Healthcare use among immigrants and natives in Sweden on disability pension, before and after changes of regulations

Healthcare use among immigrants and natives in Sweden on disability pension, before and after... Abstract Background There is limited knowledge regarding psychiatric healthcare utilization around the time of granting disability pension (DP) due to common mental disorders (CMD) among immigrants and if this is related to social insurance regulations. The aim was to evaluate patterns of psychiatric healthcare utilization before and after DP due to CMD among immigrants and natives. A second aim was to evaluate if such patterns differed before and after changes in social insurance regulations in Sweden in 2008. Methods All 28 354 individuals living in Sweden with incident DP due to CMD, before (2005–06; n = 24 298) or after (2009–10; n = 4056) changes in regulations of granting DP, were included. Patterns of psychiatric in- and specialized outpatient healthcare utilization during a 7-year window around DP granting were assessed by Generalized Estimating Equations estimating multivariate adjusted odds ratios (OR) and 95% confidence intervals (CI). Results Prevalence rates of psychiatric inpatient care were comparable among immigrants and natives, lower in non-Western immigrants (Africa, Asia and South-America). Three years after DP, non-Western immigrants in comparison to natives and Western immigrants had a stronger decrease in inpatient psychiatric healthcare: OR 0.48 (CI 0.38–0.62), 0.76 (0.70–0.83) and 1.01 (0.76–1.34), respectively. After 2008, a strong reduction in outpatient psychiatric healthcare after DP granting was observed, similarly in immigrants and natives. Conclusions Non-Western immigrants showed a different pattern of inpatient specialized healthcare after DP granting in comparison to natives. After changes in social insurance regulations, the decline in outpatient psychiatric healthcare following DP granting was comparable in immigrants and natives. Introduction Common mental disorders (CMD), i.e. anxiety and depressive disorders, represent a considerable public health problem in many European countries and have been projected to be the leading cause of loss of disability adjusted life years at global level by 2030.1 CMDs have adverse effects on everyday life and work capacity.2,3 In fact, in a number of OECD countries they represent one of the main causes of disability pension (DP), a measure of permanent work incapacity.4 Now-a-days, immigration is a global phenomenon and currently in Sweden more than 20% of the residents are first or second generation immigrants.5 In Sweden, DP is reported to be more common among immigrants in comparison to the native population, with different levels on the basis of the country of birth of the immigrants.6 An adequate healthcare intervention is fundamental in order to prevent the aggravation of a mental disorder and the risk of a subsequent DP. In fact, it has previously been shown that many mental disorders, including CMDs, can be effectively treated.7,8 A recent study reported that rates receiving specialized healthcare before granting of DP increased somewhat, possibly reflecting the aggravating severity of symptoms in the process towards permanent work incapacity.9 These findings should be discussed in the light of reports of sub-optimal treatment before granting of DP.10,11 After granted DP, a Swedish study showed a decrease in the healthcare utilization and a Finnish study reported a decrease in purchases of prescribed anti-depressants.9,12 Furthermore, several studies have suggested that psychiatric healthcare is under-utilized among immigrants, particularly in immigrants from non-Western countries, among which many are refugees.13–15 Still, to date there is no study investigating if patterns of psychiatric healthcare before and after granted DP differ between immigrants and natives. As socio-demographic factors, such as old age, being a female or having a lower level of education have been shown to be strongly associated with granting of DP due to CMD, it is important to consider such factors in related analyses.16,17 Social insurance regulations are related to levels of DP and, thus, changes of such rules can impact DP rates.9,18 In July 2008, stricter rules for being granted DP were introduced in Sweden. This led to a reduction of incident DPs, suggesting a higher level of medical severity in these new cases. For this reason, the healthcare utilization around DP granting might also vary during the time before and after regulation changes. A recent paper, in fact, showed a higher utilization of psychiatric healthcare in individuals granted DP after regulation changes.9 To date, no published study has examined if this variation differs among immigrants in comparison to natives. The aims of the study were to assess patterns of specialized healthcare due to psychiatric diagnoses before and after being granted DP due to CMD, and whether such patterns differed among immigrants and natives. A further aim was to study if patterns in different immigrant groups and natives differed if DP was granted before or after the changes of the social insurance regulations in Sweden in 2008. Methods Study population A population-based longitudinal cohort study was conducted including all individuals living in Sweden, aged between 19–64 years with incident DP due to CMD in 2005–06 or in 2009–10 (N = 30 157). Excluded were individuals who died or emigrated within 3 years after they had been granted DP in order to omit biased results of their healthcare utilization. Moreover, individuals with missing information on socio-demographic covariates (n = 1803) were excluded. The final population consisted of 28 354 individuals. Of those, 24 298 individuals (85.7%) had incident DP in 2005–06 (cohort 1) and 4056 (14.3%) individuals had incident DP in 2009–10 (cohort 2). Sensitivity analyses indicated the comparability of results in the study populations with and without exclusion due to missing values regarding socio-demographic covariates. Register data Data linked at individual level, based on the personal identity number assigned to all the residents in Sweden, were obtained from the following nationwide registers: Longitudinal integration database for health insurance and labour market studies (LISA) held by Statistics Sweden (sex, age, region of birth, educational level, type of living area, family situation and emigration). (i) National patient register (date and diagnosis of in- and specialized outpatient healthcare due to psychiatric diagnoses) and (ii) cause of death register (date of death) from the National Board of Health and Welfare. Micro-data for analyzes of social insurance (date, grade and diagnosis of DP) from the Swedish Social Insurance Agency. Disability pension All residents in Sweden aged 19–64 years, whose work capacity is long-time or permanently reduced due to disease or injury, are eligible for DP from the Social Insurance Agency. DP can be granted for 25%, 50%, 75% or 100% of ordinary working hours. In 2008, there was a change in the requirements for DP eligibility. Before 2008, all individuals could be granted temporary DP, after 2008, the reduced work capacity had to be permanent after the age of 30. For individuals aged 19–29 years, temporary DP was still possible.19,20 CMD diagnoses The main CMD DP diagnoses were coded according to the International Classification of Diseases version 10 (ICD-10)21 and categorized as follows: ‘depressive episode’ (F32), ‘recurrent depressive disorder’ (F33), ‘phobic anxiety disorder’ (F40), ‘other anxiety disorder’ (F41), ‘obsessive-compulsive disorder’ (F42) and ‘reaction to severe stress and adjustment disorder’ (F43).22 Region of birth Region of birth was grouped as follows: (1) Sweden (called natives); (2) other Western countries (Nordic countries, EU 25, Canada, USA and Oceania) and (3) non-Western countries (Africa, Asia and South America). Outcome and covariates Specialized psychiatric outpatient and inpatient healthcare utilization was defined as the outcome measure. Information on primary health care was not available. Socio-demographic variables, including sex, age, educational level, type of living area and family situation were measured at 31 December in the year before granted DP. Individuals with missing information regarding educational level (0.8%) were merged into the ‘elementary school’ category. People with missing values in the other sociodemographic variables were excluded. All variables were coded as reported in table 1. Table 1 Descriptive statistics of the 28 354 women and men, aged 19–64 years, living in Sweden, with incident DP in 2005–06 or in 2009–10 due to CMDs   All  Natives  Western  non-Western  n (%)  n (%)  n (%)  n (%)    28 354 (100)  22 156 (78.1)  1891 (6.7)  4307 (15.2)  Sexc              Male  9023 (31.8)  6540 (29.5)  559 (29.6)  1924 (44.7)      Female  19 331 (68.2)  15 616 (70.5)  1332 (70.4)  2383 (55.3)  Age (in years) when granted DPc              19–29  2053 (7.2)  1859 (8.4)  35 (1.9)  159 (3.7)      30–39  3357 (11.8)  2728 (12.3)  123 (6.5)  506 (11.7)      40–49  7015 (24.7)  5078 (22.9)  414 (21.9)  1523 (35.4)      50–59  8486 (29.9)  6144 (27.7)  715 (37.8)  1627 (37.8)      60–64  7443 (26.3)  6347 (28.6)  604 (31.9)  492 (11.4)  Education (in years)c              ≤9 (elementary school)  6326 (22.3)  4470 (20.2)  446 (23.6)  1410 (32.7)      10–12 (high school)  13 633 (48.1)  10 825 (48.9)  916 (48.4)  1892 (43.9)      ≥13 (college or university)  8395 (29.6)  6861 (31.0)  529 (28.0)  1005 (23.3)  Type of living areaa,c              Big cities  10 988 (38.8)  7366 (33.2)  978 (51.7)  2644 (61.4)      Medium-sized cities  9547 (33.7)  7827 (35.3)  537 (28.4)  1183 (27.5)      Small cities/villages  7819 (27.6)  6963 (31.4)  376 (19.9)  480 (11.1)  Family situationb,c              Married/cohabiting with no children at home  5145 (18.1)  4303 (19.4)  384 (20.3)  458 (10.6)      Married/cohabiting with children at home  8063 (28.4)  5700 (25.7)  490 (25.9)  1873 (43.5)      Single without children living at home  11 031 (38.9)  9085 (41.0)  707 (37.4)  1239 (28.8)      Single with children living at home  4115 (14.5)  3068 (13.8)  310 (16.4)  737 (17.1)  Main DP diagnosesc,d              Depressive disorder (F31-32-F33)  13 285 (46.8)  10 312 (46.5)  1014 (53.6)  1959 (45.5)      Anxiety disorder (F40-F41-F42)  6854 (24.2)  5677 (25.6)  420 (22.2)  757 (17.6)      Stress-related mental disorder (F43)  8215 (29.0)  6167 (27.8)  457 (24.2)  1591 (36.9)    All  Natives  Western  non-Western  n (%)  n (%)  n (%)  n (%)    28 354 (100)  22 156 (78.1)  1891 (6.7)  4307 (15.2)  Sexc              Male  9023 (31.8)  6540 (29.5)  559 (29.6)  1924 (44.7)      Female  19 331 (68.2)  15 616 (70.5)  1332 (70.4)  2383 (55.3)  Age (in years) when granted DPc              19–29  2053 (7.2)  1859 (8.4)  35 (1.9)  159 (3.7)      30–39  3357 (11.8)  2728 (12.3)  123 (6.5)  506 (11.7)      40–49  7015 (24.7)  5078 (22.9)  414 (21.9)  1523 (35.4)      50–59  8486 (29.9)  6144 (27.7)  715 (37.8)  1627 (37.8)      60–64  7443 (26.3)  6347 (28.6)  604 (31.9)  492 (11.4)  Education (in years)c              ≤9 (elementary school)  6326 (22.3)  4470 (20.2)  446 (23.6)  1410 (32.7)      10–12 (high school)  13 633 (48.1)  10 825 (48.9)  916 (48.4)  1892 (43.9)      ≥13 (college or university)  8395 (29.6)  6861 (31.0)  529 (28.0)  1005 (23.3)  Type of living areaa,c              Big cities  10 988 (38.8)  7366 (33.2)  978 (51.7)  2644 (61.4)      Medium-sized cities  9547 (33.7)  7827 (35.3)  537 (28.4)  1183 (27.5)      Small cities/villages  7819 (27.6)  6963 (31.4)  376 (19.9)  480 (11.1)  Family situationb,c              Married/cohabiting with no children at home  5145 (18.1)  4303 (19.4)  384 (20.3)  458 (10.6)      Married/cohabiting with children at home  8063 (28.4)  5700 (25.7)  490 (25.9)  1873 (43.5)      Single without children living at home  11 031 (38.9)  9085 (41.0)  707 (37.4)  1239 (28.8)      Single with children living at home  4115 (14.5)  3068 (13.8)  310 (16.4)  737 (17.1)  Main DP diagnosesc,d              Depressive disorder (F31-32-F33)  13 285 (46.8)  10 312 (46.5)  1014 (53.6)  1959 (45.5)      Anxiety disorder (F40-F41-F42)  6854 (24.2)  5677 (25.6)  420 (22.2)  757 (17.6)      Stress-related mental disorder (F43)  8215 (29.0)  6167 (27.8)  457 (24.2)  1591 (36.9)  a Type of living area: Big cities: Stockholm, Gothenburg and Malmö; Medium-sized cities: cities with more than 90 000 inhabitants within 30 km distance from the centre of the city; small cities/villages. b Single means living without partner and includes divorces, separated or widowed. c All the P-values from the Chi test were significant (P < 0.001) for differences among immigrant groups. d In brackets codes according the ICD-10. Table 1 Descriptive statistics of the 28 354 women and men, aged 19–64 years, living in Sweden, with incident DP in 2005–06 or in 2009–10 due to CMDs   All  Natives  Western  non-Western  n (%)  n (%)  n (%)  n (%)    28 354 (100)  22 156 (78.1)  1891 (6.7)  4307 (15.2)  Sexc              Male  9023 (31.8)  6540 (29.5)  559 (29.6)  1924 (44.7)      Female  19 331 (68.2)  15 616 (70.5)  1332 (70.4)  2383 (55.3)  Age (in years) when granted DPc              19–29  2053 (7.2)  1859 (8.4)  35 (1.9)  159 (3.7)      30–39  3357 (11.8)  2728 (12.3)  123 (6.5)  506 (11.7)      40–49  7015 (24.7)  5078 (22.9)  414 (21.9)  1523 (35.4)      50–59  8486 (29.9)  6144 (27.7)  715 (37.8)  1627 (37.8)      60–64  7443 (26.3)  6347 (28.6)  604 (31.9)  492 (11.4)  Education (in years)c              ≤9 (elementary school)  6326 (22.3)  4470 (20.2)  446 (23.6)  1410 (32.7)      10–12 (high school)  13 633 (48.1)  10 825 (48.9)  916 (48.4)  1892 (43.9)      ≥13 (college or university)  8395 (29.6)  6861 (31.0)  529 (28.0)  1005 (23.3)  Type of living areaa,c              Big cities  10 988 (38.8)  7366 (33.2)  978 (51.7)  2644 (61.4)      Medium-sized cities  9547 (33.7)  7827 (35.3)  537 (28.4)  1183 (27.5)      Small cities/villages  7819 (27.6)  6963 (31.4)  376 (19.9)  480 (11.1)  Family situationb,c              Married/cohabiting with no children at home  5145 (18.1)  4303 (19.4)  384 (20.3)  458 (10.6)      Married/cohabiting with children at home  8063 (28.4)  5700 (25.7)  490 (25.9)  1873 (43.5)      Single without children living at home  11 031 (38.9)  9085 (41.0)  707 (37.4)  1239 (28.8)      Single with children living at home  4115 (14.5)  3068 (13.8)  310 (16.4)  737 (17.1)  Main DP diagnosesc,d              Depressive disorder (F31-32-F33)  13 285 (46.8)  10 312 (46.5)  1014 (53.6)  1959 (45.5)      Anxiety disorder (F40-F41-F42)  6854 (24.2)  5677 (25.6)  420 (22.2)  757 (17.6)      Stress-related mental disorder (F43)  8215 (29.0)  6167 (27.8)  457 (24.2)  1591 (36.9)    All  Natives  Western  non-Western  n (%)  n (%)  n (%)  n (%)    28 354 (100)  22 156 (78.1)  1891 (6.7)  4307 (15.2)  Sexc              Male  9023 (31.8)  6540 (29.5)  559 (29.6)  1924 (44.7)      Female  19 331 (68.2)  15 616 (70.5)  1332 (70.4)  2383 (55.3)  Age (in years) when granted DPc              19–29  2053 (7.2)  1859 (8.4)  35 (1.9)  159 (3.7)      30–39  3357 (11.8)  2728 (12.3)  123 (6.5)  506 (11.7)      40–49  7015 (24.7)  5078 (22.9)  414 (21.9)  1523 (35.4)      50–59  8486 (29.9)  6144 (27.7)  715 (37.8)  1627 (37.8)      60–64  7443 (26.3)  6347 (28.6)  604 (31.9)  492 (11.4)  Education (in years)c              ≤9 (elementary school)  6326 (22.3)  4470 (20.2)  446 (23.6)  1410 (32.7)      10–12 (high school)  13 633 (48.1)  10 825 (48.9)  916 (48.4)  1892 (43.9)      ≥13 (college or university)  8395 (29.6)  6861 (31.0)  529 (28.0)  1005 (23.3)  Type of living areaa,c              Big cities  10 988 (38.8)  7366 (33.2)  978 (51.7)  2644 (61.4)      Medium-sized cities  9547 (33.7)  7827 (35.3)  537 (28.4)  1183 (27.5)      Small cities/villages  7819 (27.6)  6963 (31.4)  376 (19.9)  480 (11.1)  Family situationb,c              Married/cohabiting with no children at home  5145 (18.1)  4303 (19.4)  384 (20.3)  458 (10.6)      Married/cohabiting with children at home  8063 (28.4)  5700 (25.7)  490 (25.9)  1873 (43.5)      Single without children living at home  11 031 (38.9)  9085 (41.0)  707 (37.4)  1239 (28.8)      Single with children living at home  4115 (14.5)  3068 (13.8)  310 (16.4)  737 (17.1)  Main DP diagnosesc,d              Depressive disorder (F31-32-F33)  13 285 (46.8)  10 312 (46.5)  1014 (53.6)  1959 (45.5)      Anxiety disorder (F40-F41-F42)  6854 (24.2)  5677 (25.6)  420 (22.2)  757 (17.6)      Stress-related mental disorder (F43)  8215 (29.0)  6167 (27.8)  457 (24.2)  1591 (36.9)  a Type of living area: Big cities: Stockholm, Gothenburg and Malmö; Medium-sized cities: cities with more than 90 000 inhabitants within 30 km distance from the centre of the city; small cities/villages. b Single means living without partner and includes divorces, separated or widowed. c All the P-values from the Chi test were significant (P < 0.001) for differences among immigrant groups. d In brackets codes according the ICD-10. Statistical analyses Differences in the distributions of socio-demographic characteristics and the main DP diagnosis among immigrants and natives were tested using Chi-square tests. Analyzes were based on annual diagnosis-specific healthcare utilization spanning over a 7-year observation window. A time point measure was utilized, defining the year when granted DP as time point ‘t0’ (reference) and the 3 years of observation before and after DP granting year (from t–3 to t–1 and t + 1 to t + 3). In the overall sample (combining both cohorts), annual prevalence rates of in- and specialized outpatient healthcare due to psychiatric diagnoses were estimated. Repeated measure logistic regression analyses with Generalized Estimating Equations method and autoregressive correlation structure were performed in order to estimate patterns of healthcare utilization. Odds ratios (OR) with 95% confidence intervals (CI) were computed for the 3 years before (t–3 to t–1), and 3 years after granted DP (t + 1 to t + 3) in relation to the DP granting year (t0, reference). Furthermore, analyses were carried out for those granted DP before and after the 2008 changes in the social insurance legislation (cohort 1; 2005–06 and cohort 2; 2009–10). All models were adjusted for sex, age, educational level, type of living area, family situation and main DP CMD diagnoses. All analyses were conducted by SPSS v. 20. Ethical approval The project was approved by the Regional Ethical Review Board of Stockholm, Sweden. Results Of the 28 354 individuals granted DP due to CMD during the 4-year observation (2005–06 and 2009–10) (table 1), the majority (78.1%) were born in Sweden, while 6.7% were born in other Western countries and 15.2% in non-Western countries. The main DP diagnosis was depressive disorder for almost half (46.8%), followed by stress-related disorders (29.0%) and anxiety disorders (24.2%). Natives in comparison to non-Western immigrants, were more likely to be women (70.5% vs. 55.3%), to be young (8.4% in the 19–29 group vs. 3.7%) and to have a college or university education (31.0% vs. 23.3%). Immigrants from Western countries showed prevalence rates, which were generally in between those of natives and non-Western immigrants. The differences in distributions among natives and immigrant groups were all statistically significant (table 1, P < 0.001). Healthcare due to psychiatric diagnoses In the overall sample, specialized healthcare due to psychiatric diagnoses increased before the year of granted DP (t0) (table 2). The inpatient care utilization decreased after t0 while outpatient psychiatric healthcare remained at the same level. The outpatient psychiatric healthcare utilization was somewhat lower in the natives in comparison to the group of non-Western countries (t–1 natives: 22.9%, Western 21.2%, non-Western 25.2%). In cohort 2, prevalence rates were almost two times higher in comparison to cohort 1 in both outpatient and inpatient healthcare (t–1 natives: 46.5%, Western 40.8%, non-Western 49.2%; t–1 natives 8.4%, Western 7.7%, non-Western 5.8%), respectively, (data not shown). Table 2 Annual prevalence of healthcare use among individuals aged 19–64 years, living in Sweden and granted DP in 2005–06 or 2009–10 (n = 28 354) due to CMDs, stratified by region of birth Time pointsa  Inpatient  Outpatient  Sweden  Western  non-Western  Sweden  Western  non-Western  n (%)  n (%)  n (%)  n (%)  n (%)  n (%)  t–3  825 (3.7)  65 (3.4)  122 (2.8)  2401 (10.8)  176 (9.3)  451 (10.5)  t–2  1082 (4.9)  89 (4.7)  166 (3.8)  3729 (16.8)  298 (15.8)  775 (18.0)  t–1  1155 (5.2)  89 (4.7)  188 (4.3)  5084 (22.9)  400 (21.2)  1085 (25.2)  t0  1003 (4.5)  73 (3.8)  177 (4.1)  5549 (25.0)  427 (22.6)  1304 (30.3)  t + 1  822 (3.7)  66 (3.5)  126 (2.9)  5712 (25.8)  466 (24.6)  1350 (31.3)  t + 2  815 (3.7)  62 (3.3)  86 (2.0)  6034 (27.2)  491 (26.0)  1308 (30.4)  t + 3  779 (3.5)  73 (3.9)  90 (2.1)  5829 (26.3)  423 (23.0)  1196 (27.8)  Time pointsa  Inpatient  Outpatient  Sweden  Western  non-Western  Sweden  Western  non-Western  n (%)  n (%)  n (%)  n (%)  n (%)  n (%)  t–3  825 (3.7)  65 (3.4)  122 (2.8)  2401 (10.8)  176 (9.3)  451 (10.5)  t–2  1082 (4.9)  89 (4.7)  166 (3.8)  3729 (16.8)  298 (15.8)  775 (18.0)  t–1  1155 (5.2)  89 (4.7)  188 (4.3)  5084 (22.9)  400 (21.2)  1085 (25.2)  t0  1003 (4.5)  73 (3.8)  177 (4.1)  5549 (25.0)  427 (22.6)  1304 (30.3)  t + 1  822 (3.7)  66 (3.5)  126 (2.9)  5712 (25.8)  466 (24.6)  1350 (31.3)  t + 2  815 (3.7)  62 (3.3)  86 (2.0)  6034 (27.2)  491 (26.0)  1308 (30.4)  t + 3  779 (3.5)  73 (3.9)  90 (2.1)  5829 (26.3)  423 (23.0)  1196 (27.8)  a t–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP granting, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP. Table 2 Annual prevalence of healthcare use among individuals aged 19–64 years, living in Sweden and granted DP in 2005–06 or 2009–10 (n = 28 354) due to CMDs, stratified by region of birth Time pointsa  Inpatient  Outpatient  Sweden  Western  non-Western  Sweden  Western  non-Western  n (%)  n (%)  n (%)  n (%)  n (%)  n (%)  t–3  825 (3.7)  65 (3.4)  122 (2.8)  2401 (10.8)  176 (9.3)  451 (10.5)  t–2  1082 (4.9)  89 (4.7)  166 (3.8)  3729 (16.8)  298 (15.8)  775 (18.0)  t–1  1155 (5.2)  89 (4.7)  188 (4.3)  5084 (22.9)  400 (21.2)  1085 (25.2)  t0  1003 (4.5)  73 (3.8)  177 (4.1)  5549 (25.0)  427 (22.6)  1304 (30.3)  t + 1  822 (3.7)  66 (3.5)  126 (2.9)  5712 (25.8)  466 (24.6)  1350 (31.3)  t + 2  815 (3.7)  62 (3.3)  86 (2.0)  6034 (27.2)  491 (26.0)  1308 (30.4)  t + 3  779 (3.5)  73 (3.9)  90 (2.1)  5829 (26.3)  423 (23.0)  1196 (27.8)  Time pointsa  Inpatient  Outpatient  Sweden  Western  non-Western  Sweden  Western  non-Western  n (%)  n (%)  n (%)  n (%)  n (%)  n (%)  t–3  825 (3.7)  65 (3.4)  122 (2.8)  2401 (10.8)  176 (9.3)  451 (10.5)  t–2  1082 (4.9)  89 (4.7)  166 (3.8)  3729 (16.8)  298 (15.8)  775 (18.0)  t–1  1155 (5.2)  89 (4.7)  188 (4.3)  5084 (22.9)  400 (21.2)  1085 (25.2)  t0  1003 (4.5)  73 (3.8)  177 (4.1)  5549 (25.0)  427 (22.6)  1304 (30.3)  t + 1  822 (3.7)  66 (3.5)  126 (2.9)  5712 (25.8)  466 (24.6)  1350 (31.3)  t + 2  815 (3.7)  62 (3.3)  86 (2.0)  6034 (27.2)  491 (26.0)  1308 (30.4)  t + 3  779 (3.5)  73 (3.9)  90 (2.1)  5829 (26.3)  423 (23.0)  1196 (27.8)  a t–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP granting, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP. Patterns of healthcare utilization In relation to the year of granted DP, ORs of inpatient care due to psychiatric diagnoses among those born in Sweden increased from 0.81 (CI: 0.74–0.88)–1.16 (CI 1.08–1.25) (t–3 to t–1) and thereafter decreased to 0.76 (CI 0.70–0.83) at t + 3 (figure 1). This pattern was similar in immigrants, but with somewhat higher ORs in immigrants from Western countries [increased from 0.88 (CI 0.65–1.20)–1.23 (CI 0.96–1.58) and decreased to 1.01 (CI 0.76–1.34) at t + 3] and lower ORs in immigrants from non-Western countries [increased from 0.68 (CI 0.54–0.85)–1.06 (CI 0.88–1.27) and decreased to 0.48 (CI 0.38–0.62) at t + 3]. The decrease in inpatient healthcare due to psychiatric diagnoses after t0 among the non-Western immigrants was much steeper than in the other two groups. The OR of outpatient healthcare due to psychiatric diagnoses was lower in the year preceding DP and higher thereafter, regardless of the region of birth. However, the non-Western immigrants had a steeper increase up until t0 and showed a stabilization with a further decrease following 3 years after granted DP [OR 0.25 (CI 0.23–0.28), OR 1.05 (CI 0.98–1.13) and OR 0.88 (CI 0.81–0.95) at t–3, t + 1 and t + 3, respectively]. Analyses excluding individuals below 30 years showed comparable results as for the entire study population (data not shown). Figure 1 View largeDownload slide (ORs)a and 95% (CIs)b of healthcare use due to psychiatric diagnoses at different time pointsc compared to DP granting year (t0) before and after being granted DP due to CMDs in the total sample (both cohorts, granted DP in year 2005, 2006, 2009 or 2010, n = 28 354,) for natives and for immigrants born in Western countries or in non-Western Countries, respectively aAdjusted for sex, age, educational level, type of living area, family situation and DP diagnoses. bError bars indicate 95% CIs. ct–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP grant, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP Figure 1 View largeDownload slide (ORs)a and 95% (CIs)b of healthcare use due to psychiatric diagnoses at different time pointsc compared to DP granting year (t0) before and after being granted DP due to CMDs in the total sample (both cohorts, granted DP in year 2005, 2006, 2009 or 2010, n = 28 354,) for natives and for immigrants born in Western countries or in non-Western Countries, respectively aAdjusted for sex, age, educational level, type of living area, family situation and DP diagnoses. bError bars indicate 95% CIs. ct–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP grant, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP Patterns of healthcare utilization before (cohort 1) and after (cohort 2) regulatory changes Patterns of specialized outpatient care due to psychiatric diagnoses were similar in cohort 1 as in both cohorts combined, with an increase up until 2 years after granted DP both in natives and immigrants (figure 2). In cohort 2, there was a strong reduction after t0, stronger in non-Western immigrants in comparison to natives [from t + 1 to t + 3, natives: from OR 0.70 (CI 0.65–0.76) to OR 0.59 (CI 0.54–0.64); non-Western: from OR 0.66 (CI 0.57–0.77) to OR 0.38 (CI 0.32–0.46)]. Results regarding inpatient healthcare rates for cohorts 1 and 2 are not reported because of lack of power. Figure 2 View largeDownload slide (ORs)a and 95% (CIs)b of specialized outpatient healthcare use due to psychiatric diagnoses in cohort 1 (with incident DP, in 2005–2006, n = 24 298) and after (cohort 2, n = 4056) changes in social insurance regulation in Sweden in 2008 at different time pointsc compared to the year of granted DP (t0) among people with different regions of birth aAdjusted for sex, age, educational level, type of living area, family situation and DP diagnoses. bError bars indicate 95% CIs. ct–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP grant, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP Figure 2 View largeDownload slide (ORs)a and 95% (CIs)b of specialized outpatient healthcare use due to psychiatric diagnoses in cohort 1 (with incident DP, in 2005–2006, n = 24 298) and after (cohort 2, n = 4056) changes in social insurance regulation in Sweden in 2008 at different time pointsc compared to the year of granted DP (t0) among people with different regions of birth aAdjusted for sex, age, educational level, type of living area, family situation and DP diagnoses. bError bars indicate 95% CIs. ct–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP grant, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP Discussion We observed an increase in the inpatient healthcare due to psychiatric diagnoses in the years before granted DP and a decrease in the years afterwards. Immigrants from non-Western countries showed lower rates of inpatient care before and after DP compared to natives. For specialized outpatient healthcare due to psychiatric diagnoses, prevalence rates tended to be higher among immigrants from non-Western countries than among natives. Patterns of psychiatric healthcare utilization after DP were comparable with one exception: non-Western immigrants had a stronger decrease after DP granting in inpatient psychiatric healthcare than natives and immigrants from Western countries. Patterns of specialized outpatient care due to psychiatric diagnoses of cohort 2, granted DP after the change in legislation in 2008, were similar in immigrants and natives, showing a strong reduction after DP granting. Methodological considerations Strengths of this study include the utilization of high-quality population-based registers with nationwide coverage and two large cohorts including all individuals granted DP due to CMDs in the four studied years.23–25 Additional strengths include practically no loss to follow-up, no recall bias and the possibility to address several covariates. The study has also some limitations. First, by using information on inpatient and specialized outpatient care, we had no information on primary health care utilization and residual confounding by unmeasured morbidity is likely, especially in migrants.13 Secondly, the validity of DP diagnoses is often discussed, however, seldom studied. We argue that the validity of the CMD diagnoses studied here is acceptable, for the following three reasons: a high validity, regarding sick-leave diagnoses, was reported when compared to diagnoses from medical records in a Swedish study.26 Moreover, in Sweden, the medical assessments of whether a patient fulfils the criteria for being granted DP is thorough, conducted by physicians and usually preceded by long-term sickness absence demanding several medical assessments.27 Thirdly, the stigma related to mental diagnoses may contribute to the fact that such diagnoses are given only if a mental disorder has led to the work incapacity.28 Finally, in order to have statistical power we categorized the immigrants into two broad groups (Western and non-Western immigrants). Further studies, with a focus on specific immigrant groups (country or regional level), might provide more specific knowledge. Discussion of findings The prevalence of psychiatric healthcare utilization increased in the pre-DP period (t–3 to t–1), both regarding inpatient and specialized outpatient healthcare and among immigrants and natives. This is in line with previous research showing an increase in purchases of psychotropic drugs as well as in self-reported symptoms of depression and anxiety before granted DP, irrespective of DP diagnoses.12,16,29–31 In the year before being granted DP (t–1), 5.2%, 4.7% and 4.3% of the individuals born in Sweden, Western, or non-Western countries, respectively, had psychiatric inpatient healthcare. The same year (t–1) the prevalence rates of psychiatric outpatient healthcare ranged from 21.2% to 25.2%. Considering the permanent state of DP, the rates of people having had specialized healthcare can, nevertheless, be considered as low. These findings suggest that the overwhelming proportion of individuals were treated in primary healthcare before granted DP. This is noteworthy as the sick-leave guidelines recommend referral to psychiatric specialized healthcare if a sick-leave spell due to CMD lasted for longer than 6 months.32 Our findings are comparable with results from a study reporting that the quality of psychiatric healthcare was sub-optimal before granted DP.10 In particular, we found that rates of inpatient care due to psychiatric diagnoses were especially low in immigrants from non-Western countries during the entire 7-year period and significantly lower in t + 2 and t + 3 compared with the other groups. Two previous studies indicate a higher risk of sub-optimal inpatient healthcare and early treatment discontinuation in the healthcare of non-Western immigrants.13,33 The lower rates of psychiatric inpatient healthcare among immigrants from non-Western countries are particularly noteworthy because of the poorer mental health and a higher risk of DP previously shown among such immigrants.6,19,34 There might be several different explanations for such lower rates among non-Western immigrants. Attitudinal barriers to mental healthcare use, such as arising from beliefs and culture, seem to be more common among non-Western immigrants than structural barriers including lack of information or difficulties in accessing the healthcare.35,36 A different perception of the needs among non-Western immigrants, higher levels of stigmatization of mental disorders and difficulties in medical communication were suggested to play a crucial role in this regard.37 The rates of psychiatric healthcare utilization among immigrants from Western countries, which were more similar to natives, may be explained by immigrants from Western countries being more familiar with the Swedish mental healthcare system or by the duration of stay in Sweden.35 The general pattern of psychiatric healthcare utilization showed an increase before granted DP, both in in- and specialized outpatient healthcare due to psychiatric diagnoses. This is consistent with other studies: a Finnish study showed an increase in purchase of psychotropic drugs; a recent Swedish study an increase in specialized healthcare.11,12 After DP granting, utilization of inpatient health care showed a decrease. The interruption of work demands, improvements of symptoms or a referral of the patient to the primary healthcare, can be explanations of this finding.11 The stronger decrease among immigrants from non-Western countries can be interpreted by a higher risk of under-utilization of healthcare by non-Western immigrants or by a stronger improvement in the mental health status after DP granting in this population in comparison to natives. Under-utilization of employment skills and a higher risk of job strain among non-Western immigrants38–40 might also explain the lower need of psychiatric health care following DP. The prevalence rates of outpatient healthcare due to psychiatric diagnoses were generally higher after the changes of the social insurance system (2008), possibly reflecting a higher severity in mental disorders among those granted DP with the stricter criteria.9,27 Regarding general patterns, the outpatient psychiatric healthcare showed in cohort 2 a strong reduction after granted DP, while it increased in cohort 1. This is in line with a previously published study.9 Explanations for the patterns in cohort 1 can be the higher level of temporary DP in this cohort with a lower medical severity compared with individuals granted DP in cohort 2. When we compared natives with immigrants, patterns were very similar with a stronger decline after granted DP in non-Western immigrants. The greater decline might be related to either improvements regarding symptoms or to under-utilization of services, as already supposed for the decline in the inpatient healthcare among them. Conclusions The results from this study suggest that utilization of specialized healthcare due to psychiatric diagnoses increased up to the time of being granted DP due to CMD, regardless of migration background. The decline in the psychiatric inpatient healthcare rates after granted DP was stronger among immigrants from non-Western countries in comparison to those from Western countries and natives. After the change in the legislation (2008) both immigrants and natives showed a stronger reduction in the outpatient healthcare due to psychiatric diagnoses following granting of DP. Funding This study was supported by the Swedish Research Council for Health, Working Life and Welfare [grant nr 2015-00742 and 2007-1952] and Karolinska Institutet’s funding for doctoral students. Conflicts of interest: None declared. Key points The prevalence of psychiatric healthcare utilization before being granted DP due to CMDs was generally low, regardless of migration background. Immigrants from non-Western countries showed a stronger decrease of psychiatric inpatient healthcare after being granted such DP in comparison to natives and immigrants from Western countries. The stricter criteria for granting DP introduced in Sweden in 2008 might have played a similar role in immigrants and natives, with a reduction in specialized psychiatric outpatient healthcare after granting such a DP. References 1 Whiteford HA, Degenhardt L, Rehm J, et al.   Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet  2013; 382: 1575– 86. Google Scholar CrossRef Search ADS PubMed  2 Norder G, van der Ben CA, Roelen CA, et al.   Beyond return to work from sickness absence due to mental disorders: 5-year longitudinal study of employment status among production workers. Eur J Public Health  2016; 27: 79– 83. 3 Knudsen AK, Harvey SB, Mykletun A, Øverland S. Common mental disorders and long-term sickness absence in a general working population. The Hordaland Health Study. Acta Psychiatr Scand  2013; 127: 287– 97. Google Scholar CrossRef Search ADS PubMed  4 Organisation for Economic Cooperation and Development (OECD). Sick on the Job? Myths and Realities about Mental Health and Work. Paris: OECD Publishing, 2012. 5 Johansson B, Helgesson M, Lundberg I, et al.   Work and health among immigrants and native Swedes 1990–2008: a register-based study on hospitalization for common potentially work-related disorders, disability pension and mortality. BMC Public Health  2012; 12: 845. Google Scholar CrossRef Search ADS PubMed  6 Osterberg T, Gustafsson B. Disability pension among immigrants in Sweden. Soc Sci Med  2006; 63: 805– 16. Google Scholar CrossRef Search ADS PubMed  7 Furukawa TA, Streiner D, Young LT, et al.   Antidepressants plus benzodiazepines for major depression. Cochrane Database Syst Rev  2001; CD001026. 8 Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev  2007; CD001848. 9 Rahman S, Mittendorfer-Rutz E, Alexanderson K, et al.   Disability pension due to common mental disorders and healthcare use before and after policy changes; a nationwide study. Eur J Public Health  2017; 27: 90– 6. Google Scholar CrossRef Search ADS PubMed  10 Honkonen T, Aro T, Isometsä E, et al.   Quality of treatment and disability compensation in depression: comparison of 2 nationally representative samples with a 10-year interval in Finland. J Clin Psychiatry  2007; 68: 1886– 93. Google Scholar CrossRef Search ADS PubMed  11 Overland S, Glozier N, Krokstad S, Mykletun A. Undertreatment before the award of a disability pension for mental illness: the HUNT Study. Psychiatr Serv  2007; 58: 1479– 82. Google Scholar CrossRef Search ADS PubMed  12 Laaksonen M, Metsa-Simola N, Martikainen P, et al.   Trajectories of mental health before and after old-age and disability retirement: a register-based study on purchases of psychotropic drugs. Scand J Work Environ Health  2012; 38: 409– 17. Google Scholar CrossRef Search ADS PubMed  13 Lindert J, Schouler-Ocak M, Heinz A, Priebe S. Mental health, health care utilisation of migrants in Europe. Eur Psychiatr  2008; 23: 14– 20. Google Scholar CrossRef Search ADS   14 Berg JE. The level of non-Western immigrants’ use of acute psychiatric care compared with ethnic Norwegians over an 8-year period. Nordic J Psychiatr  2009; 63: 217– 22. Google Scholar CrossRef Search ADS   15 Ahonen EQ, Benavides FG, Benach J. Immigrant populations, work and health-a systematic literature review. Scand J Work Environ Health  2007; 33: 96– 105. Google Scholar CrossRef Search ADS PubMed  16 Leinonen T, Lahelma E, Martikainen P. Trajectories of antidepressant medication before and after retirement: the contribution of socio-demographic factors. Eur J Epidemiol  2013; 28: 417– 26. Google Scholar CrossRef Search ADS PubMed  17 Leinonen T, Martikainen P, Lahelma E. Interrelationships between education, occupational social class, and income as determinants of disability retirement. Scand J Public Health  2012; 40: 157– 66. Google Scholar CrossRef Search ADS PubMed  18 Allebeck P, Mastekaasa A. Swedish Council on Technology Assessment in Health Care (SBU), Chapter 5. Risk factors for sick leave–general studies. Scand J Public Health  2004; 32: 49– 108. Google Scholar CrossRef Search ADS   19 Organisation for Economic Cooperation and Development (OECD). Sickness, Disability and Work: Breaking the barriers. A synthesis of Findings Across 105 OECD Countries . Paris: OECD Publishing, 2010. 20 The Swedish Social Insurance Agency. Social Insurance in Figures 2016 . Sweden, 2016. 21 World Health Organization (WHO). International Statistical Classification of Diseases and Related Health Problems, 10 Revision, (ICD 10). Geneva: WHO, 2010. 22 Deverill C, King M. Common mental disorders. In: McManus S MH, Brugha T, Bebbington P R J, editors. Adult Psychiatric Morbidity in England . London: The NHS Information Centre for health and social care, 2009: 25– 7. 23 Ludvigsson JF, Andersson E, Ekbom A, et al.   External review and validation of the Swedish national inpatient register. BMC Public Health  2011; 11: 450. Google Scholar CrossRef Search ADS PubMed  24 Dōdsorsaker 2014  [The Cause of Death 2014]. [The National Board of Health and Welfare]. Stockholm, Sweden: Socialstyrelsen, 2015. 25 The National Board of Health and Welfare. Inpatient diseases in Sweden 1988–2013. Sweden, 2014. 26 Ljungdahl LO, Bjurulf P. The accordance of diagnoses in a computerized sick-leave register with doctor's certificates and medical records. Scand J Soc Med  1991; 19: 148– 53. Google Scholar CrossRef Search ADS PubMed  27 The Swedish Social Insurance Agency. Social Insurance in Figures 2015. Sweden, 2015. 28 Shrivastava A, Johnston M, Bureau Y. Stigma of mental illness-1: clinical reflections. Mens Sana Monographs  2012; 10: 70– 84. Google Scholar CrossRef Search ADS PubMed  29 Oksanen T, Vahtera J, Westerlund H, et al.   Is retirement beneficial for mental health? Antidepressant use before and after retirement. Epidemiology  2011; 22: 553– 9. Google Scholar CrossRef Search ADS PubMed  30 Overland S, Glozier N, Henderson M, et al.   Health status before, during and after disability pension award: the Hordaland Health Study (HUSK). Occup Environ Med  2008; 65: 769– 73. Google Scholar CrossRef Search ADS PubMed  31 Mittendorfer-Rutz E, Alexanderson K, Westerlund H, Lange T. Is transition to disability pension in young people associated with changes in risk of attempted suicide? Psychol Med  2014; 44: 1– 8. Google Scholar CrossRef Search ADS PubMed  32 Skaner Y, Nilsson GH, Arrelov B, et al.   Use and usefulness of guidelines for sickness certification: results from a national survey of all general practitioners in Sweden. BMJ Open  2011; 1: e000303. Google Scholar CrossRef Search ADS PubMed  33 Wallach-Kildemoes H, Thomsen L, Kriegbaum M, et al.   Antidepressant utilization after hospitalization with depression: a comparison between non-Western immigrants and Danish-born residents. BMC Psychiatr  2014; 14: 1– 11. Google Scholar CrossRef Search ADS   34 Gilliver SC, Sundquist J, Li X, Sundquist K. Recent research on the mental health of immigrants to Sweden: a literature review. Eur J Public Health  2014; 24 (Suppl 1): 72– 9. Google Scholar CrossRef Search ADS PubMed  35 Sareen J, Jagdeo A, Cox B, et al.   Perceived barriers to mental health service utilization in the United States, Ontario, and the Netherlands. Pychiatr Services  2007; 58: 357– 64. Google Scholar CrossRef Search ADS   36 Fassaert T, de Wit MA, Tuinebreijer WC, et al.   Perceived need for mental health care among non-western labour migrants. Soc Psychiatry Psychiatr Epidemiol  2009; 44: 208– 16. Google Scholar CrossRef Search ADS PubMed  37 Schouten BC, Meeuwesen L. Cultural differences in medical communication: a review of the literature. Patient Educ Couns  2006; 64: 21– 34. Google Scholar CrossRef Search ADS PubMed  38 Markaki Y. Do Labour Market Conditions Shape Immigrant Native Gaps in Employment Outcomes? A Comparison of 19 European Countries . United Kingdom: Institute for Social and Economic Research University of Essex, 2014. 39 Dean JA, Wilson K. ‘Education? It is irrelevant to my job now. It makes me very depressed …’: exploring the health impacts of under/unemployment among highly skilled recent immigrants in Canada. Ethn Health  2009; 14: 185– 204. Google Scholar CrossRef Search ADS PubMed  40 Laine SG, Gimeno D, Virtanen M, et al.   Job strain as a predictor of disability pension: the Finnish Public Sector Study. J Epidemiol Commun Health  2009; 63: 24– 30. Google Scholar CrossRef Search ADS   © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Healthcare use among immigrants and natives in Sweden on disability pension, before and after changes of regulations

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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1101-1262
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1464-360X
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10.1093/eurpub/ckx206
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Abstract

Abstract Background There is limited knowledge regarding psychiatric healthcare utilization around the time of granting disability pension (DP) due to common mental disorders (CMD) among immigrants and if this is related to social insurance regulations. The aim was to evaluate patterns of psychiatric healthcare utilization before and after DP due to CMD among immigrants and natives. A second aim was to evaluate if such patterns differed before and after changes in social insurance regulations in Sweden in 2008. Methods All 28 354 individuals living in Sweden with incident DP due to CMD, before (2005–06; n = 24 298) or after (2009–10; n = 4056) changes in regulations of granting DP, were included. Patterns of psychiatric in- and specialized outpatient healthcare utilization during a 7-year window around DP granting were assessed by Generalized Estimating Equations estimating multivariate adjusted odds ratios (OR) and 95% confidence intervals (CI). Results Prevalence rates of psychiatric inpatient care were comparable among immigrants and natives, lower in non-Western immigrants (Africa, Asia and South-America). Three years after DP, non-Western immigrants in comparison to natives and Western immigrants had a stronger decrease in inpatient psychiatric healthcare: OR 0.48 (CI 0.38–0.62), 0.76 (0.70–0.83) and 1.01 (0.76–1.34), respectively. After 2008, a strong reduction in outpatient psychiatric healthcare after DP granting was observed, similarly in immigrants and natives. Conclusions Non-Western immigrants showed a different pattern of inpatient specialized healthcare after DP granting in comparison to natives. After changes in social insurance regulations, the decline in outpatient psychiatric healthcare following DP granting was comparable in immigrants and natives. Introduction Common mental disorders (CMD), i.e. anxiety and depressive disorders, represent a considerable public health problem in many European countries and have been projected to be the leading cause of loss of disability adjusted life years at global level by 2030.1 CMDs have adverse effects on everyday life and work capacity.2,3 In fact, in a number of OECD countries they represent one of the main causes of disability pension (DP), a measure of permanent work incapacity.4 Now-a-days, immigration is a global phenomenon and currently in Sweden more than 20% of the residents are first or second generation immigrants.5 In Sweden, DP is reported to be more common among immigrants in comparison to the native population, with different levels on the basis of the country of birth of the immigrants.6 An adequate healthcare intervention is fundamental in order to prevent the aggravation of a mental disorder and the risk of a subsequent DP. In fact, it has previously been shown that many mental disorders, including CMDs, can be effectively treated.7,8 A recent study reported that rates receiving specialized healthcare before granting of DP increased somewhat, possibly reflecting the aggravating severity of symptoms in the process towards permanent work incapacity.9 These findings should be discussed in the light of reports of sub-optimal treatment before granting of DP.10,11 After granted DP, a Swedish study showed a decrease in the healthcare utilization and a Finnish study reported a decrease in purchases of prescribed anti-depressants.9,12 Furthermore, several studies have suggested that psychiatric healthcare is under-utilized among immigrants, particularly in immigrants from non-Western countries, among which many are refugees.13–15 Still, to date there is no study investigating if patterns of psychiatric healthcare before and after granted DP differ between immigrants and natives. As socio-demographic factors, such as old age, being a female or having a lower level of education have been shown to be strongly associated with granting of DP due to CMD, it is important to consider such factors in related analyses.16,17 Social insurance regulations are related to levels of DP and, thus, changes of such rules can impact DP rates.9,18 In July 2008, stricter rules for being granted DP were introduced in Sweden. This led to a reduction of incident DPs, suggesting a higher level of medical severity in these new cases. For this reason, the healthcare utilization around DP granting might also vary during the time before and after regulation changes. A recent paper, in fact, showed a higher utilization of psychiatric healthcare in individuals granted DP after regulation changes.9 To date, no published study has examined if this variation differs among immigrants in comparison to natives. The aims of the study were to assess patterns of specialized healthcare due to psychiatric diagnoses before and after being granted DP due to CMD, and whether such patterns differed among immigrants and natives. A further aim was to study if patterns in different immigrant groups and natives differed if DP was granted before or after the changes of the social insurance regulations in Sweden in 2008. Methods Study population A population-based longitudinal cohort study was conducted including all individuals living in Sweden, aged between 19–64 years with incident DP due to CMD in 2005–06 or in 2009–10 (N = 30 157). Excluded were individuals who died or emigrated within 3 years after they had been granted DP in order to omit biased results of their healthcare utilization. Moreover, individuals with missing information on socio-demographic covariates (n = 1803) were excluded. The final population consisted of 28 354 individuals. Of those, 24 298 individuals (85.7%) had incident DP in 2005–06 (cohort 1) and 4056 (14.3%) individuals had incident DP in 2009–10 (cohort 2). Sensitivity analyses indicated the comparability of results in the study populations with and without exclusion due to missing values regarding socio-demographic covariates. Register data Data linked at individual level, based on the personal identity number assigned to all the residents in Sweden, were obtained from the following nationwide registers: Longitudinal integration database for health insurance and labour market studies (LISA) held by Statistics Sweden (sex, age, region of birth, educational level, type of living area, family situation and emigration). (i) National patient register (date and diagnosis of in- and specialized outpatient healthcare due to psychiatric diagnoses) and (ii) cause of death register (date of death) from the National Board of Health and Welfare. Micro-data for analyzes of social insurance (date, grade and diagnosis of DP) from the Swedish Social Insurance Agency. Disability pension All residents in Sweden aged 19–64 years, whose work capacity is long-time or permanently reduced due to disease or injury, are eligible for DP from the Social Insurance Agency. DP can be granted for 25%, 50%, 75% or 100% of ordinary working hours. In 2008, there was a change in the requirements for DP eligibility. Before 2008, all individuals could be granted temporary DP, after 2008, the reduced work capacity had to be permanent after the age of 30. For individuals aged 19–29 years, temporary DP was still possible.19,20 CMD diagnoses The main CMD DP diagnoses were coded according to the International Classification of Diseases version 10 (ICD-10)21 and categorized as follows: ‘depressive episode’ (F32), ‘recurrent depressive disorder’ (F33), ‘phobic anxiety disorder’ (F40), ‘other anxiety disorder’ (F41), ‘obsessive-compulsive disorder’ (F42) and ‘reaction to severe stress and adjustment disorder’ (F43).22 Region of birth Region of birth was grouped as follows: (1) Sweden (called natives); (2) other Western countries (Nordic countries, EU 25, Canada, USA and Oceania) and (3) non-Western countries (Africa, Asia and South America). Outcome and covariates Specialized psychiatric outpatient and inpatient healthcare utilization was defined as the outcome measure. Information on primary health care was not available. Socio-demographic variables, including sex, age, educational level, type of living area and family situation were measured at 31 December in the year before granted DP. Individuals with missing information regarding educational level (0.8%) were merged into the ‘elementary school’ category. People with missing values in the other sociodemographic variables were excluded. All variables were coded as reported in table 1. Table 1 Descriptive statistics of the 28 354 women and men, aged 19–64 years, living in Sweden, with incident DP in 2005–06 or in 2009–10 due to CMDs   All  Natives  Western  non-Western  n (%)  n (%)  n (%)  n (%)    28 354 (100)  22 156 (78.1)  1891 (6.7)  4307 (15.2)  Sexc              Male  9023 (31.8)  6540 (29.5)  559 (29.6)  1924 (44.7)      Female  19 331 (68.2)  15 616 (70.5)  1332 (70.4)  2383 (55.3)  Age (in years) when granted DPc              19–29  2053 (7.2)  1859 (8.4)  35 (1.9)  159 (3.7)      30–39  3357 (11.8)  2728 (12.3)  123 (6.5)  506 (11.7)      40–49  7015 (24.7)  5078 (22.9)  414 (21.9)  1523 (35.4)      50–59  8486 (29.9)  6144 (27.7)  715 (37.8)  1627 (37.8)      60–64  7443 (26.3)  6347 (28.6)  604 (31.9)  492 (11.4)  Education (in years)c              ≤9 (elementary school)  6326 (22.3)  4470 (20.2)  446 (23.6)  1410 (32.7)      10–12 (high school)  13 633 (48.1)  10 825 (48.9)  916 (48.4)  1892 (43.9)      ≥13 (college or university)  8395 (29.6)  6861 (31.0)  529 (28.0)  1005 (23.3)  Type of living areaa,c              Big cities  10 988 (38.8)  7366 (33.2)  978 (51.7)  2644 (61.4)      Medium-sized cities  9547 (33.7)  7827 (35.3)  537 (28.4)  1183 (27.5)      Small cities/villages  7819 (27.6)  6963 (31.4)  376 (19.9)  480 (11.1)  Family situationb,c              Married/cohabiting with no children at home  5145 (18.1)  4303 (19.4)  384 (20.3)  458 (10.6)      Married/cohabiting with children at home  8063 (28.4)  5700 (25.7)  490 (25.9)  1873 (43.5)      Single without children living at home  11 031 (38.9)  9085 (41.0)  707 (37.4)  1239 (28.8)      Single with children living at home  4115 (14.5)  3068 (13.8)  310 (16.4)  737 (17.1)  Main DP diagnosesc,d              Depressive disorder (F31-32-F33)  13 285 (46.8)  10 312 (46.5)  1014 (53.6)  1959 (45.5)      Anxiety disorder (F40-F41-F42)  6854 (24.2)  5677 (25.6)  420 (22.2)  757 (17.6)      Stress-related mental disorder (F43)  8215 (29.0)  6167 (27.8)  457 (24.2)  1591 (36.9)    All  Natives  Western  non-Western  n (%)  n (%)  n (%)  n (%)    28 354 (100)  22 156 (78.1)  1891 (6.7)  4307 (15.2)  Sexc              Male  9023 (31.8)  6540 (29.5)  559 (29.6)  1924 (44.7)      Female  19 331 (68.2)  15 616 (70.5)  1332 (70.4)  2383 (55.3)  Age (in years) when granted DPc              19–29  2053 (7.2)  1859 (8.4)  35 (1.9)  159 (3.7)      30–39  3357 (11.8)  2728 (12.3)  123 (6.5)  506 (11.7)      40–49  7015 (24.7)  5078 (22.9)  414 (21.9)  1523 (35.4)      50–59  8486 (29.9)  6144 (27.7)  715 (37.8)  1627 (37.8)      60–64  7443 (26.3)  6347 (28.6)  604 (31.9)  492 (11.4)  Education (in years)c              ≤9 (elementary school)  6326 (22.3)  4470 (20.2)  446 (23.6)  1410 (32.7)      10–12 (high school)  13 633 (48.1)  10 825 (48.9)  916 (48.4)  1892 (43.9)      ≥13 (college or university)  8395 (29.6)  6861 (31.0)  529 (28.0)  1005 (23.3)  Type of living areaa,c              Big cities  10 988 (38.8)  7366 (33.2)  978 (51.7)  2644 (61.4)      Medium-sized cities  9547 (33.7)  7827 (35.3)  537 (28.4)  1183 (27.5)      Small cities/villages  7819 (27.6)  6963 (31.4)  376 (19.9)  480 (11.1)  Family situationb,c              Married/cohabiting with no children at home  5145 (18.1)  4303 (19.4)  384 (20.3)  458 (10.6)      Married/cohabiting with children at home  8063 (28.4)  5700 (25.7)  490 (25.9)  1873 (43.5)      Single without children living at home  11 031 (38.9)  9085 (41.0)  707 (37.4)  1239 (28.8)      Single with children living at home  4115 (14.5)  3068 (13.8)  310 (16.4)  737 (17.1)  Main DP diagnosesc,d              Depressive disorder (F31-32-F33)  13 285 (46.8)  10 312 (46.5)  1014 (53.6)  1959 (45.5)      Anxiety disorder (F40-F41-F42)  6854 (24.2)  5677 (25.6)  420 (22.2)  757 (17.6)      Stress-related mental disorder (F43)  8215 (29.0)  6167 (27.8)  457 (24.2)  1591 (36.9)  a Type of living area: Big cities: Stockholm, Gothenburg and Malmö; Medium-sized cities: cities with more than 90 000 inhabitants within 30 km distance from the centre of the city; small cities/villages. b Single means living without partner and includes divorces, separated or widowed. c All the P-values from the Chi test were significant (P < 0.001) for differences among immigrant groups. d In brackets codes according the ICD-10. Table 1 Descriptive statistics of the 28 354 women and men, aged 19–64 years, living in Sweden, with incident DP in 2005–06 or in 2009–10 due to CMDs   All  Natives  Western  non-Western  n (%)  n (%)  n (%)  n (%)    28 354 (100)  22 156 (78.1)  1891 (6.7)  4307 (15.2)  Sexc              Male  9023 (31.8)  6540 (29.5)  559 (29.6)  1924 (44.7)      Female  19 331 (68.2)  15 616 (70.5)  1332 (70.4)  2383 (55.3)  Age (in years) when granted DPc              19–29  2053 (7.2)  1859 (8.4)  35 (1.9)  159 (3.7)      30–39  3357 (11.8)  2728 (12.3)  123 (6.5)  506 (11.7)      40–49  7015 (24.7)  5078 (22.9)  414 (21.9)  1523 (35.4)      50–59  8486 (29.9)  6144 (27.7)  715 (37.8)  1627 (37.8)      60–64  7443 (26.3)  6347 (28.6)  604 (31.9)  492 (11.4)  Education (in years)c              ≤9 (elementary school)  6326 (22.3)  4470 (20.2)  446 (23.6)  1410 (32.7)      10–12 (high school)  13 633 (48.1)  10 825 (48.9)  916 (48.4)  1892 (43.9)      ≥13 (college or university)  8395 (29.6)  6861 (31.0)  529 (28.0)  1005 (23.3)  Type of living areaa,c              Big cities  10 988 (38.8)  7366 (33.2)  978 (51.7)  2644 (61.4)      Medium-sized cities  9547 (33.7)  7827 (35.3)  537 (28.4)  1183 (27.5)      Small cities/villages  7819 (27.6)  6963 (31.4)  376 (19.9)  480 (11.1)  Family situationb,c              Married/cohabiting with no children at home  5145 (18.1)  4303 (19.4)  384 (20.3)  458 (10.6)      Married/cohabiting with children at home  8063 (28.4)  5700 (25.7)  490 (25.9)  1873 (43.5)      Single without children living at home  11 031 (38.9)  9085 (41.0)  707 (37.4)  1239 (28.8)      Single with children living at home  4115 (14.5)  3068 (13.8)  310 (16.4)  737 (17.1)  Main DP diagnosesc,d              Depressive disorder (F31-32-F33)  13 285 (46.8)  10 312 (46.5)  1014 (53.6)  1959 (45.5)      Anxiety disorder (F40-F41-F42)  6854 (24.2)  5677 (25.6)  420 (22.2)  757 (17.6)      Stress-related mental disorder (F43)  8215 (29.0)  6167 (27.8)  457 (24.2)  1591 (36.9)    All  Natives  Western  non-Western  n (%)  n (%)  n (%)  n (%)    28 354 (100)  22 156 (78.1)  1891 (6.7)  4307 (15.2)  Sexc              Male  9023 (31.8)  6540 (29.5)  559 (29.6)  1924 (44.7)      Female  19 331 (68.2)  15 616 (70.5)  1332 (70.4)  2383 (55.3)  Age (in years) when granted DPc              19–29  2053 (7.2)  1859 (8.4)  35 (1.9)  159 (3.7)      30–39  3357 (11.8)  2728 (12.3)  123 (6.5)  506 (11.7)      40–49  7015 (24.7)  5078 (22.9)  414 (21.9)  1523 (35.4)      50–59  8486 (29.9)  6144 (27.7)  715 (37.8)  1627 (37.8)      60–64  7443 (26.3)  6347 (28.6)  604 (31.9)  492 (11.4)  Education (in years)c              ≤9 (elementary school)  6326 (22.3)  4470 (20.2)  446 (23.6)  1410 (32.7)      10–12 (high school)  13 633 (48.1)  10 825 (48.9)  916 (48.4)  1892 (43.9)      ≥13 (college or university)  8395 (29.6)  6861 (31.0)  529 (28.0)  1005 (23.3)  Type of living areaa,c              Big cities  10 988 (38.8)  7366 (33.2)  978 (51.7)  2644 (61.4)      Medium-sized cities  9547 (33.7)  7827 (35.3)  537 (28.4)  1183 (27.5)      Small cities/villages  7819 (27.6)  6963 (31.4)  376 (19.9)  480 (11.1)  Family situationb,c              Married/cohabiting with no children at home  5145 (18.1)  4303 (19.4)  384 (20.3)  458 (10.6)      Married/cohabiting with children at home  8063 (28.4)  5700 (25.7)  490 (25.9)  1873 (43.5)      Single without children living at home  11 031 (38.9)  9085 (41.0)  707 (37.4)  1239 (28.8)      Single with children living at home  4115 (14.5)  3068 (13.8)  310 (16.4)  737 (17.1)  Main DP diagnosesc,d              Depressive disorder (F31-32-F33)  13 285 (46.8)  10 312 (46.5)  1014 (53.6)  1959 (45.5)      Anxiety disorder (F40-F41-F42)  6854 (24.2)  5677 (25.6)  420 (22.2)  757 (17.6)      Stress-related mental disorder (F43)  8215 (29.0)  6167 (27.8)  457 (24.2)  1591 (36.9)  a Type of living area: Big cities: Stockholm, Gothenburg and Malmö; Medium-sized cities: cities with more than 90 000 inhabitants within 30 km distance from the centre of the city; small cities/villages. b Single means living without partner and includes divorces, separated or widowed. c All the P-values from the Chi test were significant (P < 0.001) for differences among immigrant groups. d In brackets codes according the ICD-10. Statistical analyses Differences in the distributions of socio-demographic characteristics and the main DP diagnosis among immigrants and natives were tested using Chi-square tests. Analyzes were based on annual diagnosis-specific healthcare utilization spanning over a 7-year observation window. A time point measure was utilized, defining the year when granted DP as time point ‘t0’ (reference) and the 3 years of observation before and after DP granting year (from t–3 to t–1 and t + 1 to t + 3). In the overall sample (combining both cohorts), annual prevalence rates of in- and specialized outpatient healthcare due to psychiatric diagnoses were estimated. Repeated measure logistic regression analyses with Generalized Estimating Equations method and autoregressive correlation structure were performed in order to estimate patterns of healthcare utilization. Odds ratios (OR) with 95% confidence intervals (CI) were computed for the 3 years before (t–3 to t–1), and 3 years after granted DP (t + 1 to t + 3) in relation to the DP granting year (t0, reference). Furthermore, analyses were carried out for those granted DP before and after the 2008 changes in the social insurance legislation (cohort 1; 2005–06 and cohort 2; 2009–10). All models were adjusted for sex, age, educational level, type of living area, family situation and main DP CMD diagnoses. All analyses were conducted by SPSS v. 20. Ethical approval The project was approved by the Regional Ethical Review Board of Stockholm, Sweden. Results Of the 28 354 individuals granted DP due to CMD during the 4-year observation (2005–06 and 2009–10) (table 1), the majority (78.1%) were born in Sweden, while 6.7% were born in other Western countries and 15.2% in non-Western countries. The main DP diagnosis was depressive disorder for almost half (46.8%), followed by stress-related disorders (29.0%) and anxiety disorders (24.2%). Natives in comparison to non-Western immigrants, were more likely to be women (70.5% vs. 55.3%), to be young (8.4% in the 19–29 group vs. 3.7%) and to have a college or university education (31.0% vs. 23.3%). Immigrants from Western countries showed prevalence rates, which were generally in between those of natives and non-Western immigrants. The differences in distributions among natives and immigrant groups were all statistically significant (table 1, P < 0.001). Healthcare due to psychiatric diagnoses In the overall sample, specialized healthcare due to psychiatric diagnoses increased before the year of granted DP (t0) (table 2). The inpatient care utilization decreased after t0 while outpatient psychiatric healthcare remained at the same level. The outpatient psychiatric healthcare utilization was somewhat lower in the natives in comparison to the group of non-Western countries (t–1 natives: 22.9%, Western 21.2%, non-Western 25.2%). In cohort 2, prevalence rates were almost two times higher in comparison to cohort 1 in both outpatient and inpatient healthcare (t–1 natives: 46.5%, Western 40.8%, non-Western 49.2%; t–1 natives 8.4%, Western 7.7%, non-Western 5.8%), respectively, (data not shown). Table 2 Annual prevalence of healthcare use among individuals aged 19–64 years, living in Sweden and granted DP in 2005–06 or 2009–10 (n = 28 354) due to CMDs, stratified by region of birth Time pointsa  Inpatient  Outpatient  Sweden  Western  non-Western  Sweden  Western  non-Western  n (%)  n (%)  n (%)  n (%)  n (%)  n (%)  t–3  825 (3.7)  65 (3.4)  122 (2.8)  2401 (10.8)  176 (9.3)  451 (10.5)  t–2  1082 (4.9)  89 (4.7)  166 (3.8)  3729 (16.8)  298 (15.8)  775 (18.0)  t–1  1155 (5.2)  89 (4.7)  188 (4.3)  5084 (22.9)  400 (21.2)  1085 (25.2)  t0  1003 (4.5)  73 (3.8)  177 (4.1)  5549 (25.0)  427 (22.6)  1304 (30.3)  t + 1  822 (3.7)  66 (3.5)  126 (2.9)  5712 (25.8)  466 (24.6)  1350 (31.3)  t + 2  815 (3.7)  62 (3.3)  86 (2.0)  6034 (27.2)  491 (26.0)  1308 (30.4)  t + 3  779 (3.5)  73 (3.9)  90 (2.1)  5829 (26.3)  423 (23.0)  1196 (27.8)  Time pointsa  Inpatient  Outpatient  Sweden  Western  non-Western  Sweden  Western  non-Western  n (%)  n (%)  n (%)  n (%)  n (%)  n (%)  t–3  825 (3.7)  65 (3.4)  122 (2.8)  2401 (10.8)  176 (9.3)  451 (10.5)  t–2  1082 (4.9)  89 (4.7)  166 (3.8)  3729 (16.8)  298 (15.8)  775 (18.0)  t–1  1155 (5.2)  89 (4.7)  188 (4.3)  5084 (22.9)  400 (21.2)  1085 (25.2)  t0  1003 (4.5)  73 (3.8)  177 (4.1)  5549 (25.0)  427 (22.6)  1304 (30.3)  t + 1  822 (3.7)  66 (3.5)  126 (2.9)  5712 (25.8)  466 (24.6)  1350 (31.3)  t + 2  815 (3.7)  62 (3.3)  86 (2.0)  6034 (27.2)  491 (26.0)  1308 (30.4)  t + 3  779 (3.5)  73 (3.9)  90 (2.1)  5829 (26.3)  423 (23.0)  1196 (27.8)  a t–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP granting, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP. Table 2 Annual prevalence of healthcare use among individuals aged 19–64 years, living in Sweden and granted DP in 2005–06 or 2009–10 (n = 28 354) due to CMDs, stratified by region of birth Time pointsa  Inpatient  Outpatient  Sweden  Western  non-Western  Sweden  Western  non-Western  n (%)  n (%)  n (%)  n (%)  n (%)  n (%)  t–3  825 (3.7)  65 (3.4)  122 (2.8)  2401 (10.8)  176 (9.3)  451 (10.5)  t–2  1082 (4.9)  89 (4.7)  166 (3.8)  3729 (16.8)  298 (15.8)  775 (18.0)  t–1  1155 (5.2)  89 (4.7)  188 (4.3)  5084 (22.9)  400 (21.2)  1085 (25.2)  t0  1003 (4.5)  73 (3.8)  177 (4.1)  5549 (25.0)  427 (22.6)  1304 (30.3)  t + 1  822 (3.7)  66 (3.5)  126 (2.9)  5712 (25.8)  466 (24.6)  1350 (31.3)  t + 2  815 (3.7)  62 (3.3)  86 (2.0)  6034 (27.2)  491 (26.0)  1308 (30.4)  t + 3  779 (3.5)  73 (3.9)  90 (2.1)  5829 (26.3)  423 (23.0)  1196 (27.8)  Time pointsa  Inpatient  Outpatient  Sweden  Western  non-Western  Sweden  Western  non-Western  n (%)  n (%)  n (%)  n (%)  n (%)  n (%)  t–3  825 (3.7)  65 (3.4)  122 (2.8)  2401 (10.8)  176 (9.3)  451 (10.5)  t–2  1082 (4.9)  89 (4.7)  166 (3.8)  3729 (16.8)  298 (15.8)  775 (18.0)  t–1  1155 (5.2)  89 (4.7)  188 (4.3)  5084 (22.9)  400 (21.2)  1085 (25.2)  t0  1003 (4.5)  73 (3.8)  177 (4.1)  5549 (25.0)  427 (22.6)  1304 (30.3)  t + 1  822 (3.7)  66 (3.5)  126 (2.9)  5712 (25.8)  466 (24.6)  1350 (31.3)  t + 2  815 (3.7)  62 (3.3)  86 (2.0)  6034 (27.2)  491 (26.0)  1308 (30.4)  t + 3  779 (3.5)  73 (3.9)  90 (2.1)  5829 (26.3)  423 (23.0)  1196 (27.8)  a t–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP granting, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP. Patterns of healthcare utilization In relation to the year of granted DP, ORs of inpatient care due to psychiatric diagnoses among those born in Sweden increased from 0.81 (CI: 0.74–0.88)–1.16 (CI 1.08–1.25) (t–3 to t–1) and thereafter decreased to 0.76 (CI 0.70–0.83) at t + 3 (figure 1). This pattern was similar in immigrants, but with somewhat higher ORs in immigrants from Western countries [increased from 0.88 (CI 0.65–1.20)–1.23 (CI 0.96–1.58) and decreased to 1.01 (CI 0.76–1.34) at t + 3] and lower ORs in immigrants from non-Western countries [increased from 0.68 (CI 0.54–0.85)–1.06 (CI 0.88–1.27) and decreased to 0.48 (CI 0.38–0.62) at t + 3]. The decrease in inpatient healthcare due to psychiatric diagnoses after t0 among the non-Western immigrants was much steeper than in the other two groups. The OR of outpatient healthcare due to psychiatric diagnoses was lower in the year preceding DP and higher thereafter, regardless of the region of birth. However, the non-Western immigrants had a steeper increase up until t0 and showed a stabilization with a further decrease following 3 years after granted DP [OR 0.25 (CI 0.23–0.28), OR 1.05 (CI 0.98–1.13) and OR 0.88 (CI 0.81–0.95) at t–3, t + 1 and t + 3, respectively]. Analyses excluding individuals below 30 years showed comparable results as for the entire study population (data not shown). Figure 1 View largeDownload slide (ORs)a and 95% (CIs)b of healthcare use due to psychiatric diagnoses at different time pointsc compared to DP granting year (t0) before and after being granted DP due to CMDs in the total sample (both cohorts, granted DP in year 2005, 2006, 2009 or 2010, n = 28 354,) for natives and for immigrants born in Western countries or in non-Western Countries, respectively aAdjusted for sex, age, educational level, type of living area, family situation and DP diagnoses. bError bars indicate 95% CIs. ct–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP grant, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP Figure 1 View largeDownload slide (ORs)a and 95% (CIs)b of healthcare use due to psychiatric diagnoses at different time pointsc compared to DP granting year (t0) before and after being granted DP due to CMDs in the total sample (both cohorts, granted DP in year 2005, 2006, 2009 or 2010, n = 28 354,) for natives and for immigrants born in Western countries or in non-Western Countries, respectively aAdjusted for sex, age, educational level, type of living area, family situation and DP diagnoses. bError bars indicate 95% CIs. ct–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP grant, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP Patterns of healthcare utilization before (cohort 1) and after (cohort 2) regulatory changes Patterns of specialized outpatient care due to psychiatric diagnoses were similar in cohort 1 as in both cohorts combined, with an increase up until 2 years after granted DP both in natives and immigrants (figure 2). In cohort 2, there was a strong reduction after t0, stronger in non-Western immigrants in comparison to natives [from t + 1 to t + 3, natives: from OR 0.70 (CI 0.65–0.76) to OR 0.59 (CI 0.54–0.64); non-Western: from OR 0.66 (CI 0.57–0.77) to OR 0.38 (CI 0.32–0.46)]. Results regarding inpatient healthcare rates for cohorts 1 and 2 are not reported because of lack of power. Figure 2 View largeDownload slide (ORs)a and 95% (CIs)b of specialized outpatient healthcare use due to psychiatric diagnoses in cohort 1 (with incident DP, in 2005–2006, n = 24 298) and after (cohort 2, n = 4056) changes in social insurance regulation in Sweden in 2008 at different time pointsc compared to the year of granted DP (t0) among people with different regions of birth aAdjusted for sex, age, educational level, type of living area, family situation and DP diagnoses. bError bars indicate 95% CIs. ct–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP grant, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP Figure 2 View largeDownload slide (ORs)a and 95% (CIs)b of specialized outpatient healthcare use due to psychiatric diagnoses in cohort 1 (with incident DP, in 2005–2006, n = 24 298) and after (cohort 2, n = 4056) changes in social insurance regulation in Sweden in 2008 at different time pointsc compared to the year of granted DP (t0) among people with different regions of birth aAdjusted for sex, age, educational level, type of living area, family situation and DP diagnoses. bError bars indicate 95% CIs. ct–3: 3 years before DP, t–2: 2 years before DP, t–1: 1 years before DP, t–0: year of DP grant, t + 1: 1 years after DP, t + 2: 2 years after DP, t + 3: 3 years after DP Discussion We observed an increase in the inpatient healthcare due to psychiatric diagnoses in the years before granted DP and a decrease in the years afterwards. Immigrants from non-Western countries showed lower rates of inpatient care before and after DP compared to natives. For specialized outpatient healthcare due to psychiatric diagnoses, prevalence rates tended to be higher among immigrants from non-Western countries than among natives. Patterns of psychiatric healthcare utilization after DP were comparable with one exception: non-Western immigrants had a stronger decrease after DP granting in inpatient psychiatric healthcare than natives and immigrants from Western countries. Patterns of specialized outpatient care due to psychiatric diagnoses of cohort 2, granted DP after the change in legislation in 2008, were similar in immigrants and natives, showing a strong reduction after DP granting. Methodological considerations Strengths of this study include the utilization of high-quality population-based registers with nationwide coverage and two large cohorts including all individuals granted DP due to CMDs in the four studied years.23–25 Additional strengths include practically no loss to follow-up, no recall bias and the possibility to address several covariates. The study has also some limitations. First, by using information on inpatient and specialized outpatient care, we had no information on primary health care utilization and residual confounding by unmeasured morbidity is likely, especially in migrants.13 Secondly, the validity of DP diagnoses is often discussed, however, seldom studied. We argue that the validity of the CMD diagnoses studied here is acceptable, for the following three reasons: a high validity, regarding sick-leave diagnoses, was reported when compared to diagnoses from medical records in a Swedish study.26 Moreover, in Sweden, the medical assessments of whether a patient fulfils the criteria for being granted DP is thorough, conducted by physicians and usually preceded by long-term sickness absence demanding several medical assessments.27 Thirdly, the stigma related to mental diagnoses may contribute to the fact that such diagnoses are given only if a mental disorder has led to the work incapacity.28 Finally, in order to have statistical power we categorized the immigrants into two broad groups (Western and non-Western immigrants). Further studies, with a focus on specific immigrant groups (country or regional level), might provide more specific knowledge. Discussion of findings The prevalence of psychiatric healthcare utilization increased in the pre-DP period (t–3 to t–1), both regarding inpatient and specialized outpatient healthcare and among immigrants and natives. This is in line with previous research showing an increase in purchases of psychotropic drugs as well as in self-reported symptoms of depression and anxiety before granted DP, irrespective of DP diagnoses.12,16,29–31 In the year before being granted DP (t–1), 5.2%, 4.7% and 4.3% of the individuals born in Sweden, Western, or non-Western countries, respectively, had psychiatric inpatient healthcare. The same year (t–1) the prevalence rates of psychiatric outpatient healthcare ranged from 21.2% to 25.2%. Considering the permanent state of DP, the rates of people having had specialized healthcare can, nevertheless, be considered as low. These findings suggest that the overwhelming proportion of individuals were treated in primary healthcare before granted DP. This is noteworthy as the sick-leave guidelines recommend referral to psychiatric specialized healthcare if a sick-leave spell due to CMD lasted for longer than 6 months.32 Our findings are comparable with results from a study reporting that the quality of psychiatric healthcare was sub-optimal before granted DP.10 In particular, we found that rates of inpatient care due to psychiatric diagnoses were especially low in immigrants from non-Western countries during the entire 7-year period and significantly lower in t + 2 and t + 3 compared with the other groups. Two previous studies indicate a higher risk of sub-optimal inpatient healthcare and early treatment discontinuation in the healthcare of non-Western immigrants.13,33 The lower rates of psychiatric inpatient healthcare among immigrants from non-Western countries are particularly noteworthy because of the poorer mental health and a higher risk of DP previously shown among such immigrants.6,19,34 There might be several different explanations for such lower rates among non-Western immigrants. Attitudinal barriers to mental healthcare use, such as arising from beliefs and culture, seem to be more common among non-Western immigrants than structural barriers including lack of information or difficulties in accessing the healthcare.35,36 A different perception of the needs among non-Western immigrants, higher levels of stigmatization of mental disorders and difficulties in medical communication were suggested to play a crucial role in this regard.37 The rates of psychiatric healthcare utilization among immigrants from Western countries, which were more similar to natives, may be explained by immigrants from Western countries being more familiar with the Swedish mental healthcare system or by the duration of stay in Sweden.35 The general pattern of psychiatric healthcare utilization showed an increase before granted DP, both in in- and specialized outpatient healthcare due to psychiatric diagnoses. This is consistent with other studies: a Finnish study showed an increase in purchase of psychotropic drugs; a recent Swedish study an increase in specialized healthcare.11,12 After DP granting, utilization of inpatient health care showed a decrease. The interruption of work demands, improvements of symptoms or a referral of the patient to the primary healthcare, can be explanations of this finding.11 The stronger decrease among immigrants from non-Western countries can be interpreted by a higher risk of under-utilization of healthcare by non-Western immigrants or by a stronger improvement in the mental health status after DP granting in this population in comparison to natives. Under-utilization of employment skills and a higher risk of job strain among non-Western immigrants38–40 might also explain the lower need of psychiatric health care following DP. The prevalence rates of outpatient healthcare due to psychiatric diagnoses were generally higher after the changes of the social insurance system (2008), possibly reflecting a higher severity in mental disorders among those granted DP with the stricter criteria.9,27 Regarding general patterns, the outpatient psychiatric healthcare showed in cohort 2 a strong reduction after granted DP, while it increased in cohort 1. This is in line with a previously published study.9 Explanations for the patterns in cohort 1 can be the higher level of temporary DP in this cohort with a lower medical severity compared with individuals granted DP in cohort 2. When we compared natives with immigrants, patterns were very similar with a stronger decline after granted DP in non-Western immigrants. The greater decline might be related to either improvements regarding symptoms or to under-utilization of services, as already supposed for the decline in the inpatient healthcare among them. Conclusions The results from this study suggest that utilization of specialized healthcare due to psychiatric diagnoses increased up to the time of being granted DP due to CMD, regardless of migration background. The decline in the psychiatric inpatient healthcare rates after granted DP was stronger among immigrants from non-Western countries in comparison to those from Western countries and natives. After the change in the legislation (2008) both immigrants and natives showed a stronger reduction in the outpatient healthcare due to psychiatric diagnoses following granting of DP. Funding This study was supported by the Swedish Research Council for Health, Working Life and Welfare [grant nr 2015-00742 and 2007-1952] and Karolinska Institutet’s funding for doctoral students. Conflicts of interest: None declared. Key points The prevalence of psychiatric healthcare utilization before being granted DP due to CMDs was generally low, regardless of migration background. Immigrants from non-Western countries showed a stronger decrease of psychiatric inpatient healthcare after being granted such DP in comparison to natives and immigrants from Western countries. The stricter criteria for granting DP introduced in Sweden in 2008 might have played a similar role in immigrants and natives, with a reduction in specialized psychiatric outpatient healthcare after granting such a DP. References 1 Whiteford HA, Degenhardt L, Rehm J, et al.   Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet  2013; 382: 1575– 86. Google Scholar CrossRef Search ADS PubMed  2 Norder G, van der Ben CA, Roelen CA, et al.   Beyond return to work from sickness absence due to mental disorders: 5-year longitudinal study of employment status among production workers. Eur J Public Health  2016; 27: 79– 83. 3 Knudsen AK, Harvey SB, Mykletun A, Øverland S. 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The European Journal of Public HealthOxford University Press

Published: Nov 30, 2017

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