DP due to CMD and suicidal behaviour_Rahman et al_2016

Disability pension due to common
mental disorders and subsequent
suicidal behaviour: a population-based
prospective cohort study
Syed Ghulam Rahman,1
Kristina Alexanderson,1
Jussi Jokinen,2,3
Ellenor Mittendorfer-Rutz1
To cite: Rahman SG,
Alexanderson K, Jokinen J,
et al. Disability pension due
to common mental disorders
and subsequent suicidal
behaviour: a population-
based prospective cohort
study. BMJ Open 2016;6:
e010152. doi:10.1136/
bmjopen-2015-010152
▸ Prepublication history for
this paper is available online.
To view these files please
visit the journal online
(http://dx.doi.org/10.1136/
bmjopen-2015-010152).
Received 1 October 2015
Revised 11 March 2016
Accepted 17 March 2016
1
Division of Insurance
Medicine, Department of
Clinical Neuroscience,
Karolinska Institutet,
Stockholm, Sweden
2
Division of Psychiatry,
Department of Clinical
Neuroscience, Karolinska
Institutet, Karolinska
University Hospital,
Stockholm, Sweden
3
Division of Psychiatry,
Department of Clinical
Sciences, Umeå University,
Umeå, Sweden
Correspondence to
Dr Syed Ghulam Rahman;
syed.rahman@ki.se
ABSTRACT
Objective: Adverse health outcomes, including
suicide, in individuals on disability pension (DP) due to
mental diagnoses have been reported. However,
scientific knowledge on possible risk factors for
suicidal behaviour (suicide attempt and suicide) in this
group, such as age, gender, underlying DP diagnoses,
comorbidity and DP duration and grade, is surprisingly
sparse. This study aimed to investigate associations of
different measures (main and secondary diagnoses,
duration and grade) of DP due to common mental
disorders (CMD) with subsequent suicidal behaviour,
considering gender and age differences.
Design: Population-based prospective cohort study
based on Swedish nationwide registers.
Methods: A cohort of 46 515 individuals aged
19–64 years on DP due to CMD throughout 2005 was
followed-up for 5 years. In relation to different measures
of DP, univariate and multivariate HRs and 95% CIs for
suicidal behaviour were estimated by Cox regression. All
analyses were stratified by gender and age.
Results: During 2006–2010, 1036 (2.2%) individuals
attempted and 207 (0.5%) completed suicide. Multivariate
analyses showed that a main DP diagnosis of ‘stress-
related mental disorders’ was associated with a lower risk
of subsequent suicidal behaviour than ‘depressive
disorders’ (HR range 0.4–0.7). Substance abuse or
personality disorders as a secondary DP diagnosis
predicted suicide attempt in all subgroups (HR range
1.4–2.3) and suicide in women and younger individuals
(HR range 2.6–3.3). Full-time DP was associated with a
higher risk of suicide attempt compared with part-time DP
in women and both age groups (HR range 1.4–1.7).
Conclusions: Depressive disorders as the main DP
diagnosis and substance abuse or personality disorders
as the secondary DP diagnosis were risk markers for
subsequent suicidal behaviour in individuals on DP due to
CMD. Particular attention should be paid to younger
individuals on DP due to anxiety disorders because of the
higher suicide risk.
BACKGROUND
Disability pension (DP) is a major public
health issue in many European countries1 2
and increasingly so regarding mental DP
diagnoses.1 3–5
In Sweden in 2012, mental
diagnoses accounted for 40% of the DPs
granted to individuals aged 30–64 years and
for 84% among those aged 19–29 years.3
The
majority of the mental DP diagnoses are
common mental disorders (CMD)—that is,
depressive, anxiety or stress-related mental
disorders.1 6
These are diagnoses for which
treatment and rehabilitation measures are
available, and inactivity—for example, in
terms of long-term or permanent exclusion
from work due to DP—may have adverse
effects.7
DP itself may imply alteration of
health behaviour (eg, regarding alcohol and
tobacco use, exercise, diet) or social isola-
tion.8
This can be due to lack of ties to the
labour market and eventually lack of the
potential positive effects of paid work, includ-
ing social contacts with colleagues, prospects
of career and income progression, a sense of
purpose, or even daily routines and struc-
tures.9
It is possible that individuals who have
been on DP for a shorter period might
experience fewer adverse effects of being ex-
cluded from the labour market than indivi-
duals on DP for a longer time.10
Similarly,
Strengths and limitations of this study
▪ This population-based, prospective cohort study
used data of high quality.
▪ The study did not suffer from any loss to
follow-up.
▪ Considered diagnoses were not self-reported, but
derived from administrative registers and pro-
vided by physicians.
▪ Some analyses were based on only a few suicide
cases.
▪ We considered suicide attempts that led to
inpatient care, thus the results are mainly valid
for suicide attempts of greater medical severity.
Rahman SG, et al. BMJ Open 2016;6:e010152. doi:10.1136/bmjopen-2015-010152 1
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part-time DP might be more protective concerning such
adverse health or social outcomes than full-time DP.11 12
Adverse health outcomes, including suicide, among
‘disability pensioners’, especially those granted a DP
early in adult life because of mental diagnoses, have
been shown previously.8 13
However, to date little is
known about specific risk factors related to eventual
worse outcomes in individuals on DP,8
such as suicide
attempt or suicide. Suicidal behaviour can be considered
the most extreme consequence of mental disorders, par-
ticularly depressive disorders or depression comorbid
with anxiety.14–16
Patients with a depressive disorder
have a higher risk of subsequent suicidal behaviour in
the case of comorbidity with another mental or a
somatic disorder, than patients with depressive disorders
without such comorbidity.17–19
To date, knowledge is
lacking regarding associations between DP due to differ-
ent diagnoses with and without comorbidity with regard
to subsequent suicidal behaviour.
There are well-documented gender and age differences
with regard to both DP and suicidal behaviour.13 14 20
However, there is a lack of studies investigating if gender
and age are associated with suicidal behaviour among
recipients of DP due to CMD, and across different mea-
sures of DP (such as main diagnosis, secondary diagnosis,
duration and grade). Previous studies have found that
sociodemographic factors, such as educational level,
family situation, country of birth, and type of area of resi-
dence, are associated with morbidity (defined as previous
suicide attempt or in- or out-patient care due to mental
diagnoses) and subsequent suicidal behaviour.14 17 21–24
In addition, excess mortality including suicide among DP
recipients due to mental diagnoses compared with the
general population not on DP has been reported.25–27
Therefore, it is relevant to take account of sociodemo-
graphic factors and health factors in analyses of the asso-
ciation between DP and subsequent suicidal behaviour.
Aim
This study aimed to examine (1) how different measures
of DP (main diagnosis, secondary diagnosis, duration
and grade) were associated with subsequent suicidal
behaviour (suicide attempt and suicide) in individuals
on DP due to CMD and (2) possible differences in these
associations with regard to gender and age.
METHODS AND MATERIALS
Design
A nationwide population-based prospective cohort study
based on Swedish register data was conducted. The
cohort comprised all individuals aged 19–64 years, living
in Sweden on 31 December 2004, who were on full- or
part-time DP due to CMD throughout 2005 (n=48 803).
Individuals treated as inpatients or with specialised out-
patient healthcare on the schizophrenic spectrum or
with bipolar disorders or having this as a secondary DP
diagnosis in 2001–2005 (n=1886) and people receiving
old-age pension during 2005 (n=402) were excluded.
The final cohort therefore included 46 515 individuals.
They were followed-up for 5 years (2006–2010).
Annual data covering 2001–2010 were obtained from
the following four nationwide registers: (1) longitudinal
integration database for health insurance and labour
market studies (LISA) held by Statistics Sweden, includ-
ing sociodemographic information on gender, age, edu-
cational level, type of area of residence, country of birth,
family situation; (2) two registers held by the National
Board of Health and Welfare, namely (i) National
Patient Register including information on date and diag-
nosis of inpatient and specialised outpatient care and
(ii) Cause of Death Register with data on date and cause
of death; (3) micro-data for analyses of social insurance
(MiDAS) with information on the date, diagnoses (the
main and secondary DP diagnoses), duration and grade
of DP from the National Social Insurance Agency. Data
from these registers were linked at individual level using
the unique personal identification number of all resi-
dents in Sweden.
The DP system in Sweden
All residents in Sweden aged 19–64 years who, because
of disease or injury, have a long-lasting or permanent
reduction in their work capacity can be granted a tempor-
ary or permanent DP from the Social Insurance Agency
for 25%, 50%, 75%, or 100% of ordinary working hours.3
Since 2003, individuals aged 19–29 years can also be
granted a temporary DP if health reasons lead to failure
to complete compulsory or upper secondary school in
due time.3
DP amounts to 65% of lost income, up to a
certain level. For those with no previous income, there is
a minimum sum.
Risk factors
Main and secondary DP diagnoses
All information on DP diagnoses was based on the corre-
sponding codes of the International Classification of
Diseases, V.10 (ICD-10).28
Information on the main and
secondary DP diagnoses was available from MiDAS.
Main DP diagnoses were categorised as: ‘depressive dis-
orders’ including ‘depressive episode’ (F32) and ‘recurrent
depressive disorder’ (F33); ‘anxiety disorders’ comprising
‘phobic anxiety disorder’ (F40); ‘other anxiety disorder’
(F41); ‘obsessive–compulsive disorder’ (F42); and ‘stress-
related mental disorders’ including ‘reaction to severe
stress, adjustment disorders, acute stress reaction and post-
traumatic stress disorder’ (F43).29 30
Secondary diagnoses were categorised as: ‘no secondary
diagnosis’; ‘substance abuse disorders’ (F10–F19); ‘person-
ality disorders’ (F60–F69); ‘other mental disorders’
(F00–F99 except F10–F19, F60–F69); ‘musculoskeletal dis-
orders’ (M00–M99); and ‘other somatic disorders’ (all
diagnoses except M00–M99 and F00–F99).
The excluded bipolar and schizophrenic spectrum dis-
orders included the following ICD-10 codes: F20–F29
and F31.
2 Rahman SG, et al. BMJ Open 2016;6:e010152. doi:10.1136/bmjopen-2015-010152
Open Access

Duration
DP duration was calculated by subtracting the start date
of DP from the end date of exposure (31 December
2005) in gross days. Thereafter, the days were converted
into years and were categorised as ‘1 year’, ‘2–3 years’ or
‘≥4 years’.
Grade
Grade of DP, in 2005, was categorised as full-time (100%)
or part-time (25%, 50% or75%).
Confounders
All sociodemographic characteristics were measured at
baseline (31 December 2004): age, gender, educational
level, family situation, country of birth, and type of
area of residence. Age was dichotomised into 19–44 and
45–64 years. Educational level was categorised into three
groups according to the total number of years of educa-
tion at three levels: ‘compulsory (0–9 years)’, ‘upper sec-
ondary (10–12 years)’, and ‘university (≥13 years)’.
Family situation was coded into four groups: ‘married/
cohabiting with children living at home’, ‘married/coha-
biting with no children living at home’, ‘single without
children living at home’, and ‘single with children living
at home’. Country of birth included ‘Sweden’, ‘other
Nordic countries’, ‘EU 25 (except Nordic countries)’,
and ‘rest of the world’. Type of area of residence was
divided into ‘big cities’, ‘medium-sized cities’ and ‘small
cities/villages’. Missing values were coded as separate
categories. Healthcare factors—that is, previous suicide
attempt, inpatient and specialised outpatient care due to
mental diagnoses—were measured from 2001 to 2005
and were dichotomised as ‘yes’ and ‘no’.
Outcome measures
The outcome was suicidal behaviour in terms of suicide
attempt or completed suicide.
Information on suicide attempt and suicide in 2006–
2010 was obtained from the inpatient-care and cause of
death register, respectively. As suicides are often under-
reported or reported as ‘undetermined’ causes,31 32
information on ‘determined’ (X60–84) and ‘undeter-
mined’ (Y10–34) suicide was combined to limit under-
reporting and to compensate for regional and temporal
variation in ascertainment methods. A similar procedure
was performed for suicide attempt. This is a common
procedure in research on suicidal behaviour.33
The com-
bined outcome measures are hereafter called suicide
attempt and suicide, respectively.
Statistical analysis
χ2
statistics were used to test significant gender and age
differences in the cohort. Univariate HRs and 95% CIs
for the risk factors with regard to suicide attempt and
suicide were estimated by Cox proportional hazard
regression models, after confirming that the proportion-
ate hazard assumption had been met. All individuals
were followed-up from 1 January 2006 until the event
(suicide attempt; suicide), emigration, death (due to
causes other than X06–84 and Y10–34, in the analyses
related to suicide as an outcome), or end of follow-up
(31 December 2010), whichever occurred first. The
partial likelihood ratio test was used to test for possible
interactions between the exposure variables (main and
secondary DP diagnoses, and duration and grade of DP)
and age and gender in relation to the outcome mea-
sures. Multivariate models were built with adjustment for
sociodemographic and healthcare factors and mutual
adjustment for all other covariates. Before the outcome
measures were combined, sensitivity analyses were carried
out by calculating HRs and 95% CIs for all exposure
measures in relation to determined and undetermined
suicide both separately and after combination. After en-
suring that these estimates were comparable, we intro-
duced the combined variable into the model. Similar
tests were performed for determined and undetermined
suicide attempt. All analyses were stratified by gender and
age and performed using SPSS V.22.
Ethics statement
The project was evaluated and approved by the Regional
Ethics Review Board of Stockholm, Sweden.
RESULTS
Of the 46 515 individuals on DP due to CMD during
2005, the majority (66.4%) were women and 70% were
aged 45–64 years (table 1). Nearly half of the women
(48.3%) had depressive disorders as the main DP diag-
nosis, while a large proportion of the men had anxiety
disorders as the main DP diagnosis (31.7%). Depressive
disorders as the main DP diagnosis was more common
among the older individuals (51.5%), whereas anxiety
disorders as the main DP diagnosis was more common
among the younger ones (43.1%). The two predominant
main DP diagnoses for the entire cohort were ‘depres-
sive episode’ (36.8%) and ‘stress-related mental dis-
order’ (23.6%) (data not shown in table 1).
In the cohort, nearly half of the individuals did not
have any secondary DP diagnosis (43.1%) (table 1).
Substance abuse disorders as the secondary diagnosis
was more prevalent among men and older individuals,
while personality disorders were more common among
women and younger individuals (p<0.001). The majority
of the individuals had a full-time DP (75.6%). A part-
time DP was more common among women (28%) than
men (17.4%) and among older (26.7%) than younger
(19.2%) individuals (p<0.001).
Regarding the covariates, nearly half (47%) of the study
population had received upper secondary education, most
lived in big or medium-sized cities (74%), and 75% were
born in Sweden (data not shown in table 1). Almost half
(42%) lived without a partner and without children at
home.
In the cohort, 1036 (2.2%) individuals were treated as
inpatients due to a suicide attempt, and 207 (0.5%)
Open Access

committed suicide during the 5-year follow-up (2006–
2010) (table 2). Women were more likely than men to
attempt suicide (women, 2.4%; men, 2.0%; p<0.01),
while a higher proportion of men completed suicide
(women, 0.3%; men, 0.7%; p<0.001). Mean follow-up
time for suicide attempt and suicide was 4.85 (SD 0.70)
and 4.91 (SD 0.52) years, respectively.
Tables 2 and 3 show univariate HRs and tables 4 and
5 show multivariate HRs for suicide attempt and suicide,
stratified by gender and age with regard to main and
secondary DP diagnoses as well as duration and grade
of DP.
In the univariate analyses, ‘anxiety disorders’ as the
main diagnosis was associated with a higher risk of
suicide attempt in both women and men (range of HRs
1.4–1.5) and suicide in the younger age group (HR 1.9;
95% CI 1.1 to 3.3) compared with ‘depressive disorders’
as the main diagnosis. These associations became insig-
nificant after sociodemographic variables had been con-
trolled for in the multivariate models, except for suicide
in individuals aged 19–44 years (HR 1.7; 95% CI 1.0 to
3.0). Compared with ‘depressive disorders’, ‘stress-related
mental disorders’ as the main diagnosis was associated
with a lower risk of both suicide attempt and suicide
(except for women and the age group 19–44 years) in
both crude and multivariate adjusted models. There was
a significant interaction between age and main diagnosis
(p=0.017) regarding suicide. Individuals aged 45–64 years
with a main DP diagnosis of ‘stress-related mental disor-
ders’ had a significantly lower risk of committing suicide
during the follow-up compared with individuals with
‘depressive disorders’ as the main DP diagnosis (HR 0.3;
95% CI 0.2 to 0.6). This association was not observed in
younger individuals.
In the univariate models, all analysed mental secondary
diagnoses were associated with a higher risk of subsequent
suicide attempt, regardless of gender and age (range of
HRs 1.2–7.1). These associations remained significant
(range of HRs 1.3–2.3) in the multivariate models, except
the association of ‘other mental disorders’ as the second-
ary diagnosis with subsequent suicide attempt in men and
the age group 45–64 years. ‘Substance abuse disorders’
and ‘personality disorders’ as the secondary diagnosis
were also associated with a higher risk of suicide (range of
HRs 1.9–9.6) in women and in both age groups in the
crude analyses compared with their counterparts without
a secondary diagnosis. However, in the adjusted model,
only ‘substance abuse disorders’ predicted suicide among
women and younger individuals (range of HRs 2.6–3.3).
A statistically significant interaction was found between
gender and secondary diagnosis (p=0.029) in relation to
subsequent suicide. Women with ‘substance abuse disor-
ders’ or ‘personality disorders’ as the secondary DP
diagnosis were at a higher risk of subsequent suicide
compared with women without a secondary diagnosis.
Such associations were not observed among men.
A DP duration of 4 years or more predicted suicide
attempt in women and older individuals (range of HRs
Table1Descriptivestatisticswithregardtomainandsecondarydisabilitypension(DP)diagnosesanddurationandgradeofDPinthecohortof46515womenandmen,aged19–64years,livingin
Swedenon31December2004,andin2005onDPduetocommonmentaldisorders
AllWomenMenAge19–44yearsAge45–64years
pValuefor
differencebyχ2
CharacteristicNPercentnPercentnPercentnPercentnPercent
Total4651510030883100156321001393110032584100
MainDPdiagnosis
Depressivedisorders2203247.41490748.3712545.6524237.61679051.5<0.001
Anxietydisorders1351629.1855827.7495831.7600743.1750923.0
Stress-relatedmentaldisorders1096723.6741824.0354922.7268219.3828525.4
SecondaryDPdiagnosis
Nosecondarydiagnosis2004243.11325442.9678843.4521737.41482545.5<0.001
Substanceabusedisorders9502.03781.25723.73442.56061.9
Personalitydisorders23135.012944.210196.512328.810813.3
Othermentaldisorders1232926.5823726.7409226.2492435.3740522.7
Musculoskeletaldisorders491110.5371612.011957.69807.0393112.1
Othersomaticdisorders597012.8400413.0196612.612348.9473614.5
NumberofyearsonDPin2005
1599412.5416813.5182611.7228016.4371411.4>0.01
2–32084644.81416245.9668442.8672648.31412043.3
≥41967542.31255340.6712245.6492535.41475045.3
DPgradein2005
Part-time1137124.4865128.0272017.4267119.2870026.7<0.001
Full-time3514475.62223272.01291282.61126080.82388473.3
Open Access

Table 2 Univariate HRs with 95% CI for suicide attempt and suicide (in 2006–2010), in 46 515 individuals, aged 19–64 years, living in Sweden on 31 December 2004, and on disability pension (DP)
due to common mental disorders in 2005, stratified by gender
Suicide attempt Suicide
Women Men Women Men
Characteristic n Per cent HR (95% CI) n Per cent HR (95% CI) n Per cent HR (95% CI) n Per cent HR (95% CI)
Main DP diagnosis
Depressive disorders 355 34.3 1 139 13.4 1 53 25.6 1 50 24.2 1
Anxiety disorders 278 26.8 1.4 (1.2 to 1.6) 140 13.5 1.5 (1.1 to 1.8) 32 15.5 1.1 (0.7 to 1.6) 47 22.7 1.3 (0.9 to 2.0)
Stress-related mental disorders 99 9.6 0.6 (0.5 to 0.7) 25 2.4 0.4 (0.2 to 0.5) 17 8.2 0.6 (0.4 to 1.1) 8 3.9 0.3 (0.2 to 0.7)
Secondary DP diagnosis
No secondary diagnosis 232 22.4 1 100 9.7 1 34 16.4 1 45 21.7 1
Substance abuse disorders 43 4.2 7.1 (5.1 to 9.8) 34 3.3 4.3 (2.9 to 6.3) 9 4.3 9.6 (4.6 to 20.1) 7 3.4 1.9 (0.9 to 4.3)
Personality disorders 83 8.0 3.8 (2.9 to 4.8) 39 3.8 2.7 (1.8 to 3.8) 12 5.8 3.6 (1.9 to 7.0) 9 4.4 1.3 (0.7 to 2.8)
Other mental disorders 253 24.4 1.8 (1.5 to 2.1) 95 9.2 1.6 (1.2 to 2.1) 27 13.0 1.3 (0.8 to 2.1) 29 14.0 1.1 (0.7 to 1.7)
Musculoskeletal disorders 56 5.4 0.9 (0.6 to 1.2) 10 1.0 0.6 (0.3 to 1.1) <7 2.9 0.6 (0.3 to 1.5) <7 2.4 0.6 (0.3 to 1.6)
Other somatic disorders 65 6.3 0.9 (0.7 to 1.2) 26 2.5 0.9 (0.6 to 1.4) 14 6.8 1.4 (0.7 to 2.5) 10 4.8 0.8 (0.4 to 1.5)
Number of years on DP in 2005
1 100 13.7 1 42 13.8 1 13 12.7 1 14 13.3 1
2–3 308 42.1 0.9 (0.7 to 1.1) 137 45.1 0.9 (0.6 to 1.3) 46 45.1 1.0 (0.6 to 1.9) 51 48.6 1.0 (0.6 to 1.8)
≥4 324 44.3 1.1 (0.9 to 1.4) 125 41.1 0.8 (0.5 to 1.1) 43 42.2 1.1 (0.6 to 2.1) 40 38.1 0.7 (0.4 to 1.4)
DP grade in 2005
Part-time 84 8.1 1 42 4.1 1 16 7.7 1 10 4.8 1
Full-time 648 62.8 3.1 (2.4 to 3.8) 262 25.4 1.3 (1.0 to 1.9) 86 41.6 2.1 (1.2 to 3.6) 95 45.9 2.0 (1.1 to 3.9)
Table 3 Univariate HRs with 95% CI for suicide attempt and suicide (2006–2010), in 46 515 individuals, aged 19–64 years and living in Sweden on 31 December 2004, and on disability pension
(DP) due to common mental disorders in 2005, stratified by age
Age 19–44 years Age 45–64 years Age 19–44 years Age 45–64 years
Characteristic n Per cent HR (95% CI) n Per cent HR (95% CI) n Per cent HR (95% CI) n Per cent HR (95% CI)
Main DP diagnosis
Depressive disorders 217 21.0 1 277 26.7 1 20 9.7 1 83 43.0 1
Anxiety disorders 278 26.8 1.1 (0.9 to 1.3) 140 13.5 1.1 (0.9 to 1.4) 44 21.3 1.9 (1.1 to 3.3) 35 16.9 0.9 (0.6 to 1.4)
Stress-related mental disorders 62 6.0 0.6 (0.4 to 0.7) 62 6.0 0.5 (0.3 to 0.6) 12 5.8 1.2 (0.6 to 2.4) 13 6.3 0.3 (0.2 to 0.6)
No secondary diagnosis 140 13.5 1 192 18.5 1 20 9.7 1 59 28.5 1
Substance abuse disorders 40 3.9 4.7 (3.3 to 6.7) 37 3.6 5.0 (3.5 to 7.2) 8 3.9 6.3 (2.8 to 14.3) 8 3.9 3.5 (1.7 to 7.3)
Personality disorders 85 8.2 2.6 (2.0 to 3.5) 37 3.6 2.7 (1.9 to 3.8) 13 6.3 2.8 (1.4 to 5.6) 8 3.9 1.9 (1.0 to 3.9)
Other mental disorders 233 22.5 1.8 (1.5 to 2.2) 115 11.1 1.2 (1.0 to 1.5) 30 14.5 1.6 (0.9 to 2.7) 27 13.0 0.9 (0.6 to 1.4)
Musculoskeletal disorders 23 2.2 0.9 (0.6 to 1.4) 43 4.2 0.8 (0.6 to 1.2) <7 1.9 1.1 (0.4 to 3.1) 7 3.4 0.5 (0.2 to 1.0)
Other somatic disorders 36 3.5 1.1 (0.8 to 1.6) 55 5.3 0.9 (0.7 to 1.2) <7 1.0 0.4 (0.1 to 1.8) 22 10.6 1.2 (0.7 to 1.9)
1 95 17.1 1 47 9.8 1 7 9.2 1 20 15.3 1
2–3 254 45.6 0.9 (0.7 to 1.1) 191 39.9 1.1 (0.8 to 1.5) 39 51.3 1.9 (0.9 to 4.2) 58 44.3 0.8 (0.5 to 1.3)
≥4 208 37.3 1.0 (0.8 to 1.3) 241 50.3 1.3 (1.0 to 1.8) 30 39.5 2.0 (0.9 to 4.5) 53 40.5 0.7 (0.4 to 1.1)
DP grade in 2005
Part-time 56 5.4 1 70 6.8 1 7 3.4 1 19 9.2 1
Full-time 501 48.6 2.2 (1.6 to 2.9) 409 39.6 2.2 (1.7 to 2.8) 69 33.3 2.4 (1.1 to 5.1) 112 54.1 2.2 (1.3 to 3.6)
RahmanSG,etal.BMJOpen2016;6:e010152.doi:10.1136/bmjopen-2015-0101525
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1.2–1.4) in the crude models, compared with individuals
with a DP duration of 1 year. These associations were not
statistically signiﬁcant in the adjusted models. In the
univariate analyses, full-time DP was associated with a
higher risk of suicidal behaviour in both genders and
age categories (range of HRs 1.3–3.1) compared with
Table 4 Multivariate HRs with 95% CI for suicide attempt and suicide (2006–2010), in 46 515 individuals, aged 19–64 years
and living in Sweden on 31 December 2004, and on disability pension (DP) due to common mental disorders in 2005,
stratified by gender*
Women Men Women Men
Characteristic HR (95% CI) HR (95% CI) HR (95% CI) HR (95% CI)
Main DP diagnosis
Depressive disorders 1 1 1 1
Anxiety disorders 1.0 (0.9 to 1.2) 1.0 (0.8 to 1.2) 0.9 (0.6 to 1.4) 1.3 (0.8 to 2.0)
Stress-related mental disorders 0.8 (0.6 to 1.0) 0.6 (0.4 to 0.9) 0.9 (0.5 to 1.6) 0.4 (0.2 to 0.9)
No secondary diagnosis 1 1 1 1
Substance abuse disorders 2.1 (1.5 to 2.9)† 1.6 (1.0 to 2.4) 3.3 (1.5 to 7.1)† 0.8 (0.3 to 1.7)
Personality disorders 1.4 (1.1 to 1.8)† 1.4 (1.0 to 2.1) 1.8 (0.9 to 3.5) 0.9 (0.4 to 1.8)
Other mental disorders 1.3 (1.1 to 1.5)† 1.2 (0.9 to 1.6) 1.1 (0.6 to 1.8) 0.9 (0.6 to 1.5)
Musculoskeletal disorders 1.1 (0.8 to 1.5) 0.7 (0.4 to 1.4) 0.8 (0.3 to 2.0) 0.7 (0.3 to 1.9)
Other somatic disorders 1.1 (0.9 to 1.5) 1.0 (0.7 to 1.6) 1.6 (0.9 to 3.0) 0.8 (0.4 to 1.7)
1 1 1 1 1
2–3 0.9 (0.7 to 1.1) 1.0 (0.7 to 1.4) 1.0 (0.5 to 1.8) 1.0 (0.6 to 1.8)
≥4 1.0 (0.8 to 1.2) 0.9 (0.6 to 1.3) 1.0 (0.5 to 1.8) 0.7 (0.4 to 1.3)
DP grade in 2005
Part-time 1 1 1 1
Full-time 1.7 (1.4 to 2.2)† 0.9 (0.6 to 1.3) 1.5 (0.8 to 2.6) 1.7 (0.9 to 3.3)
*Adjusted for: age, educational level, family situation, country of birth, type of area of residence, previous suicide attempt, inpatient care due
to mental diagnoses, specialised outpatient care due to mental diagnoses.
†Significant also with 99% CI (p<0.01).
Table 5 Multivariate HRs with 95% CI for suicide attempt and suicide (2006–2010), in 46 515 individuals, aged 19–64 years
and living in Sweden on 31 December 2004, and on disability pension (DP) due to common mental disorders in 2005,
stratified by age*
Age 19–44 years Age 45–64 years Age 19–44 years Age 45–64 years
Characteristic HR (95% CI) HR (95% CI) HR (95% CI) HR (95% CI)
Main DP diagnosis
Depressive disorders 1 1 1 1
Anxiety disorders 1.1 (0.9 to 1.3) 0.9 (0.8 to 1.2) 1.7 (1.0 to 3.0) 0.9 (0.6 to 1.3)
Stress-related mental disorders 0.8 (0.6 to 1.1) 0.7 (0.5 to 0.9) 1.7 (0.8 to 3.6) 0.4 (0.2 to 0.8)†
No secondary diagnosis 1 1 1 1
Substance abuse disorders 2.3 (1.6 to 3.3)† 1.5 (1.1 to 2.2)† 2.6 (1.1 to 6.1) 1.0 (0.5 to 2.3)
Personality disorders 1.5 (1.1 to 2.0)† 1.6 (1.1 to 2.2)† 1.7 (0.8 to 3.4) 1.1 (0.5 to 2.3)
Other mental disorders 1.5 (1.2 to 1.9)† 1.0 (0.8 to 1.3) 1.3 (0.8 to 2.4) 0.8 (0.5 to 1.3)
Musculoskeletal disorders 1.1 (0.7 to 1.8) 0.9 (0.7 to 1.3) 1.7 (0.6 to 4.9) 0.6 (0.3 to 1.3)
Other somatic disorders 1.2 (0.8 to 1.8) 1.1 (0.8 to 1.4) 0.5 (0.1 to 2.1) 1.3 (0.8 to 2.2)
1 1 1 1 1
2–3 0.8 (0.7 to 1.1) 1.0 (0.7 to 1.3) 1.8 (0.8 to 4.0) 0.7 (0.4 to 1.2)
≥4 0.9 (0.7 to 1.4) 1.0 (0.7 to 1.4) 1.7 (0.7 to 3.8) 0.6 (0.3 to 0.9)
DP grade in 2005
Part-time 1 1 1 1
Full-time 1.4 (1.1 to 1.9)† 1.5 (1.1 to 1.9)† 1.3 (0.6 to 3.0) 1.7 (1.0 to 2.8)
*Adjusted for gender, educational level, family situation, country of birth, type of area of residence, previous suicide attempt, inpatient care due
to mental diagnoses, and specialised outpatient care due to mental diagnoses.
†Significant also with 99% CI (p<0.01).
Open Access

individuals on part-time DP. After multivariate adjust-
ment, these associations remained significant (range of
HRs 1.4–1.7) except for suicide attempt and suicide
among men, and suicide in women and younger indivi-
duals. Statistically significant interaction was observed
between gender and DP grade (p=0.001) in relation to
subsequent suicide attempt. Women on full-time DP had
a higher risk of future suicide attempt than women who
were on part-time DP. No such association was found for
their male counterparts (table 4).
DISCUSSION
In this nationwide prospective cohort study of people on
DP due to CMD, we explored the risk of suicidal behav-
iour related to DP diagnoses, duration and grade.
Stress-related mental disorders as the main DP diagnosis
was associated with a lower risk of subsequent suicidal
behaviour compared with depressive disorders as the
main DP diagnosis. Moreover, comorbid substance abuse
disorders and personality disorders as well as full-time
DP were associated with a higher risk of suicide attempt
and suicide during follow-up. Some gender and age dif-
ferences in these associations emerged.
To the best of our knowledge, this is the first study to
investigate different measures of DP as risk factors for
suicidal behaviour in individuals on DP due to CMD.
The main strengths of our study are the use of high-
quality population-based Swedish nationwide register
data34 35
and the prospective cohort design with several
years of follow-up. We included register data from differ-
ent sources on the whole working-age population of
Sweden and thereby avoided selection and recall bias.
Moreover, there was no loss to follow-up and all data
were register based, including physician-based diagnoses
—that is, not based on self-reports. The study group was
large and the statistical power was sufficient even with
regard to such uncommon outcomes as suicide attempt
and suicide. This study also had the opportunity to
include a wide range of potential confounders such as
educational level, family situation, country of birth, type
of area of residence, and previous healthcare.
There are some limitations of the study. In spite of the
long follow-up, there were only 207 suicides, leading to
wide CIs. Another limitation is that only the main, and
when given, the secondary DP diagnoses could be
included. Additional diagnoses that might have been
stated in the sickness certificate as contributing to
patients’ work incapacity were not included in the
MiDAS register. Having such information might have
improved the analyses; however, most studies on DP only
have access to the main diagnosis. A topic of frequent
discussion in this research field is the validity of DP diag-
noses. There are no studies on this, so far. A study con-
ducted in Sweden in 1991 showed high validity of
sick-leave diagnoses compared with diagnoses from
medical records.36
In addition, DP in most cases is pre-
ceded by long-term absence due to sickness and is
granted after a long process of medical evaluation and
work capacity assessment, as DP benefits are often paid
for several years.3
Moreover, owing to the stigma sur-
rounding mental diagnoses,37 38
the validity of mental
DP diagnoses can be assumed to be good, meaning that
people with a mental DP diagnosis are likely to have a
mental disorder. On the other hand, this also means
that some individuals with mental disorders might not
have been given a mental diagnosis as the main DP diag-
nosis, but as a secondary diagnosis to a somatic main DP
diagnosis. Thus, they would not be included in this
study. This can also be seen as a strength, as our group
of CMDs is more strictly defined than if secondary diag-
noses were also used for inclusion, or as a limitation, as
we do not know if including them would have affected
the results. Further studies on these issues are required.
Moreover, the stigma of mental disorders might have
led to under-reporting of some mental disorders as sec-
ondary diagnoses. The reported secondary diagnoses
might therefore reflect greater medical severity. It should
also be mentioned that we considered suicide attempts that
led to inpatient care, thus the results are mainly valid for
suicide attempts of greater medical severity. In addition, it
is important to keep in mind that DP not only reflects to
what extent the disease affects an individual’s work capacity,
but also factors at other structural levels such as possibilities
and demands at the labour market, adjustment policies,
attitudes, and the economic situation of a country.39
Such
factors may influence not only the level of DP in a
country39 40
but also the level of suicidal behaviour,41 42
which thus may have affected the results of this study.
In this study, the risk of subsequent suicidal behaviour
related to a main DP diagnosis of anxiety did not differ
from that of a main DP diagnosis of depressive disorder,
while those with stress-related mental disorders as the
main DP diagnosis had a lower risk of future suicidal
behaviour. This is in line with a study on diagnosis-
specific sickness absence that suggested higher risk esti-
mates for subsequent suicide among people on sickness
absence due to depressive and anxiety disorders than
due to stress-related mental disorders, after adjustment
for sociodemographic factors.43
There was a significant interaction between age and
main DP diagnoses in relation to suicide. While there
was a significantly lower risk of suicide in the older age
group (45–64 years) with a main DP diagnosis of ‘stress-
related mental disorders’ compared with ‘depressive dis-
orders’, this association was not found in the younger
individuals. On the other hand, ‘anxiety disorders’ as
the main diagnosis were associated with a higher risk of
subsequent suicide in the individuals aged 19–44 years,
compared with the same age group with a main DP diag-
nosis of ‘depressive disorders’ in the multivariate ana-
lyses. One likely explanation of such findings is age
differences in the association of mental disorders with
suicide risk.14 44
Anxiety disorders often have an early
onset, and younger individuals may tend to have greater
impulsivity, which might contribute to suicidal behav-
iour.45
Moreover, early-onset anxiety disorders leading to
Open Access

DP might be more difficult to treat and probably are
associated with a high degree of comorbidity. Anxiety
disorders are highly comorbid with depressive or person-
ality disorders,14 15 46
and also might have contributed
to suicidal behaviour among these young individuals.
Early detection and adequate treatment of anxiety disor-
ders for prevention of suicidal behaviour might be of
particular importance,15 16
especially in younger indivi-
duals. These associations warrant further investigation.
Our analyses show that having a mental secondary DP
diagnosis was associated with a higher risk of suicide
attempt and suicide compared with not having a second-
ary diagnosis. This is in line with previous research on
the general population14 47
or individuals with a diag-
nosed mental disorder.17 18 48
Moreover, we found that
substance abuse disorder was the strongest predictor of
subsequent suicide attempt. These findings are consist-
ent with previous studies showing that substance abuse is
a strong risk factor for suicidal behaviour.19 47 49
A significant interaction was observed between gender
and substance abuse as secondary DP diagnosis in rela-
tion to subsequent suicide. Substance abuse might be
less prevalent and less frequently diagnosed in women
than men. Therefore, it can be hypothesised that having
such a DP diagnosis might be a reflection of a severe
medical condition, particularly in women, which in turn
might be a reason for their higher suicide risk.14 19 49
It
is therefore possible that health consequences of sub-
stance abuse disorders might be worse in women than
men.50
Moreover, substance abuse disorders may aggra-
vate an existing comorbid depression, which itself is a
risk factor for suicidal behaviour.50–53
Personality disorder as a secondary DP diagnosis was
strongly associated with a higher risk of suicide attempt
compared with those who did not have any secondary
DP diagnosis. Current literature suggests that personality
disorder, comorbid with depression or by itself, involves
a higher risk of suicide attempt.54 55
Full-time DP was associated with a higher risk of sui-
cidal behaviour compared with part-time DP. This is in
line with a previous study reporting a higher risk of sui-
cidal behaviour associated with full-time compared with
part-time sickness absence.56
Full-time DP might here be
associated with a greater severity of the underlying dis-
order. On the other hand, full-time DP might be related
to an alteration in health behaviour (regarding alcohol
consumption, smoking, physical activity, diet, etc) or to
social isolation,8 57
which might be associated with total
exclusion from the labour market.9
More knowledge is
required on such associations.8
Statistically significant interaction was observed
between gender and DP grade: women with full-time DP
had a higher risk of subsequent suicide attempt than
women with part-time DP. The proportion of women on
part-time DP tends to be much higher compared with
men in Sweden.3
It might be anticipated that, if women
are granted full-time DP, they might have a greater sever-
ity of the underlying mental disorder and therefore be
at higher risk of subsequent suicide attempt.56
Further
studies are warranted to investigate pathways to suicidal
behaviour related to DP grade.
CONCLUSION
This first study of associations between measures of DP
due to CMD with subsequent risk of suicidal behaviour
among individuals on such DP found several such associa-
tions. In general, depressive disorders as the main DP diag-
nosis and substance abuse or personality disorder as the
secondary DP diagnosis were risk markers for subsequent
suicidal behaviour in such individuals. Some gender and
age differences in these associations emerged. Approaches
for intervention in this group of ‘disability pensioners’
should therefore consider the individual variation in risk
factors with regard to gender and age. Particular attention
should be paid to younger individuals on DP due to
anxiety disorders because of the higher suicide risk.
Contributors EM-R was responsible for the core idea, and all authors
contributed to the study design. SGR and EM-R carried out the data analyses
and drafted the manuscripts. SGR, KA, JJ and EM-R participated in
interpretation of results, critically revised the manuscript for important
intellectual content, contributed to successive drafts, and agreed on the final
version. All authors read and approved the final manuscript.
Funding The Swedish Research Council for Health, Working Life and Welfare,
the Swedish Research Council (Project numbers: K2009-61P-21304-04-4;
K2009-61X-21305-01-1; K2011-80P-21782-01-4) and the Karolinska
Institutet’s funding for doctoral students.
Competing interests None declared.
Ethics approval The Regional Ethics Review Board of Stockholm, Sweden
(Dnr 2007/762-31).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Open Access This is an Open Access article distributed in accordance with
the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different terms, provided
the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/4.0/
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cohort study
behaviour: a population-based prospective
disorders and subsequent suicidal
Disability pension due to common mental
Mittendorfer-Rutz
Syed Ghulam Rahman, Kristina Alexanderson, Jussi Jokinen and Ellenor
doi: 10.1136/bmjopen-2015-010152
2016 6:BMJ Open
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