 years after baseline. SEP-MetS associations were assessed for moderation by sex, and sex-stratified accordingly. Associations between SEP measures (education, income and occupational prestige), health literacy and self-management skills, and MetS development were investigated using logistic regression analyses. The mediating effects of health literacy and self-management skills on the SEP-MetS associations were investigated using the Karlson-Holm-Breen method. RESULTS: Among males and females, respectively 9.4% and 7.1% developed MetS. For males, education was inversely associated with MetS development; health literacy (7.1%) and self-management skills (1.9%) mediated a proportion of these educational differences. For females, education, income and occupational prestige were inversely associated with MetS development; health literacy (respectively 5.9% and 6.4%) and self-management skills (respectively 4.1% and 3.7%) mediated a proportion of the educational and occupational differences in MetS development. Neither health literacy nor self-management skills mediated female income differences in MetS development. CONCLUSIONS: Socioeconomic differences in MetS development differ between males and females. Both for males and females, health literacy and self-management skills mediated a small proportion of socioeconomic differences in MetS development.

Socioeconomic differences in major depressive disorder onset among adults are partially explained by lifestyle factors: A longitudinal analysis of the Lifelines Cohort Study.

BACKGROUND: Major depressive disorder (MDD) onset varies by socioeconomic position (SEP), this could be explained by lifestyle factors, but little is known about this pathway. Our study aims to disentangle the interplay between SEP measures (i.e., education, income and occupational prestige) and MDD onset and to examine to what extent these associations are mediated by lifestyle (i.e., occupational- and leisure time physical activity, smoking, alcohol intake, diet quality, sleep and central adiposity). METHODS: A subsample (n = 76,045) of the Lifelines Cohort Study without MDD at baseline was included. MDD onset was measured after a median follow-up time of 3.8 years with the Mini International Neuropsychiatric Interview (MINI). Direct associations between SEP, lifestyle and MDD onset were estimated using logistic regression analyses. Mediating percentages were estimated using the Karlson-Holm-Breen method. RESULTS: 1864 participants (2.5 %) showed MDD at follow-up. SEP was inversely associated with MDD onset, with education showing the strongest association. Educational, income and occupational differences in MDD onset were for 18.7 %, 5.9 % and 21.7 % explained by lifestyle factors (mainly smoking, alcohol intake and central adiposity). LIMITATIONS: SEP and lifestyle factors were measured simultaneously at baseline. MDD status (only based on a screening tool) was only measured at baseline and 3.8 years later. CONCLUSIONS: Compared to their lower SEP counterparts, higher SEP individuals had a lower risk of MDD onset. This was partially explained by a healthier lifestyle (mainly less smoking, alcohol intake and central adiposity) of the higher SEP individuals.

The association between early marriage and mental disorder among young migrant and non-migrant women: a Norwegian register-based study.

BACKGROUND: Marriage is considered beneficial for mental health when stable and of high quality. Yet, it is unclear whether marriage is equally advantageous for everyone regardless of marital timing or migrant background. This study aimed to investigate the association between early marriage and mental disorder, defined by outpatient mental healthcare (OPMH) service use, and whether the association varies between migrant and non-migrant women. METHODS: Using data from four Norwegian national registers, we applied discrete-time logistic regression analyses to study the aims of interest, among 602 473 young women aged 17-35 years. All women were followed from 2006 or the year they turned 17, and until first OPMH consultation, 2015 (study end), the year they turned 35, when emigrated, died, or changed marital status from married to separated, divorced, or widowed. RESULTS: Results show that unmarried and early married women had increased odds of mental disorder when compared to on-time married women. However, the differences between the early and on-time married women were explained by differences in educational level. There was no significant interaction between marital status and migrant background. CONCLUSIONS: Differences in mental health between early- and on time married women are attributed to poorer educational attainment of women who marry early. Furthermore, migrant background seems to have a limited role in the association between marital timing and mental disorder. The promotion of formal education among young women could contribute to the accumulation of socioeconomic and psychosocial resources, thus, reducing the risk of mental disorder, also among early married women.

The relationship between motherhood and use of mental health care services among married migrant and non-migrant women: a national register study.

BACKGROUND: Giving birth to one's first child is a life changing event. Beyond the post-partum period, little is known about the association between becoming a mother and mental disorder among migrant women. This study investigates outpatient mental health (OPMH) service use, a proxy for mental disorder, among married migrant and non-migrant women who become mothers and those who do not. METHODS: Using Norwegian register data, we followed 90,195 married women, aged 18-40 years, with no children at baseline between 2008-2013 to see if becoming a mother was associated with OPMH service use. Data were analysed using discrete time analyses. RESULTS: We found an interaction between motherhood and migrant category. Married non-migrant mothers, both in the perinatal period and beyond, had lower odds of OPMH use than married non-mothers. There was no association between motherhood and OPMH service use for migrants. However, there was no significant interaction between motherhood and migrant category when we excluded women who had been in Norway less than five years. Among women aged 25-40 years, a stable labour market attachment was associated with lower odds of OPMH use for non-migrants but not migrants, regardless of motherhood status. CONCLUSIONS: The perinatal period is not associated with increased odds of OPMH use and appears to be associated with lower odds for married non-migrant women. Selection effects and barriers to care may explain the lack of difference in OPMH service use that we found across motherhood status and labour market attachment for married migrant women. Married migrant women in general have a lower level of OPMH use than married non-migrants. Married migrant women with less than five years in Norway and those with no/weak labour market attachment may experience the greatest barriers to care. Further research to bridge the gap between need for, and use of, mental health care among migrant women is required.

The association between persistent low parental income during preschool age and mental disorder in adolescence and early adulthood: a Norwegian register-based study of migrants and non-migrants.

BACKGROUND: Low socioeconomic status during childhood is associated with increased risk of mental disorders later in life. Yet, there is limited research on whether this association varies by migrant background, despite an overrepresentation of migrants among the economically disadvantaged. METHODS: Using national register data on a study population of 577,072 individuals, we investigated the association between persistent low parental income during preschool, measured at age 3-5 years and mental disorder during adolescence and early adulthood, measured between ages 16-25. Outpatient mental healthcare (OPMH) service use was a proxy for mental disorder and was measured between 2006 and 2015. We applied discrete-time logistic regression analyses with interaction terms to study differences in the relationship between persistent low parental income and OPMH service use by migrant background and gender. RESULTS: Persistent low parental income during preschool age was associated with increased odds of OPMH service use in adolescence and early adulthood (aOR = 1.99, 95% CI 1.90-2.08), even after adjusting for gender, migrant background, parental education and persistent lower income at later ages (aOR = 1.33, 95% CI 1.27-1.40). Statistically significant interactions between migrant background and persistent low parental income were recalculated and presented as marginal yearly probabilities. These results showed that the association was in the opposite direction for migrants; those in the higher income group had higher probability of OPMH service use, although the differences were non-significant for some groups. The relationship did not vary by gender. CONCLUSIONS: Social inequalities in mental health, as measured by OPMH service use, may have an onset already in childhood. Interventions to reduce inequalities should therefore start early in the life course. Since the association differed for migrants, future research should aim to investigate the mechanisms behind these disparities.

Socioeconomic differences in metabolic syndrome development: examining the mediating role of chronic stress using the Lifelines Cohort Study.

BACKGROUND: Metabolic syndrome (MetS) development strongly varies based on individuals' socioeconomic position (SEP), but to date, no studies have assessed the mediating role of perceived stress from long-term difficulties (chronic stress) in this association. The aim of this study is to examine the mediating role of chronic stress in the associations of the SEP measures education, occupational prestige and income, with MetS development, and whether associations between chronic stress and MetS are moderated by sex. METHODS: We used an adult subsample (n = 53,216) from the Lifelines Cohort Study without MetS at baseline. MetS development was measured 3.9 years after baseline (follow-up), and defined according to National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATPIII) criteria. Direct associations between SEP, chronic stress and MetS development were estimated using multivariable logistic and linear regression analyses, and were adjusted for age, sex, the other SEP measures, and time between baseline and follow-up. The mediating percentages of chronic stress explaining the associations between SEP and MetS development were estimated using the Karlson-Holm-Breen method. RESULTS: Upon follow-up, 7.4% of the participants had developed MetS. Years of education and occupational prestige were inversely associated with MetS development. Chronic stress suppressed the association between education and MetS development (5.6%), as well as the association between occupational prestige and MetS development (6.2%). No effect modification of sex on the chronic stress-MetS pathway was observed. CONCLUSIONS: Chronic stress does not explain educational and occupational differences in developing MetS. In fact, individuals with more years of education or higher occupational prestige perceive more chronic stress than their lower SEP counterparts. Further, no difference between males and females was observed regarding the relationship between chronic stress and MetS development.

The impact of the COVID lockdown on alcohol consumption in the Netherlands. The role of living arrangements and social isolation.

BACKGROUND: The COVID-19 pandemic and the subsequent lockdown have a strong impact on health and health behaviours, such as alcohol consumption. Although there is some evidence of an overall decline in alcohol consumption during the lockdown, studies also show an increase in risky drinking patterns, e.g. solitary drinking, and differences between subgroups of individuals, e.g. depending on their living arrangement. Yet most studies rely on cross-sectional designs with retrospective questions, and small samples. METHODS: A longitudinal study was conducted using 13 waves of the COVID-Questionnaire within the Lifelines cohort from the northern Netherlands (n = 63,194). The outcome was alcohol consumption (glasses per week) between April 2020 and July 2021. Linear fixed-effects models were fitted to analyse trends in alcohol consumption, and these were compared with pre-COVID drinking levels. Moreover, the role of living arrangement and feelings of social isolation as potential moderators was tested. RESULTS: Alcohol consumption during the pandemic was lower than in previous years, and the seasonal pattern differed from the pre-COVID one, with levels being lower when lockdown measures were stricter. Moreover, the seasonal pattern differed by living arrangement: those living alone saw a relative increase in drinking throughout tight lockdown periods, whereas those living with children showed the strongest increase during the summer. Social isolation showed a weaker moderation effect. CONCLUSIONS: Overall alcohol levels were down in the pandemic, and in particular during strict lockdowns. Those living on their own and those who felt more isolated reacted more strongly to the lockdown, the longer it lasted.

Outpatient mental health service use following contact with primary health care among migrants in Norway: A national register study.

Majority of mental health problems are treated in primary care, while a minority require specialised treatment. This study aims to identify factors that predict contact with outpatient mental healthcare services (OPMH) among individuals who have been diagnosed with a mental health problem in primary healthcare services (PHC), with a special focus on migrants. Using linked national Norwegian registry data, we followed 1,002,456 individuals who had been diagnosed with a mental health problem in PHC for a period of two years. Using Cox regression, we applied Andersen's Model of Healthcare Utilisation to assess differences in risk of OPMH use between the majority population and eight migrant groups. We also conducted interaction analyses to see if the relationship between OPMH use and predisposing factors (gender, age, migrant status, civil status, education) differed across migrant groups. Migrants from Nordic countries, Western Europe and the Middle-East/North Africa had a higher risk of using OPMH services compared to the majority, while migrants from EU Eastern Europe, Sub-Saharan Africa and South Asia had a lower risk after controlling for all factors. Hazard ratios for non-EU Eastern Europeans and East/South East Asian's did not differ. Men had a higher risk than women. Additionally, the relationship between predisposing factors and OPMH use differed for some migrant groups. Education was not related to OPMH contact among five migrant groups. While lack of help-seeking at the primary care level may explain some of the lower rates of specialist service use observed for migrants compared to non-migrants in previous studies, there appear to be barriers for some migrant groups at the secondary level too. This warrants further investigation. Future research should look at differences between referrals and actual uptake of services among different migrant groups.

The changing relationship between socio-economic background and family formation in four European countries.

Family formation, a process that includes union formation, fertility, and their timing and order, has become increasingly diverse and complex in Europe. We examine how the relationship between socio-economic background and family formation has changed over time in France, Italy, Romania, and Sweden, using first wave Generations and Gender Survey data. Competing Trajectories Analysis, a procedure which combines event-history analysis with sequence analysis, allows us to examine family formation as a process, capturing differences in both the timing of the start of family formation and the pathways that young adults follow. Regarding timing, socio-economic background differences in France and Sweden have remained relatively small, whereas in Italy and Romania higher parental education has become more strongly associated with postponement. Pathways tend to diverge by socio-economic background, particularly in Sweden and France. These results indicate that while family formation patterns have changed, they continue to be stratified by socio-economic background.