Original article 27
Health in women on long-term sick leave because of pain or mental illness Per Lytsya,b, Kjerstin Larssona,c and Ingrid Anderzéna,b Mental illness and pain are common causes of long-term sick absence and major difficulties in vocational rehabilitation. The aim of this study was to investigate health in a group of women with pain or mental illness who had exhausted their days of sickness benefit. This crosssectional study uses baseline data from 355 women on long-term sick leave participating in controlled intervention studies aiming at returning to work. The study population filled in a written questionnaire with questions of self-rated health and sleep quality and validated indexes of mental health, satisfaction with life and general self-efficacy. Clinical psychiatric screening was performed on 230 individuals. The study population had a mean age of 48.8 years (SD 8.4), with an average time on sick leave of 7.8 years (SD 3.2). Self-rated health and sleep quality was poor compared with other populations. In all, 80.1% had at least one psychiatric diagnosis according to the psychiatric screening, and the average numbers of psychiatric diagnoses were 2.2 (SD 1.9). Foreign-born women showed significantly higher levels of mental illness, poorer selfrated health and sleep quality and lower self-efficacy and life satisfaction than native Swedish women. Women with
Introduction Sweden has, like many other European countries, had an increasing number of individuals outside the labour market because of health reasons in the past two decades. The increase in long-term sick leave is mainly caused by an increase in mental health problems, which, often accompanied with chronic pain (Linder et al., 2009), are now among the most common reason for long-term sickness absence (Søgaard and Bech, 2009; Henderson et al., 2011). The increase in mental ill health is of societal interest as it has been proposed as a threat to the welfare of the state (Sundquist et al., 2007). The economic burden of psychiatric disorders has increased markedly in Sweden, where the costs are mainly indirect (Tiainen and Rehnberg, 2010). Naturally, being outside the labour market because of mental ill health is also a problem for the individual as it affects personal well-being and functioning. There is evidence that individuals on longterm sick leave because of psychiatric disorders are at risk of future deteriorating health and premature mortality (Melchior et al., 2010; Mittendorfer-Rutz et al., 2012). Thus, management and prevention of ill health are major public health and occupational health challenges. 0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
long sick leave because of mental illness and/or pain have poor self-rated health and sleep quality, high prevalence of mental illness and low self-efficacy and life satisfaction. Psychiatric screening suggests more extensive mental illness than what was stated on the sick leave certificates. The health of foreign-born women seems to be worse than that of native Swedish women. International Journal of Rehabilitation Research 38:27–33 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. International Journal of Rehabilitation Research 2015, 38:27–33 Keywords: ethnic group, mental health, pain, self-efficacy, self-rated health, sick leave a Department of Public Health and Caring Sciences, Uppsala University, bArbets Rehab, Occupational and Environmental Medicine, Uppsala University Hospital, Uppsala and cDepartment of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
Correspondence to Per Lytsy, MD, PhD, Department of Public Health and Caring Sciences, Husargatan 3, Box 564, Uppsala University, SE-75122, Uppsala, Sweden Tel: + 46 18 4716552; fax: + 46 18 471 66 75; e-mail: [email protected] Received 25 February 2014 Accepted 31 July 2014
The increase of individuals outside the labour force because of ill health has initiated several regulatory and political actions in Sweden. A major change was carried out in 2008, when the parliament adopted a new act, reforming the sick leave system (Regeringens proposition, 2007/2008). Before this, individuals with long-term illness receiving sick certificates from their physicians would routinely have their provisional sick absence prolonged, enabling potentially very long periods of sick leave with health insurance cover. The new act introduced a time limit of 1 year for noncritically ill patients on sick leave. Patients reaching the maximum period are routinely transferred to the Swedish Public Employment insurance, for a 3-month re-examination programme, aiming at return to work in a controlled or a competitive employment. During 2010–2012, 41 000 individuals in Sweden lost their sick leave benefits, not because their health had improved, but because of the newly introduced time restrictions. From a medical rehabilitation point of view, it is of interest to investigate different aspects of health in this group as the various health situations are major determinants for returning to work (Von Celsing et al., 2012). DOI: 10.1097/MRR.0000000000000080
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
28 International Journal of Rehabilitation Research
2015, Vol 38 No 1
The aim of the present study was to investigate health, using validated questionnaires and clinical assessments, in a group of women with pain or mental illness who had exhausted their days of sickness benefit. The secondary aims of this study were to investigate whether there were subgroup differences in health according to study participants’ age, time on sick leave and country of origin.
Methods Study population
This cross-sectional study uses baseline clinical assessments and self-reported questionnaire data from participants in two randomized-controlled trials (Vitalis 1 and 2) in Uppsala County in Sweden. The first trial recruited only women, whereas the second also included men. Because of a low number of men (n = 26) in the second cohort, the current study only uses data from women. Baseline investigations did not differ between the trials’ designs other than somewhat changed questionnaire instruments, described below. Participants were recruited through the Uppsala office of the Swedish Social Insurance Administration, who identified a total of 1305 individuals expected to reach their maximum time of sick leave during the period June 2010 to December 2012. Of these, 1035 individuals were found to be eligible as they fulfilled the inclusion criteria, these being: (a) on sick leave for a pain or a mental disorder and (b) aged between 20 and 64 years, as well as not fulfilling the exclusion criteria, which were: (a) at present suicidal risk; (b) ongoing alcohol/substance abuse; (c) severe mental illness (schizophrenia, bipolar disorder type I); and (d) in an ongoing psychotherapy or vocational rehabilitation programme. Of the 448 individuals who provided informed consent to participate, the following were excluded from the present study: men (n = 26), individuals not returning the questionnaire (n = 46) and withdrawn consent/exclusion (n = 47). Thus, the final sample included 355 women. The recruitment procedure is shown in Fig. 1. Participants were asked to fill in a 16-page questionnaire about 1–4 months ahead of the date when they were expected to lose their sick leave benefits. The questionnaire included questions about their social situation, country of birth, education, number of children in the household, lifestyle and household economy. The health situation was assessed using SWLS (Satisfaction With Life Scale) (Diener et al., 1985), HADS (the Hospital Anxiety and Depression Scale) (Zigmond and Snaith, 1983), the GHQ-12 (General Health Questionnaire) (Goldberg and Blackwell, 1970) and the General Selfefficacy Scale (Schwartzer et al., 1997). Self-rated health was assessed by the question: ‘In general, how would you rate your health?’ and self-rated sleep quality was assessed as ‘In general, how would you rate your sleep quality?’ Both questions used the response categories very good, good, neither good nor poor, poor and very poor.
Alcohol risk use was assessed using the summed score of AUDIT-C (the alcohol use disorders identification test – consumption) with a cutoff of greater than 3 (women) (Bush et al., 1998). Queries about the use of pharmaceuticals were phrased as four separate questions: ‘Do you use: antidepressive medication/tranquillizers /sedatives/analgesics?’ Of the final sample consisting of 355 individuals, 230 met with a physician and/or a psychologist, who screened the participant for psychiatric disease using the Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) and assessed the patient’s GAF (Global Assessment of Functioning) (Hall, 1995). Participants who received interventions also performed a self-rating MADRS (Montgomery–Åsberg Depression Rating Scale) (Montgomery and Asberg, 1979). Data on sick certificate diagnosis/diagnoses current employment status, type and time on sick leave, for participants in the intervention group (n = 230), were provided by the Swedish Social Insurance Administration. The sick certificate diagnoses were used, by a physician, to classify the participants’ main problem as psychiatric, pain related or both. Three subgroup comparisons were made on the basis of age, time on sick leave and country of origin. Participants were categorized into three age groups on the basis of lowest (18–43 years), mid two (44–54 years) and highest (55–64 years) quartiles of age as well as into ‘time on sick leave’ as lowest (< 5 years), mid two (5–10 years) and highest quartiles (>10 years). All participants provided written informed consent to the study, which was approved by the regional ethics committee (Dnr 2010/088 and 2010/088/1). Statistical analyses
χ2-Tests were used to investigate differences in proportions and t-test/analysis of variance to investigate differences in means. Missing values in the indexes were handled by replacement of the individual’s mean scores when the following conditions were fulfilled: SWLS – three or more items (of five); HADS – four of more items (of seven); and GHQ-12 – seven or more items (of 12). An exception from this was the General Self-efficacy Scale, where missing items were handled as proposed by Schwartzer (2011): a sum score was calculated as long as no more than three items were missing. All tests were two-sided and a P-value of less than 0.05 was considered statistically significant. Data analyses were carried out using the Statistical Package for the Social Sciences version 21 (IBM Corp., Armonk, New York, USA).
Results Characteristics of the study sample
The study population had a mean age of 48.8 years (SD 8.4, range 25–64 years), with an average time on sick
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Health in women on long-term sick leave Lytsy et al. 29
Fig. 1
Total number of individuals reaching the maximum time and thus identified by health insurance office: 1305 Excluded for having other diagnosis then mental illness or pain according to sick leave certificate: 270 Total number of individuals having mental illness and/or pain who were invited to participate through mail: 1035
Nonresponders to written invitation: 587
Total number of individuals giving informed consent to participate in study: 448
Final sample: 355 women
Excluded from present study: 93 Reasons: No show/no data: 46 Male: 26 Ethics or severe disease or other rehabilitation program: 21
Flow chart of the recruitment procedure of the study sample.
leave of 7.8 years (SD 3.2, range 1–16.9 years). Sole painrelated disorders were the most common type of problem on the sick leave certificates (38.9%), followed by a combination of pain and psychiatric disease (31.0%) and psychiatric disorders alone (30.1%). About two-third of the study population had an employer, whereas about one-third were unemployed. About one-fifth (19.6%) of the population had primary school as their highest education; 46.5% had secondary schooling; and 33.9% had studied at university. There was a widespread use of analgesics (74.6%), antidepressants (45.4%), sedatives (34.0%) and tranquillizers (20.0%) in the study population. Self-rated health and self-rated sleep quality were, respectively, assessed as ‘poor’ or ‘very poor’ by 63.2 and 63.9% of the study population. Data on the characteristics of the study population and their self-assessed health according to the scales and surveys in the questionnaire are presented in Table 1. Subgroup comparisons of self-reported data
There were no major group differences in characteristics or health assessments according to age or length of sick leave categorization. Furthermore, there were no major differences in characteristics or health assessments according to age group categorization, other than a higher proportion of employed (P < 0.05) and lower educated women in the older age group (P < 0.01) (not shown). There were no significant differences in age, years on insurance benefit and education between women born in
or outside Sweden. Foreign-born women were, however, more likely to be unemployed (45.2 vs. 30.8%) and had worse self-rated sleep quality and health than their Swedish-born counterparts (Table 1). Foreign-born women further scored significantly worse on several of the instruments assessing life satisfaction (SWLS), general health (GHQ) and mental health (HADS, MADRS) (Table 1). Moreover, foreign-born women, in comparison with native Swedish women, reported more frequent use of tranquillizers, sedatives and analgesics and were less likely to be alcohol risk users (Table 1).
MINI screening
In all, 80.1% of the total population had at least one diagnosis according to the MINI screening. The average number of MINI diagnoses in the total screened population was 2.2 (SD 1.9, range 0–10). More than half (56.5%) of women with only pain-related disorders on their sick leave certificate had one or more diagnoses on the MINI screening. The most common diagnoses on the MINI screening were as follows: major depressive disorder (75.2%); suicidality (defined as ≥ 1 point) (37.9%); panic disorder (34.6%); social phobia (18.6%); and generalized anxiety disorder (18.5%). Women born outside Sweden were about twice as likely to be suicidal and more than five times as likely to have post-traumatic stress disorder according to the MINI screening (Table 2). Women born outside Sweden had significantly
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
30 International Journal of Rehabilitation Research
Table 1
2015, Vol 38 No 1
Study group characteristics, by country of birth and total Born in Sweden (n = 280, 79%)
Age [mean (SD)] 48.6 (8.8) Years on insurance 8.0 (3.3) benefits [mean (SD)] (n = 269) Employment status (%) Unemployed 30.8 Highest education (%) Primary school 17.6 Secondary school 47.5 University 34.9 Main diagnoses on sick certificate (%) Psychiatric 32.5 Pain 39.3 Both psychiatric and 28.2 pain Self-rated health Very good 0.4 Good 11.3 Neither good nor 31.3 poor Poor 42.0 Very poor 15.3 Self-rated sleep quality Very good 1.8 Good 12.2 Neither good nor 26.6 poor Poor 39.2 Very poor 20.1 SWLS 15.5 (6.9) HADS Depression 8.3 (4.4) Anxiety 10.0 (4.8) MADRS [mean (SD)] 16.7 (9.2) (n = 210) GHQ 18.4 (7.4) Self-efficacy [mean 23.7 (6.4) (SD)] GAF [mean (SD)] 65.3 (12.8) (n = 112) Use of antidepressives 43.0 Use of tranquillizers 16.0 Use of sedatives 31.2 Use of analgesics 71.3 Current smoker 20.7 Alcohol risk use (AUDIT41.6 C ≥ 3) (%) Experience of critical life 90.3 event (%)
Born outside Sweden (n = 75, 21%)
P-value
Total (n = 355)
49.6 (6.7) 7.3 (3.1)
0.34 0.10
48.8 (8.4) 7.8 (3.2)
45.2
0.02
33.9
27.0 42.9 30.2
0.25
19.6 46.5 33.9
21.3 37.3 41.3
0.055
30.1 38.9 31.0
0 1.4 12.7
< 0.001
0.3 9.3 27.2
49.3 36.6
43.5 19.7
1.4 1.4 18.1
1.7 9.9 24.4
< 0.001
39.2 41.9 13.2 (6.8)
0.013
12.1 (4.9) 14.2 (4.6) 28.2 (11.2)
< 0.001 < 0.001 < 0.001
13.3 (7.3) 18.8 (6.9)
< 0.001 < 0.001
59.4 (9.4)
0.034
54.9 35.7 45.1 87.5 26.5 12.9
0.083 0.001 0.035 0.004 0.326 < 0.001
85.3
0.271
39.2 24.7 15.1 (7.0) 9.1 (4.8) 10.9 (5.1) 18.8 (10.6) 17.4 (7.6) 22.7 (6.8) 64.0 (12.3) 45.4 20.0 34.0 74.6 21.8 35.8 89.3
AUDIT-C, alcohol use disorders identification test – consumption; HADS, Hospital Anxiety and Depression Scale; GAF, Global Assessment of Functioning; GHQ, General Health Questionnaire; MADRS, Montgomery–Åsberg Depression Rating Scale; SWLS, Satisfaction With Life Scale.
more MINI diagnoses compared with women born in Sweden [3.1 (SD 1.8) vs. 2.0 (SD 1.9), P = 0.02].
Discussion The aim of this study was to describe health in women with pain or mental illness who had exhausted their days of sickness benefit. The main findings in this group were poor self-rated health and sleep quality, high prevalence of mental illness (e.g. depression, suicidality, panic disorder and generalized anxiety) and low self-efficacy and life satisfaction. Foreign-born women were significantly
worse off, with higher levels of anxiety, depression, suicidality and post-traumatic stress, and poorer self-rated health and sleep quality disorder compared with native Swedish women. Comparisons with previous studies Self-rated health and self-rated sleep quality
More than half of the study group reported poor or very poor self-rated health and self-rated sleep quality. The corresponding percentages for foreign-born women were even worse in terms of self-rated health. This is a very high incidence of poor self-rated health compared with a random sample of 2954 women from two Swedish healthcare regions, where 9% rated their health as poor or very poor (Eriksson et al., 2001). Mental health
Anxiety was assessed using HADS, depression was assessed using both HADS and MADRS, and MINI was performed to screen for psychiatric diagnoses. The mean HADS scores were elevated, for both anxiety and depression, compared with scores reported in recently published studies (Høyer et al., 2011). Høyer et al. (2011) reported lower mean values for anxiety (6.2) and depression (4.3) in Swedish women with breast cancer. Lower levels of anxiety (7.6) and depression (7.8) were also reported in a Swedish study of a comparable group of women with long-term musculoskeletal pain (Pietilä Holmner et al., 2013). This indicates almost twice as high levels of anxiety and depression for foreign-born women in our study. The depression scores assessed with MADRS for native Swedish women were 16.7, which is comparable with the scores reported in a Swedish sample of long-term chronic pain patients treated in a rehabilitation hospital (Ericsson et al., 2002). The mean score for foreign-born women in our study was 27.7, which is highly elevated. Foreignborn women reported more frequent use of psychotropic drugs, which is in agreement with a previous study of psychiatric illness and drug treatment in different ethnic groups in Sweden (Bayard-Burfield et al., 2001). The MINI screening indicated a high prevalence of probable depressive episodes, suicidality, panic disorder, social phobia and generalized anxiety disorder. The prevalence of suicidality and generalized anxiety disorder was twice as high for foreign-born women compared with native Swedish women. The prevalence of posttraumatic stress disorder was more than five times higher for foreign-born women compared with native Swedish women (25.0 vs. 4.8%). Comorbidity with pain and concomitant depression has been found to reduce quality of life, affect disability and restrict working capacity by reducing mental activity and functioning in a Swedish study of women on long-term sick leave (Jansen et al., 2011).
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Health in women on long-term sick leave Lytsy et al. 31
Table 2
Results of screening for psychiatric disease, by country of birth and total, %
MINI screening diagnoses Major depressive episode (current, recurrent or past) Suicidality (current, any risk) Manic or hypomanic episode Panic disorder (current or past) Social phobia Obsessive–compulsive disorder Post-traumatic stress disorder Alcohol dependence or abuse Psychotic disorders (current or lifetime) Anorexia nervosa Bulimia nervosa Generalized anxiety disorder Antisocial personality disorder
Born in Sweden (n = 166)
Born outside Sweden (n = 40)
P-value
Total (n = 206)
72.3 31.3 6.7 33.1 17.0 4.8 4.8 1.2a 1.8a 0a 1.8a 15.7 0.6a
87.5 65.0 10.0a 41.0 25.6 2.5a 25.0 5.0a 5.0a 0a 2.6a 30.8 0a
0.065 < 0.001 0.500 0.356 0.252 1.000 < 0.001 0.170 0.250 NA 0.573 0.039 1.000
75.2 37.9 7.4 34.6 18.6 4.4 8.7 1.9a 2.4 0a 2.0a 18.5 0.5a
MINI, Mini International Neuropsychiatric Interview. a Subgroup
Health in women on long-term sick leave because of pain or mental illness Per Lytsya,b, Kjerstin Larssona,c and Ingrid Anderzéna,b Mental illness and pain are common causes of long-term sick absence and major difficulties in vocational rehabilitation. The aim of this study was to investigate health in a group of women with pain or mental illness who had exhausted their days of sickness benefit. This crosssectional study uses baseline data from 355 women on long-term sick leave participating in controlled intervention studies aiming at returning to work. The study population filled in a written questionnaire with questions of self-rated health and sleep quality and validated indexes of mental health, satisfaction with life and general self-efficacy. Clinical psychiatric screening was performed on 230 individuals. The study population had a mean age of 48.8 years (SD 8.4), with an average time on sick leave of 7.8 years (SD 3.2). Self-rated health and sleep quality was poor compared with other populations. In all, 80.1% had at least one psychiatric diagnosis according to the psychiatric screening, and the average numbers of psychiatric diagnoses were 2.2 (SD 1.9). Foreign-born women showed significantly higher levels of mental illness, poorer selfrated health and sleep quality and lower self-efficacy and life satisfaction than native Swedish women. Women with
Introduction Sweden has, like many other European countries, had an increasing number of individuals outside the labour market because of health reasons in the past two decades. The increase in long-term sick leave is mainly caused by an increase in mental health problems, which, often accompanied with chronic pain (Linder et al., 2009), are now among the most common reason for long-term sickness absence (Søgaard and Bech, 2009; Henderson et al., 2011). The increase in mental ill health is of societal interest as it has been proposed as a threat to the welfare of the state (Sundquist et al., 2007). The economic burden of psychiatric disorders has increased markedly in Sweden, where the costs are mainly indirect (Tiainen and Rehnberg, 2010). Naturally, being outside the labour market because of mental ill health is also a problem for the individual as it affects personal well-being and functioning. There is evidence that individuals on longterm sick leave because of psychiatric disorders are at risk of future deteriorating health and premature mortality (Melchior et al., 2010; Mittendorfer-Rutz et al., 2012). Thus, management and prevention of ill health are major public health and occupational health challenges. 0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
long sick leave because of mental illness and/or pain have poor self-rated health and sleep quality, high prevalence of mental illness and low self-efficacy and life satisfaction. Psychiatric screening suggests more extensive mental illness than what was stated on the sick leave certificates. The health of foreign-born women seems to be worse than that of native Swedish women. International Journal of Rehabilitation Research 38:27–33 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. International Journal of Rehabilitation Research 2015, 38:27–33 Keywords: ethnic group, mental health, pain, self-efficacy, self-rated health, sick leave a Department of Public Health and Caring Sciences, Uppsala University, bArbets Rehab, Occupational and Environmental Medicine, Uppsala University Hospital, Uppsala and cDepartment of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
Correspondence to Per Lytsy, MD, PhD, Department of Public Health and Caring Sciences, Husargatan 3, Box 564, Uppsala University, SE-75122, Uppsala, Sweden Tel: + 46 18 4716552; fax: + 46 18 471 66 75; e-mail: [email protected] Received 25 February 2014 Accepted 31 July 2014
The increase of individuals outside the labour force because of ill health has initiated several regulatory and political actions in Sweden. A major change was carried out in 2008, when the parliament adopted a new act, reforming the sick leave system (Regeringens proposition, 2007/2008). Before this, individuals with long-term illness receiving sick certificates from their physicians would routinely have their provisional sick absence prolonged, enabling potentially very long periods of sick leave with health insurance cover. The new act introduced a time limit of 1 year for noncritically ill patients on sick leave. Patients reaching the maximum period are routinely transferred to the Swedish Public Employment insurance, for a 3-month re-examination programme, aiming at return to work in a controlled or a competitive employment. During 2010–2012, 41 000 individuals in Sweden lost their sick leave benefits, not because their health had improved, but because of the newly introduced time restrictions. From a medical rehabilitation point of view, it is of interest to investigate different aspects of health in this group as the various health situations are major determinants for returning to work (Von Celsing et al., 2012). DOI: 10.1097/MRR.0000000000000080
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
28 International Journal of Rehabilitation Research
2015, Vol 38 No 1
The aim of the present study was to investigate health, using validated questionnaires and clinical assessments, in a group of women with pain or mental illness who had exhausted their days of sickness benefit. The secondary aims of this study were to investigate whether there were subgroup differences in health according to study participants’ age, time on sick leave and country of origin.
Methods Study population
This cross-sectional study uses baseline clinical assessments and self-reported questionnaire data from participants in two randomized-controlled trials (Vitalis 1 and 2) in Uppsala County in Sweden. The first trial recruited only women, whereas the second also included men. Because of a low number of men (n = 26) in the second cohort, the current study only uses data from women. Baseline investigations did not differ between the trials’ designs other than somewhat changed questionnaire instruments, described below. Participants were recruited through the Uppsala office of the Swedish Social Insurance Administration, who identified a total of 1305 individuals expected to reach their maximum time of sick leave during the period June 2010 to December 2012. Of these, 1035 individuals were found to be eligible as they fulfilled the inclusion criteria, these being: (a) on sick leave for a pain or a mental disorder and (b) aged between 20 and 64 years, as well as not fulfilling the exclusion criteria, which were: (a) at present suicidal risk; (b) ongoing alcohol/substance abuse; (c) severe mental illness (schizophrenia, bipolar disorder type I); and (d) in an ongoing psychotherapy or vocational rehabilitation programme. Of the 448 individuals who provided informed consent to participate, the following were excluded from the present study: men (n = 26), individuals not returning the questionnaire (n = 46) and withdrawn consent/exclusion (n = 47). Thus, the final sample included 355 women. The recruitment procedure is shown in Fig. 1. Participants were asked to fill in a 16-page questionnaire about 1–4 months ahead of the date when they were expected to lose their sick leave benefits. The questionnaire included questions about their social situation, country of birth, education, number of children in the household, lifestyle and household economy. The health situation was assessed using SWLS (Satisfaction With Life Scale) (Diener et al., 1985), HADS (the Hospital Anxiety and Depression Scale) (Zigmond and Snaith, 1983), the GHQ-12 (General Health Questionnaire) (Goldberg and Blackwell, 1970) and the General Selfefficacy Scale (Schwartzer et al., 1997). Self-rated health was assessed by the question: ‘In general, how would you rate your health?’ and self-rated sleep quality was assessed as ‘In general, how would you rate your sleep quality?’ Both questions used the response categories very good, good, neither good nor poor, poor and very poor.
Alcohol risk use was assessed using the summed score of AUDIT-C (the alcohol use disorders identification test – consumption) with a cutoff of greater than 3 (women) (Bush et al., 1998). Queries about the use of pharmaceuticals were phrased as four separate questions: ‘Do you use: antidepressive medication/tranquillizers /sedatives/analgesics?’ Of the final sample consisting of 355 individuals, 230 met with a physician and/or a psychologist, who screened the participant for psychiatric disease using the Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) and assessed the patient’s GAF (Global Assessment of Functioning) (Hall, 1995). Participants who received interventions also performed a self-rating MADRS (Montgomery–Åsberg Depression Rating Scale) (Montgomery and Asberg, 1979). Data on sick certificate diagnosis/diagnoses current employment status, type and time on sick leave, for participants in the intervention group (n = 230), were provided by the Swedish Social Insurance Administration. The sick certificate diagnoses were used, by a physician, to classify the participants’ main problem as psychiatric, pain related or both. Three subgroup comparisons were made on the basis of age, time on sick leave and country of origin. Participants were categorized into three age groups on the basis of lowest (18–43 years), mid two (44–54 years) and highest (55–64 years) quartiles of age as well as into ‘time on sick leave’ as lowest (< 5 years), mid two (5–10 years) and highest quartiles (>10 years). All participants provided written informed consent to the study, which was approved by the regional ethics committee (Dnr 2010/088 and 2010/088/1). Statistical analyses
χ2-Tests were used to investigate differences in proportions and t-test/analysis of variance to investigate differences in means. Missing values in the indexes were handled by replacement of the individual’s mean scores when the following conditions were fulfilled: SWLS – three or more items (of five); HADS – four of more items (of seven); and GHQ-12 – seven or more items (of 12). An exception from this was the General Self-efficacy Scale, where missing items were handled as proposed by Schwartzer (2011): a sum score was calculated as long as no more than three items were missing. All tests were two-sided and a P-value of less than 0.05 was considered statistically significant. Data analyses were carried out using the Statistical Package for the Social Sciences version 21 (IBM Corp., Armonk, New York, USA).
Results Characteristics of the study sample
The study population had a mean age of 48.8 years (SD 8.4, range 25–64 years), with an average time on sick
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Health in women on long-term sick leave Lytsy et al. 29
Fig. 1
Total number of individuals reaching the maximum time and thus identified by health insurance office: 1305 Excluded for having other diagnosis then mental illness or pain according to sick leave certificate: 270 Total number of individuals having mental illness and/or pain who were invited to participate through mail: 1035
Nonresponders to written invitation: 587
Total number of individuals giving informed consent to participate in study: 448
Final sample: 355 women
Excluded from present study: 93 Reasons: No show/no data: 46 Male: 26 Ethics or severe disease or other rehabilitation program: 21
Flow chart of the recruitment procedure of the study sample.
leave of 7.8 years (SD 3.2, range 1–16.9 years). Sole painrelated disorders were the most common type of problem on the sick leave certificates (38.9%), followed by a combination of pain and psychiatric disease (31.0%) and psychiatric disorders alone (30.1%). About two-third of the study population had an employer, whereas about one-third were unemployed. About one-fifth (19.6%) of the population had primary school as their highest education; 46.5% had secondary schooling; and 33.9% had studied at university. There was a widespread use of analgesics (74.6%), antidepressants (45.4%), sedatives (34.0%) and tranquillizers (20.0%) in the study population. Self-rated health and self-rated sleep quality were, respectively, assessed as ‘poor’ or ‘very poor’ by 63.2 and 63.9% of the study population. Data on the characteristics of the study population and their self-assessed health according to the scales and surveys in the questionnaire are presented in Table 1. Subgroup comparisons of self-reported data
There were no major group differences in characteristics or health assessments according to age or length of sick leave categorization. Furthermore, there were no major differences in characteristics or health assessments according to age group categorization, other than a higher proportion of employed (P < 0.05) and lower educated women in the older age group (P < 0.01) (not shown). There were no significant differences in age, years on insurance benefit and education between women born in
or outside Sweden. Foreign-born women were, however, more likely to be unemployed (45.2 vs. 30.8%) and had worse self-rated sleep quality and health than their Swedish-born counterparts (Table 1). Foreign-born women further scored significantly worse on several of the instruments assessing life satisfaction (SWLS), general health (GHQ) and mental health (HADS, MADRS) (Table 1). Moreover, foreign-born women, in comparison with native Swedish women, reported more frequent use of tranquillizers, sedatives and analgesics and were less likely to be alcohol risk users (Table 1).
MINI screening
In all, 80.1% of the total population had at least one diagnosis according to the MINI screening. The average number of MINI diagnoses in the total screened population was 2.2 (SD 1.9, range 0–10). More than half (56.5%) of women with only pain-related disorders on their sick leave certificate had one or more diagnoses on the MINI screening. The most common diagnoses on the MINI screening were as follows: major depressive disorder (75.2%); suicidality (defined as ≥ 1 point) (37.9%); panic disorder (34.6%); social phobia (18.6%); and generalized anxiety disorder (18.5%). Women born outside Sweden were about twice as likely to be suicidal and more than five times as likely to have post-traumatic stress disorder according to the MINI screening (Table 2). Women born outside Sweden had significantly
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30 International Journal of Rehabilitation Research
Table 1
2015, Vol 38 No 1
Study group characteristics, by country of birth and total Born in Sweden (n = 280, 79%)
Age [mean (SD)] 48.6 (8.8) Years on insurance 8.0 (3.3) benefits [mean (SD)] (n = 269) Employment status (%) Unemployed 30.8 Highest education (%) Primary school 17.6 Secondary school 47.5 University 34.9 Main diagnoses on sick certificate (%) Psychiatric 32.5 Pain 39.3 Both psychiatric and 28.2 pain Self-rated health Very good 0.4 Good 11.3 Neither good nor 31.3 poor Poor 42.0 Very poor 15.3 Self-rated sleep quality Very good 1.8 Good 12.2 Neither good nor 26.6 poor Poor 39.2 Very poor 20.1 SWLS 15.5 (6.9) HADS Depression 8.3 (4.4) Anxiety 10.0 (4.8) MADRS [mean (SD)] 16.7 (9.2) (n = 210) GHQ 18.4 (7.4) Self-efficacy [mean 23.7 (6.4) (SD)] GAF [mean (SD)] 65.3 (12.8) (n = 112) Use of antidepressives 43.0 Use of tranquillizers 16.0 Use of sedatives 31.2 Use of analgesics 71.3 Current smoker 20.7 Alcohol risk use (AUDIT41.6 C ≥ 3) (%) Experience of critical life 90.3 event (%)
Born outside Sweden (n = 75, 21%)
P-value
Total (n = 355)
49.6 (6.7) 7.3 (3.1)
0.34 0.10
48.8 (8.4) 7.8 (3.2)
45.2
0.02
33.9
27.0 42.9 30.2
0.25
19.6 46.5 33.9
21.3 37.3 41.3
0.055
30.1 38.9 31.0
0 1.4 12.7
< 0.001
0.3 9.3 27.2
49.3 36.6
43.5 19.7
1.4 1.4 18.1
1.7 9.9 24.4
< 0.001
39.2 41.9 13.2 (6.8)
0.013
12.1 (4.9) 14.2 (4.6) 28.2 (11.2)
< 0.001 < 0.001 < 0.001
13.3 (7.3) 18.8 (6.9)
< 0.001 < 0.001
59.4 (9.4)
0.034
54.9 35.7 45.1 87.5 26.5 12.9
0.083 0.001 0.035 0.004 0.326 < 0.001
85.3
0.271
39.2 24.7 15.1 (7.0) 9.1 (4.8) 10.9 (5.1) 18.8 (10.6) 17.4 (7.6) 22.7 (6.8) 64.0 (12.3) 45.4 20.0 34.0 74.6 21.8 35.8 89.3
AUDIT-C, alcohol use disorders identification test – consumption; HADS, Hospital Anxiety and Depression Scale; GAF, Global Assessment of Functioning; GHQ, General Health Questionnaire; MADRS, Montgomery–Åsberg Depression Rating Scale; SWLS, Satisfaction With Life Scale.
more MINI diagnoses compared with women born in Sweden [3.1 (SD 1.8) vs. 2.0 (SD 1.9), P = 0.02].
Discussion The aim of this study was to describe health in women with pain or mental illness who had exhausted their days of sickness benefit. The main findings in this group were poor self-rated health and sleep quality, high prevalence of mental illness (e.g. depression, suicidality, panic disorder and generalized anxiety) and low self-efficacy and life satisfaction. Foreign-born women were significantly
worse off, with higher levels of anxiety, depression, suicidality and post-traumatic stress, and poorer self-rated health and sleep quality disorder compared with native Swedish women. Comparisons with previous studies Self-rated health and self-rated sleep quality
More than half of the study group reported poor or very poor self-rated health and self-rated sleep quality. The corresponding percentages for foreign-born women were even worse in terms of self-rated health. This is a very high incidence of poor self-rated health compared with a random sample of 2954 women from two Swedish healthcare regions, where 9% rated their health as poor or very poor (Eriksson et al., 2001). Mental health
Anxiety was assessed using HADS, depression was assessed using both HADS and MADRS, and MINI was performed to screen for psychiatric diagnoses. The mean HADS scores were elevated, for both anxiety and depression, compared with scores reported in recently published studies (Høyer et al., 2011). Høyer et al. (2011) reported lower mean values for anxiety (6.2) and depression (4.3) in Swedish women with breast cancer. Lower levels of anxiety (7.6) and depression (7.8) were also reported in a Swedish study of a comparable group of women with long-term musculoskeletal pain (Pietilä Holmner et al., 2013). This indicates almost twice as high levels of anxiety and depression for foreign-born women in our study. The depression scores assessed with MADRS for native Swedish women were 16.7, which is comparable with the scores reported in a Swedish sample of long-term chronic pain patients treated in a rehabilitation hospital (Ericsson et al., 2002). The mean score for foreign-born women in our study was 27.7, which is highly elevated. Foreignborn women reported more frequent use of psychotropic drugs, which is in agreement with a previous study of psychiatric illness and drug treatment in different ethnic groups in Sweden (Bayard-Burfield et al., 2001). The MINI screening indicated a high prevalence of probable depressive episodes, suicidality, panic disorder, social phobia and generalized anxiety disorder. The prevalence of suicidality and generalized anxiety disorder was twice as high for foreign-born women compared with native Swedish women. The prevalence of posttraumatic stress disorder was more than five times higher for foreign-born women compared with native Swedish women (25.0 vs. 4.8%). Comorbidity with pain and concomitant depression has been found to reduce quality of life, affect disability and restrict working capacity by reducing mental activity and functioning in a Swedish study of women on long-term sick leave (Jansen et al., 2011).
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Health in women on long-term sick leave Lytsy et al. 31
Table 2
Results of screening for psychiatric disease, by country of birth and total, %
MINI screening diagnoses Major depressive episode (current, recurrent or past) Suicidality (current, any risk) Manic or hypomanic episode Panic disorder (current or past) Social phobia Obsessive–compulsive disorder Post-traumatic stress disorder Alcohol dependence or abuse Psychotic disorders (current or lifetime) Anorexia nervosa Bulimia nervosa Generalized anxiety disorder Antisocial personality disorder
Born in Sweden (n = 166)
Born outside Sweden (n = 40)
P-value
Total (n = 206)
72.3 31.3 6.7 33.1 17.0 4.8 4.8 1.2a 1.8a 0a 1.8a 15.7 0.6a
87.5 65.0 10.0a 41.0 25.6 2.5a 25.0 5.0a 5.0a 0a 2.6a 30.8 0a
0.065 < 0.001 0.500 0.356 0.252 1.000 < 0.001 0.170 0.250 NA 0.573 0.039 1.000
75.2 37.9 7.4 34.6 18.6 4.4 8.7 1.9a 2.4 0a 2.0a 18.5 0.5a
MINI, Mini International Neuropsychiatric Interview. a Subgroup
