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Are All-Cause and Diagnosis-Specific Sickness Absence, and Sick-Leave Duration Risk
Indicators for Suicidal Behavior? - A Nationwide Register-Based Cohort Study of 4.9
Million Inhabitants of Sweden
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Mo Wang1, Kristina Alexanderson1, Bo Runeson2, Jenny Head3, Maria Melchior4, Aleksander
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Perski5, Ellenor Mittendorfer-Rutz1
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Stockholm, Sweden
Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet,
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Stockholm, Sweden
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United Kingdom
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Epidemiology of Occupational and Social Determinants of Health, Villejuif, France
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Department of Clinical Neuroscience, Centre for Psychiatric Research, Karolinska Institutet,
Department of Epidemiology and Public Health, University College London, London,
INSERM U1018, CESP Centre for Research in Epidemiology and Population Health,
Stress Research Institute, Stockholm University, Stockholm, Sweden
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Send requests for offprint to Corresponding author:
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Mo Wang
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Department of Clinical Neuroscience
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Division of Insurance Medicine
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Karolinska Institutet
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171 77 Stockholm
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Sweden
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E-mail: mo.wang@ki.se
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Tel.: +46-8-524 83237
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Fax: +46-8- 524 832 05
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Keywords: sickness absence, suicide attempt, suicide.
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Number of words abstract: 250
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Number of words main text: 4,346
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ABSTRACT
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OBJECTIVES. Resent studies have found an increased risk of suicide in people on sickness
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absence , but less is known about to what extent diagnosis-specific sickness absence is a risk
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indicator for suicidal behavior. This study aimed to examine all-cause and diagnosis-specific
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sickness absence and sick-leave duration as risk indicators for suicide attempt and suicide.
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METHODS. This is a population-based prospective cohort study. All non-retired adults
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(N=4,923,404) who lived in Sweden 31.12.2004 were followed up for six years regarding
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suicide attempt and suicide (2005-2010). Hazard ratios (HR) and 95% confidence intervals
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(CI) for suicidal behavior were calculated, using people with no sick-leave spells in 2005 as
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reference.
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RESULTS. In analyses adjusted for socio-demographic factors and previous mental health
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care, suicide attempt, and current antidepressants prescription, sickness absence predicted
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suicide attempt (HR 2.37; 95% CI: 2.25 to 2.50 for women; HR 2.69; 95% CI: 2.53 to 2.86
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for men) and suicide (HR 1.91; 95% CI: 1.60 to 2.29 for women; HR 1.92; 95% CI: 1.71 to
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2.14 for men), particularly mental sickness absence (range of HR: 2.74 - 3.64). The risks were
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also increased for somatic sickness absence, e.g. musculoskeletal and digestive diseases and
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injury/poisoning (range of HR: 1.57-3.77). Moreover, the risks increased with sick-leave
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duration.
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CONCLUSIONS. Sickness absence was a clear risk indicator for suicidal behavior,
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irrespective of sick-leave diagnoses and among both women and men. Awareness of such
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risks is recommended when monitoring sickness certification. Further studies are warranted in
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order to gain more detailed knowledge on these associations.
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What this paper adds
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Sickness absence is a common health care recommendation in a number of European
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countries, but no population-based studies have yet investigated the association of all-
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cause and diagnosis-specific sickness absence as well as sick-leave duration with both
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subsequent suicide attempt and suicide, adjusting for previous mental disorders and
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suicidal behavior.
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Previous studies showed that all-cause sickness absence and sickness absence due to
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mental and musculoskeletal diagnoses was associated with an increased risk of
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suicide.
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In this study, an increased risk of suicide attempt and suicide was found among both
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women and men with sickness absence due to mental and some specific somatic
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diagnoses as well as with sick-leave duration.
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Somatic sick-leave diagnoses associated with suicide attempt and suicide included
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injury/poisoning, musculoskeletal, digestive, circulatory, nervous and respiratory
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diseases. All-cause and diagnosis-specific sickness absence as well as sick-leave
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duration as risk indicators for suicide attempt and suicide should be noted when
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monitoring sickness certification.
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INTRODUCTION
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In recent years, there is a growing interest in research on sickness absence; a common health
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care recommendation for patients in Western as well as in Northern European countries.(1)
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Due to increasing rates during the last 20 years, (1, 2) sickness absence today is seen as a
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public health issue, resulting in salient policy concerns about large economic costs and
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possible negative outcomes for those on sick leave.(1) Particularly mental disorders such as
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depression and stress-related disorders, have been noted to represent an increasing share of
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sick-leave diagnoses in several European countries.(3)
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Notably, previous research has mainly focused on risk factors for sickness absence, rather
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than on long-term outcomes of being sickness absent.(4) Nevertheless, recently some studies
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have identified sickness absence as a risk indicator for premature death in working
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populations.(5, 6) Previous research has also shown that including information on sick-leave
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diagnoses can improve prediction of mortality.(6) Additionally, long periods of sickness
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absence might entail social isolation and unhealthy life styles (high alcohol and tobacco use),
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which might have an effect on the aggravation of symptoms per se.(7)
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To date, however, little is known about associations of all-cause and diagnosis-specific
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sickness absence as well as sick-leave duration with suicidal behavior. Suicide is an important
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cause of mortality for all ages worldwide.(8) The World Health Organisation (WHO) reported
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that the annual number of suicide deaths is nearly one million.(8) Suicidal behavior is often
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associated with mental disorder and leads to tremendous suffering for the individuals'
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families.(9) It is also associated with considerable costs for the society.(10) Socio-
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demographic factors such as male sex, lower educational level, being unmarried, and
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unemployement are associated with higher risk of suicide.(11) Suicide attempt constitutes
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another public health issue and is approximately 20 times more frequent than completed
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suicide.(8)
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All-cause sickness absence was found to be predictive of suicide completion in a large
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prospective cohort study of municipal employees in Finland.(12) This association was
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replicated in a large study of the general Danish population.(11) More recently, people with
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mental sickness absence have been reported to have an increased risk for suicide in an
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occupational cohort study of employees in the French Gas and Electricity Company.(13)
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Swedish cohort studies also demonstrated the increased risk of suicide among people sickness
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absent due to specific mental diagnoses and musculoskeletal diagnoses.(14, 15) To the best of
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our knowledge, this is the first population-based cohort study investigating the association of
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sickness absence due to mental and various somatic diagnoses with suicide attempt and
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suicide adjusting for socio-demographics, previous mental disorders, suicide attempt and
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current antidepressant prescription.
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The aim of this study was to scrutinize all-cause and diagnosis-specific sickness absence as
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well as sick-leave duration as risk indicators for suicide attempt and suicide, using nationwide
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register-based data including more than 4.9 million inhabitants in Sweden, adjusting for a
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number of socio-demographic and socio-economic factors and previous in- and outpatient
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mental health care, suicide attempt, and current antidepressants prescription.
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METHODS
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Study population
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A prospective population-based cohort study was conducted. The study population comprised
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a cohort of all individuals who lived in Sweden on 31.12.2004, and then were aged 16-64, and
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not on old-age (N=36,322) or disability pension (incapacity benefit, N=583,893) during 2005,
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and without an ongoing sick-leave spell at the turn of 2004/2005 (N=206,656); N= 4,923,404.
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The cohort was followed up from 01.01.2005 for 6 years, till 31.12.2010. We used register
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data obtained and merged for each individual from Swedish authorities. Registers were
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merged by means of the individuals’ personal identification numbers attributed to all Swedish
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inhabitants.
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Sickness absence
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Exposure was measured as having at least one new (incident) sick-leave spell during 2005.
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Data on all new sick-leave spells with sickness benefit initiated during 2005 were obtained
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from the Social Insurance Agency (SIA) regarding start date, sick-leave diagnosis, and
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duration. Sick-leave duration from the first new spell in 2005 was grouped in five categories:
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1-14, 15-90, 91-180, 181-365, and more than 365 days. All first new sickness spells were
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followed till they ended even if this happened after 2005. The main diagnosis on the sickness
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certificate of the first new sick-leave spell in 2005 was used. The following categories of
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medical sick-leave diagnoses were used, based on the International Classification of Diseases,
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10th edition (ICD-10): 1) Certain infectious and parasitic diseases (A00-B99); 2) Neoplasms
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(C00-D48); 3) Diseases of the blood and blood-forming organs and certain disorders
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involving the immune mechanism (D50-D89); 4) Endocrine, nutritional and metabolic
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diseases (E00-E90); 5) Mental and behavioral disorders (F00-F99); 6) Diseases of the nervous
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system (G00-G99); 7) Diseases of the eye and adnexa (H00-H59); 8) Diseases of the ear and
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mastoid process (H60-H95); 9) Diseases of the circulatory system (I00-I99); 10) Diseases of
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the respiratory system (J00-J99); 11) Diseases of the digestive system (K00-K93); 12)
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Diseases of the skin and subcutaneous tissue (L00-L99); 13) Diseases of the musculoskeletal
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system and connective tissue (M00-M99); 14) Diseases of the genitourinary system (N00-
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N99); 15) Pregnancy, childbirth and the puerperium (O00-O99); 16) Congenital
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malformations, deformations and chromosomal abnormalities (Q00-Q99); 17) Symptoms,
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signs and abnormal clinical and laboratory findings (R00-R99); 18) Injury, poisoning and
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certain other consequences of external causes (S00-T98); 19) External causes of morbidity
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(V01-Y98); 20) Factors influencing health status and contact with health services (Z00-Z99).
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Diagnostic categories of sickness absence with less than 20 cases of suicide attempt/suicide
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and those with missing diagnoses (20%) were combined into “other disorders” in the analyses
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of diagnosis-specific sickness absence.
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Social insurance system in Sweden
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During the exposure period, all people in Sweden above the age of 16 were eligible for
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sickness benefits if having an income from work or unemployment or parental benefits.
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Sickness benefit amounted up to 80% of lost income if unable to work due to a disease or
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injury.(16) Employees received sick pay for the first two weeks of the sick-leave spell from
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the employer, thereafter from SIA. All other groups had benefits from SIA. All had one
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qualifying day, with the exception of self-employed, who could have more qualifying days.
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Covariates
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Information on sex, age, educational level, area of residence, country of birth, and family
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situation at baseline (31.12.2004) was obtained from Statistics Sweden, as indicated in Table
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1. Information on previous suicide attempt, previous mental health care and antidepressants
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(July – December 2005) was obtained from the National Board of Health and Welfare.
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Previous inpatient care for suicide attempt during 2000-2004 was dichotomized as suicide
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attempt (ICD-10: X60-X84) and no suicide attempt. Previous specialized mental health care
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(ICD-10: F00-F99) was categorized based on the median length of inpatient care 2000-2004
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(no inpatient care; ≤median length; >median length) and total number of outpatient care visits,
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2001–2004 (no visits; ≤median visits; >median visits). The median for specialized inpatient
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and outpatient care due to mental disorders was 5 days and 1 visit, respectively (Table 1).
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Antidepressant prescription was coded following the Anatomic Therapeutic Chemical
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classification system (ATC) code N06a, and categorized as a dichotomous variable.
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Outcome measures
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Information on inpatient care due to suicide attempt and on suicide from 01.01.2005 up to
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31.12.2010 was obtained from the National Board of Health and Welfare. These outcome
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measures were coded according to ICD-10: suicide attempt/suicide (X60-X84).
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Analyses
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Crude and adjusted hazard ratios (HR) and 95% confidence intervals (CI) for suicide attempt
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and suicide in relation to the exposure variables were estimated by Cox proportional hazard
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regression models after testing that the proportional hazard assumption was met. Analyses
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have been stratified by sex in those cases where the partial likelihood ratio test indicated an
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interaction with sex. Individuals were followed until the event (suicide attempt, death due to
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suicide), death (due to other reasons than suicide), emigration, or end of follow-up
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(31.12.2010) whichever came first. Follow-up time (mean 6 years, SD 0.6) started from the
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first day of the first new sick-leave spell with benefits. For participants with no new sick-
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leave spell in 2005, follow-up started from 01.01.2005. Participants with no new sick-leave
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spells were used as the reference group. Besides the crude model, we adjusted hazard ratios
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for socio-demographic factors in the first model. The final model was adjusted for previous
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mental health care from in- and outpatient care, suicide attempt from inpatient care and
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current antidepressant prescription. Data processing was performed using SPSS for Windows
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version 20.0.
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RESULTS
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Table 1 shows descriptive statistics of the study population regarding exposure, covariates,
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and outcome characteristics. The 4,923,404 individuals in the cohort consisted of 2,337,295
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women (47.5%) and 2,586,109 men. Among those, 8.5% of the women and 5.2% of the men
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had at least one new sick-leave spell in 2005 (mean 127 days, SD 251, median length 35 days,
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range 1-1956 days). Generally, women’s sick-leave spells were longer than men’s. The
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majority of the study population was under 45 years of age, had achieved a medium
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educational level, was single/divorced/separated/widowed without children living at home,
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lived in big cities, and were born in Sweden. Also, the majority had no previous specialized
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inpatient (98.8% of women, 99.0% of men) or outpatient mental health care (97.8% of
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women, 98.3% of men). Of all, 0.4% of women and 0.2% of men had been treated in inpatient
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care due to suicide attempt before study entry (2000 to 2004). During the six years of follow-
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up, more women (0.4%) than men (0.3%) were admitted to inpatient care due to attempted
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suicide, while more men (0.1%) than women (0.03%) committed suicide. More women
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(5.4%) than men (2.8%) were prescribed antidepressants in 2005 (Table 1).
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(Table 1 here)
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Suicide attempt
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Table 2 and 3 show uni- and multivariate HRs for all-cause and diagnosis-specific sickness
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absence as well as sick-leave duration in 2005 and the risk of attempting suicide for women
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and men, respectively. A total of 2,246 female and 1,446 male suicide attempters had had at
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least one sick-leave spell in 2005. Most of the individuals had been sickness absent due to
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mental diagnoses, followed by musculoskeletal diagnoses, injury, and poisoning (Table 2 and
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3). There were 695 suicide attempt cases occurring during the first sick-leave spell and 2997
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suicide attempt cases after that sick-leave spell.
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Crude HRs for suicide attempt were increased among women with a new sick-leave spell in
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2005 (HR 2.52; 95% CI: 2.40 to 2.64). The HR of suicide attempt was highest for those who
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had been sickness absent due to mental diagnoses (HR 6.16; 95% CI: 5.76 to 6.59), followed
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by sickness absence due to symptoms and signs, injury/poisoning, diseases of the digestive,
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and the musculoskeletal system (range of HRs: 1.28-1.94). Suicide attempt risk increased with
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increasing sick-leave duration. In the final model, including adjustment for socio-
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demographic factors and previous mental health care, suicide attempt and antidepressants,
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sickness absence in 2005 was predictive of suicide attempt for women (HR 2.37; 95% CI:
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2.25 to 2.50). The HR of suicide attempt was 2.98 (95% CI: 2.77 to 3.21) for women sickness
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absent due to mental diagnoses, followed by sickness absence due to symptoms and signs,
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injury, musculoskeletal, respiratory, digestive (range of HR: 1.45-2.13). There was an excess
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risk of suicide attempt with increasing sick-leave days. The HR for suicide attempt was 3.35
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among women with sickness absence of more than 365 days (95% CI: 3.13 to 3.80) (Table 2).
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(Table 2 here)
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We observed that all-cause sickness absence was associated with an increased risk of suicide
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attempt in men (HR 3.73; 95% CI: 3.52 to 3.95) in the univariate analysis (Table 3). Men had
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a strongly increased risk of suicide attempt in case of mental sickness absence (HR 11.99;
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95% CI: 11.03 to 13.03) (model 0). The risk of suicide attempt increased with increasing sick-
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leave days (range of HRs: 2.89-7.32). The final model showed that the HR of suicide attempt
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was 2.69 among men with sickness absence (CI: 2.53 to 2.86) and 3.64 among men with
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mental sickness absence (CI: 3.32 to 4.00). Sickness absence due to all analyzed somatic
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diagnoses, with the exception of respiratory diagnoses, were also associated with an increased
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risk of suicide attempt for men (range of HR: 1.79-3.77). The HR of suicide attempt was 3.46
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among men with sickness absence of 181-365 days even after controlling for all covariates. In
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the partial likelihood ratio test, diagnosis-specific sickness absence showed significant
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interaction with sex. Men with sickness absence due to mental and nervous diagnoses had
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higher risk of suicide attempt than women in the multivariate analyses (P<0.001). Sick-leave
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duration showed significant interaction with sex. Men with all categories of sick-leave
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duration with the exception of more than 365 days had higher risk of suicide attempt than
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women (p<0.05). Adjusting for mental health care and suicide attempt had a stronger effect
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on the estimates among men than women, particulary with regard to mental sickness absence.
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(Table 3 here)
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Suicide
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Table 4 and 5 present crude and adjusted HRs of all-cause and diagnosis-specific sickness
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absence as well as sick-leave duration and suicide for women and men, respectively. A total
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of 174 women and 404 men with at least one new sick-leave spell in 2005 committed suicide
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during the follow-up (Table 4 and 5). There were 79 suicide cases emerging during the first
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new sickness absence spell and 499 suicide cases after that spell.
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Increased risks of suicide among women with sickness absence were oberseved in the crude
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model (HR 2.63; 95% CI: 2.22 to 3.11). The HR of suicide was highest for women with
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mental sickness absence (HR 6.69; 95% CI: 5.29 to 8.46). In the final model, we found an
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increased risk of suicide among women on sick-leave compared to those without sickness
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absence (HR 1.91; 95% CI: 1.60 to 2.29). The risk was high among women with sickness
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absence due to mental diagnoses (HR 2.74; 95% CI: 2.12 to 3.53). Also, increased suicide
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risks were observed among women with sickness absence due to musculoskeletal diagnoses
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(HR 1.58; 95% CI: 1.03 to 2.43). The risk of suicide was highest among women with sickness
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absence of 181-365 days (HR 3.55; 95% CI: 2.36 to 5.34) (Table 4).
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(Table 4 here)
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Table 5 shows crude and adjusted HRs of all-cause and diagnosis-specific sickness absence
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and suicide for men. An increased risk of suicide was observed among men (HR 2.92; 95%
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CI: 2.63 to 3.25) with sickness absence, particularly in men on mental sickness absence (HR
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8.48; 95% CI: 7.20 to 9.97) (model 0). In the multivariate model, the risk estimates of suicide
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were highest among men with sickness absence due to mental diagnoses (HR 2.96; 95% CI:
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2.48 to 3.54). Sickness absence due to musculoskeletal diagnoses and injury/poisoning also
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predicted suicide (range of HR: 1.66-1.76). The HR of suicide was 2.34 among men with
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sickness absence of 181-365 days (95% CI: 1.70 to 3.23).
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(Table 5 here)
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DISCUSSION
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The present study, based on a cohort of over 4.9 million people shows that all-cause and
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diagnosis-specific sickness absence and sick-leave duration predict subsequent suicide
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attempt and suicide, both among women and men. Women and men with sickness absence
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showed 2-fold increased HRs of suicide attempt and suicide compared with those with no
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sickness absence. These analyses were adjusted for a number of socio-demographic factors,
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previous specialized in- and outpatient mental health care, previous suicide attempt from
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inpatient care and prescription of antidepressants in 2005. Sickness absence due to mental
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diagnoses was strongly associated with suicide attempt and suicide in both women and men,
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somewhat stronger in men. Somatic sickness absence diagnoses associated with suicide
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attempt included injury/poisoning, symptoms and signs, musculoskeletal, digestive,
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circulatory, nervous and respiratory diseases. Also, individuals on sickness absence due to
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musculoskeletal diagnoses and injury/poisoning had an increased risk of suicide. In addition,
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increasing sick-leave duration increased the risk of suicide attempt and suicide both among
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women and men.
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Methodological considerations
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To the best of our knowledge, this is the first study investigating the association of all-cause
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and diagnosis-specific sickness absence with suicidal behavior based on data from registers
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with national coverage.(17, 18) Moreover, the large sample size of the study offered
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satisfactory statistical power for the analyses of sickness absence with rare outcomes like
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suicide attempt and suicide. Other strengths are that we could control for several potential
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confounders, including previous specialized in- and outpatient care due to mental disorders,
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suicide attempt, and antidepressants, the prospective design with a long follow-up (six years),
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and that all information could be followed through the six years (no drop out). An additional
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strength of this study is the good quality of data in the used Swedish registers.(17, 18) One
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reason for the good quality of the data is that those registers have an administrative
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background and are not formed for research purposes. Data on sickness absence was derived
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from the Social Insurance Agency (SIA). However, missclassifications and under-reporting of
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mental diagnoses as well as missing data on sick-leave diagnoses are possible.(16) The, so far,
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only study of validity of sick-leave diagnoses, however, showed acceptable valitidy.(19)
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Information on sick-leave diagnosis was missing in about 20% of the spells. Data on suicide
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attempt and suicide were obtained from the national patient register and the cause of death
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register from the National Board of Health and Welfare. Information on main diagnoses and
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causes of death is missing in around 1% of cases in these registers.(17)
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Other limitations are that by including only suicide attempts which require inpatient care, we
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might have missed medically less serious suicide attempts.(20) Nevertheless, a sensitivity
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analysis including suicide attempts from specialized psychiatric outpatient care did not change
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the results. Still, we are aware of the fact that by controlling for data on inpatient care due to
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suicide attempt, residual confounding is possible, as not all suicide attempts require treatment
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in inpatient care.(21) Second, we only used the first sick-leave spell that occured in 2005, not
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taking recurrent sickness absences into account. However, the predominant proportion of the
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individuals had only one new sick-leave spell (84.8%) in 2005. As in all studies of this design
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it is difficult to parse out the effect of the disorder from the effects of the sickness absence due
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to that disorder.(4) Moreover, most sick-leave spells <14 days were not included for
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employed individuals. It is also important to bear in mind that sickness absence is a complex
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phenomenon in which comorbidity may occur and the Social Insurance Agency only registers
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the main diagnosis of each sick-leave spell. In this study, we were able to control for
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underlying mental disorders by using information on previous inpatient and outpatient care
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due to mental disorders (2000-2004) and prescription of antidepressants (July -December
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2005). However, some residual confounding due to comorbid disorders is likely and further
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studies are needed to elucidate such phenomena.
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Sickness absence as a risk indicator for suicidal behavior
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We found that sickness absence in 2005 implied a two-fold higher risk of suicide after
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controlling for socio-demographic factors and previous mental health care, suicide attempt
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and antidepressants. This corresponds to previous findings, showing that males on sickness
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absence had a 1.87 times higher risk of committing suicide, for women the estimate of suicide
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risk was 2.19, after adjustment for socio-demographic and socio-economic characteristics as
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well as own and parental psychiatric hospitalization.(11) In this study we further explored
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those matters and an association was now also found between sickness absence and suicide
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attempt, indicating a two-fold higher HR in individuals with sickness absence even after
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controlling for all the covariates. This is the first study looking at the association between all-
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cause sickness absence and suicide attempt, suggesting strong associations between sickness
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absence and suicide attempt.
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Also, the duration of the first new sick-leave spell was associated with a risk of suicide
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attempt and suicide. To our knowledge, this is the first study addressing the sick-leave
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duration as a risk indicator for suicide attempt, while such an association has been previously
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reported for suicide completion.(12) While long-term sick leave may be directly related to the
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severity of the disorder, it might also adversely change the individual’s health behavior as
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well as the social and socio-economic life situation.(7) Future studies are warranted to
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elucidate the effects of long-term sickness absence on the prognosis of the underlying disorder
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as well as on development of other morbidity.(4)
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Sickness absence due to mental diagnoses
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We found a 2.74 fold increased risk for suicide among women and a 2.96 fold increased risk
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among men sickness absent due to mental diagnoses. This is consistent with a previous
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occupational study, reporting a five-fold increased risk of suicide for employees on sickness
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absent due to mental diagnoses after adjusting for socio-demographic factors, tobacco, and
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alcohol use.(13) Another Swedish study found a 3.37 fold increased risk for suicide in
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individuals mental sickness absent after controlling for socio-demographic factors and health
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care.(15) Previous research also showed that sickness absence particularly due to substance
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abuse, depression and anxiety was strongly associated with subsequent suicide.(15) We could
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now also show that mental sickness absence was associated with a 2.98 fold risk for suicide
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attempt among women and 3.64 among men after controlling for all the covariates.
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Generally, the risk of suicidal behavior related to diagnoses-specific sickness absence was
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similar in women and men, suggesting that sickness absence might be an equally important
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risk indicator for suicide attempt and suicide among both women and men, despite the sex
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differences in prevalence and incidence of sickness absence.(22) Still, among those with
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mental sickness absence men had a somewhat higher risk of suicide attempt (3.64 fold higher
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risk) than women who had a 2.98 fold higher risk. Also, the risk estimates of suicide attempt
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were more strongly reduced among men with mental sickness absence after controlling for
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previous mental health care, suicide attempt and antidepressants, compared to the estimates
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among women. The association between mental sickness absence and suicidal behavior seems
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to be stronger influenced by previous mental health care among men compared to women.
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One possible explanation of these findings is that men had more severe mental disorders with
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more frequent mental health care contacts when sickness absent compared to women.(23, 24)
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This might be balanced with the fact that the incidence of mental disorders is more common
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among women in most studies.(25, 26) Nevertheless, our results could also be explained by
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the higher threshold among men for reporting mental complaints and for help-seeking.(27)
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Compared to women, men also may be more likely to have detrimental health-related
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behaviors such as high alcohol consumption, which might result in a higher risk of sickness
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absence and suicide.(28)
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Sickness absence due to somatic diagnoses
407
A high risk of suicide attempt and suicide was also observed among individuals sickness
408
absent due to a number of different somatic diagnoses even after controlling for all the
409
covariates. Our findings showed an excess risk of suicide attempt in people with the following
410
sick-leave diagnoses: circulatory, digestive, respiratory, musculoskeletal, and nervous
411
diseases, symptoms and signs, as well as injury and poisoning. An increased risk of suicide
412
was found in persons with sickness absence due to musculoskeletal diagnoses and
413
injury/poisoning. These somatic diagnoses were reported to be associated with suicidal
414
behavior in previous studies from different treatment settings.(29, 30) Somatic disorders are
415
often accompanied by pain, co-morbid mental disorders, and limitations in social life, which
416
may be associated with suicidal behavior.(29) For instance, a history of depression was shown
417
to be significantly associated with diseases of the nervous, circulatory, and respiratory system
418
both in male and female suicide victims.(31) Even if we were able to control for previous
419
mental health care, we may have missed mental disorders not treated in specialized in- or
420
outpatient health care as well as undetected and untreated mental disorders.(27) Around a
421
quarter of suicide victims suffering from depression have been treated for their
422
depression.(32) Previous research suggests that only about a third of individuals with mental
423
disorders seek medical care.(27) Therefore, it is possible that unrecognized or unmeasured co-
19
424
existing mental disorder underlies the association of somatic sickness absence and suicidal
425
behavior.
426
427
We found a two-fold risk of suicide attempt and suicide (only in men) in individuals on
428
sickness absence due to injury/poisoning. This might be partly due to underlying alcohol
429
abuse or dependence, related both to injuries and suicidal behavior. We also observed an
430
increased risk of suicide attempt and suicide equally high among women and men on sickness
431
absent due to musculoskeletal diagnoses. This finding is comparable to a 1.5-1.9 fold
432
increased risk of suicide related to sickness absence due to musculoskeletal diagnoses
433
reported earlier.(14) Adjustment for health care due to mental disorders and antidepressants
434
prescription lowered the risk estimates for suicidal behavior related to sickness absence due to
435
musculoskeletal disorders. This indicates an influence of mental disorders on the association
436
between sickness absence due to musculoskeletal diagnoses and suicide attempt and
437
suicide.(33) An association between sickness absence due to musculoskeletal diagnoses and
438
suicide attempt stratified by sex has not been shown previously.
439
440
We observed an increased risk of suicide attempt in women sickness absent due to symptoms
441
and signs. This diagnostic group may include, for example, chronic fatigue syndrome, which
442
is more prevalent in women than in men and possibly associated with a substantial degree of
443
depression.(30) Previous studies also showed that chronic fatigue is associated with
444
considerable functional impairment and disability in social, physical and occupational aspects,
445
especially when it occurs with depression.(34) This may provide an explanation to the
446
association between sickness absence due to symptoms and signs and suicide attempt. An
447
association between sickness absence due to circulatory diagnoses and suicide attempt was
448
only found in men. Our study also showed that men sickness absent due to nervous diagnoses
20
449
had a considerably higher risk of suicide attempt than women. Studies from other treatment
450
settings showed associations between circulatory and nervous diseases and suicidal
451
behavior.(29) These associations may be due to the strong comorbidity between circulatory
452
and nervous diseases with depression.(29, 35) However, these associations were inconsistent
453
with regard to sex differences. (29, 35, 36) Further studies are required to investigate potential
454
sex differences in the association of sickness absence due to somatic diagnoses with suicidal
455
behavior.
456
457
458
Conclusions
459
We found that sickness absence was a clear risk indicator for suicidal behavior, irrespective of
460
somatic or mental sick-leave diagnoses and among both women and men. Our findings might
461
be of importance for those who monitor sick-leave cases to be aware of those risks.
462
21
463
FUNDING: The study was funded by the Swedish Research Council and Karolinska
464
Institutet funds for doctoral education and the Swedish Research Council.
465
466
COMPETING INTERESTS: None.
467
468
ETHICS APPROVAL: The study was approved by the Regional Ethical Review Board of
469
Stockholm, Sweden.
470
471
472
22
473
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474
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568
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569
570
571
Haukkala A, Konttinen H, Uutela A, et al. Gender differences in the associations
27
572
Table 1. Descriptive Statistics of the Study Population of 4,923,404 Women and Men.
Women
N
Study populationa, all
Men
%
N
%
2,337,295
47.5
2,586,109
52.5
2,138,824
91.5
2,452,405
94.8
First new sick-leave spell with mental diagnoses
44,702
1.9
22,164
0.9
First new sick-leave spell with somatic diagnoses
153,769
6.6
111,540
4.3
1-14
35,509
1.5
21,425
0.8
15-90
150,461
6.4
101,914
3.9
91-180
25,460
1.1
16,678
0.6
181-365
14,902
0.6
10,619
0.4
> 365
24,019
1.0
15,734
0.6
16–24
463,031
19.8
486,659
18.8
25–34
524,779
22.5
562,523
21.8
35–44
530,363
22.7
594,640
23.0
45–54
448,822
19.2
510,592
19.7
55–64
370,300
15.8
431,696
16.7
424,344
18.2
573,643
22.2
1,036,646
44.4
1,218,925
47.1
839,222
35.9
752,291
29.1
37,083
1.6
41,250
1.6
At least one new sick-leave spell in 2005
No new sick-leave spell in 2005
Sick-leave duration (days)b
Age group, years
Educational level (years)
Low (≤9)
Medium (10–12)
High (>12)
Missing information
28
Family situation
Married/living with partner without children
331,564
14.2
317,356
12.3
Married/living with partner with children
845,795
36.2
881,070
34.1
Single/divorced/separated/widowed without
706,067
30.2
1,065,129
41.2
Single/divorced/separated/widowed with children
226,614
9.7
65,986
2.6
Adolescents living with parents, 16–20 years
227,246
9.7
256,552
9.9
9 <0.01
16
<0.01
children
Missing information
Area of residencec
Big cities
901,571
38.6
960,235
37.1
Medium-sized cities
822,759
35.2
914,122
35.3
Small cities/villages
612,965
26.2
711,752
27.5
1 987,201
85.0
2,230,733
86.3
Other Northern European countries
74,307
3.2
69,358
2.7
EU25 without Northern European countries
50,901
2.2
54,377
2.1
224,619
9.6
231,282
8.9
267
0.01
359
0.01
2,312,851
98.8
2,555,715
99.0
≤ 5 days
12,849
0.6
16,621
0.5
> 5 days
11,595
0.5
13,773
0.5
Country of birth
Sweden
Rest of the world
Missing information
Previous inpatient care due to mental disorders, days
(2000-2004;Median: 5 days)
No previous care
Previous outpatient care due to mental disorders,
visits (2001-2004;Median visits: 1)
29
No previous visits
2,286,981
97.8
2,541,244
98.3
1 visit
28,901
1.2
25,600
1.0
> 1 visit
21,413
0.9
19,264
0.7
8,402
0.4
4,661
0.2
10,136
0.4
7,557
0.3
759
0.03
2,597
0.1
126,483
5.4
73,051
2.8
Previous suicide attemptd (2000-2004)
Suicide attemptd during follow-up time (2005-2010)
Suicided during follow-up time (2005-2010)
Antidepressants in 2005
573
574
575
576
577
578
a
Aged 16–64 years and living in Sweden on 31.12.2004, neither on old-age nor disability pension and without
an ongoing sick-leave spell at the turn of 2004/2005.
b
From the first sick-leave spell in 2005.
c
Area of residence: big cities: Stockholm, Göteborg 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.
d
From inpatient care.
30
579
Table 2. Crude and Adjusted Hazard Ratios (HR) and 95% Confidence Intervals (CI) for Suicide Attempt, following the first new Sick-Leave
580
Spell in 2005, in General,due to Different Sick-leave Diagnoses (ICD-10), Women.
Sick-leave, Diagnostic Categories
Model 0a
Model 1b
Model 2c
N
Suicide
Attempts
N (%)
All-cause sickness absence, 2005d
250,351
2,246 (0.9)
2.52 (2.40 to 2.64)
3.60 (3.43 to 3.78)
2.37 (2.25 to 2.50)
Mental and behavioral disorders
44,702
972 (2.2)
6.16 (5.76 to 6.59)
8.42 (7.86 to 9.02)
2.98 (2.77 to 3.21)
Diseases of the nervous system
6,182
21 (0.3)
0.95 (0.62 to 1.46)
1.54 (1.00 to 2.36)
1.31 (0.85 to 2.01)
Diseases of the respiratory system
12,849
51 (0.4)
1.10 (0.84 to 1.45)
1.90 (1.44 to 2.50)
1.57 (1.19 to 2.07)
Diseases of the digestive system
6,291
42 (0.7)
1.87 (1.38 to 2.54)
2.67 (1.97 to 3.61)
2.13 (1.57 to 2.89)
Musculoskeletal system/connective tissue
47,387
217 (0.5)
1.28 (1.12 to 1.46)
1.87 (1.64 to 2.15)
1.64 (1.43 to 1.88)
Diseases of the genitourinary system
6,256
25 (0.4)
1.12 (0.75 to 1.65)
1.89 (1.28 to 2.80)
1.45 (0.98 to 2.15)
Pregnancy, childbirth and the puerperium
20,146
53 (0.3)
0.73 (0.56 to 0.96)
0.85 (0.65 to 1.11)
0.96 (0.74 to 1.26)
Symptoms and signse
9,267
64 (0.7)
1.94 (1.52 to 2.49)
2.75 (2.15 to 3.52)
2.11 (1.65 to 2.70)
Injury and poisoningf
16,746
94 (0.6)
1.57 (1.28 to 1.92)
2.38 (1.94 to 2.92)
2.08 (1.70 to 2.56)
All other disordersd,g
80,525
707 (0.9)
2.47 (2.28 to 2.66)
3.57 (3.30 to 3.87)
2.71 (2.51 to 2.94)
Sick-leave duration (days)
All
Hazard ratios (95% CI)
31
1-14
35,509
227 (0.6)
1.76 (1.54 to 2.01)
2.28 (2.00 to 2.61)
1.95 (1.70 to 2.22)
15-90
150,461
1,064 (0.7)
1.98 (1.86 to 2.11)
2.88 (2.70 to 3.08)
2.13 (1.99 to 2.27)
91-180
25,460
271 (1.1)
3.00 (2.66 to 3.39)
4.10 (3.63 to 4.64)
2.52 (2.23 to 2.85)
181-365
14,902
203 (1.4)
3.92 (3.41 to 4.50)
5.71 (4.96 to 6.57)
2.71 (2.35 to 3.12)
> 365
24,019
481 (2,0)
5.72 (5.22 to 6.27)
9.24 (8.41 to 10.16)
3.35 (3.13 to 3.80)
2,086,944
7,890 (0.4)
1
1
1
No sickness absence (reference group)
581
582
583
584
585
586
587
588
589
590
591
592
593
594
595
a
Model 0: Crude.
Model 1: Adjusted for age, educational level, area of residence, country of birth and family situation.
c
Model 2: Adjusted for age, educational level, area of residence, country of birth and family situation, previous in- and outpatient care due to mental disorders, previous
suicide attempt from inpatient care and antidepressants in 2005.
d
Including sick-leave spells for which diagnoses were missing (20% of all the sick-leave spells).
e
Including abnormal clinical and laboratory findings.
f
Including certain other consequences of external causes.
g
Including certain infectious and parasitic diseases; neoplasms; diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism;
endocrine, nutritional and metabolic diseases; diseases of the eye and adnexa; diseases of the ear and mastoid process; diseases of the circulatory system; diseases of the skin
and subcutaneous tissue; congenital malformations, deformations and chromosomal abnormalities; external causes of morbidity and mortality; factors influencing health status
and contact with health services.
b
32
596
Table 3. Crude and Adjusted Hazard Ratios (HR) and 95% Confidence Intervals (CI) for Suicide Attempt, following Sick-Leave Spell in 2005 in
597
General, due to Different Sick-leave Diagnoses (ICD-10) and in Different Sick-leave Duration, Men.
Model 0a
N
Suicide
Attempts
N (%)
All-cause sickness absence, 2005d
166,370
1,446 (0.9)
3.73 (3.52 to 3.95)
4.24 (4.00 to 4.50)
2.69 (2.53 to 2.86)
Mental and behavioral disorders
22,164
611 (2.8)
11.99 (11.03 to 13.03)
12.92 (11.88 to 14.07)
3.64 (3.32 to 4.00)
Diseases of the nervous system
3,228
31 (1.0)
4.13 (2.90 to 5.87)
5.08 (3.57 to 7.23)
3.77 (2.65 to 5.37)
Diseases of the circulatory system
8,603
32 (0.4)
1.61 (1.14 to 2.28)
2.59 (1.82 to 3.67)
2.16 (1.52 to 3.06)
Diseases of the respiratory system
7,659
26 (0.3)
1.44 (0.98 to 2.12)
1.77 (1.20 to 2.60)
1.39 (0.94 to 2.04)
Diseases of the digestive system
7,862
30 (0.4)
1.63 (1.14 to 2.34)
1.96 (1.37 to 2.80)
1.81(1.26 to 2.59)
Musculoskeletal system/connective tissue
37,833
153 (0.4)
1.72 (1.46 to 2.01)
1.94 (1.65 to 2.28)
1.79 (1.53 to 2.11)
Injury and poisoninge
25,566
151 (0.6)
2.51 (2.14 to 2.96)
2.39 (2.04 to 2.81)
2.13 (1.81 to 2.51)
All other disordersd,f
53,455
412 (0.8)
3.32 (3.01 to 3.67)
3.96 (3.58 to 4.38)
2.83 (2.56 to 3.14)
1-14
21,425
148 (0.7)
2.89 (2.45 to 3.40)
3.43 (2.91 to 4.04)
2.61 (2.22 to 3.08)
15-90
101,914
713 (0.7)
2.99 (2.77 to 3.23)
3.33 (3.07 to 3.60)
2.44 (2.25 to 2.65)
Sick-leave, Diagnostic Categories
All
Model 1b
Model 2c
Hazard ratios (95% CI)
Sick-leave duration (days)
33
91-180
16,678
173 (1.0)
4.50 (3.87 to 5.24)
5.10 (4.38 to 5.94)
2.75 (2.36 to 3.20)
181-365
10,619
149 (1.4)
6.23 (5.30 to 7.33)
7.41 (6.29 to 8.73)
3.46 (2.93 to 4.08)
> 365
15,734
263 (1.7)
7.32 (6.47 to 8.28)
9.33 (8.23 to 10.57)
3.31 (2.91 to 3.77)
1
1
1
No sickness absence (reference group)
598
599
600
601
602
603
604
605
606
607
608
609
a
2,419,739 6,111 (0.3)
Model 0: Crude.
Model 1: Adjusted for age, educational level, area of residence, country of birth and family situation.
c
Model 2: Adjusted for age, educational level, area of residence, country of birth and family situation, previous in- and outpatient care due to mental disorders, previous
suicide attempt from inpatient care and antidepressants in 2005.
d
Including sick-leave spells for which diagnoses were missing (20% of all the sick-leave spells).
e
Including certain other consequences of external causes.
f
Including certain infectious and parasitic diseases; neoplasms; diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism;
endocrine, nutritional and metabolic diseases; diseases of the eye and adnexa; diseases of the ear and mastoid process; diseases of the skin and subcutaneous tissue; diseases of
the genitourinary system; congenital malformations, deformations and chromosomal abnormalities; symptoms, signs and abnormal clinical and laboratory findings; external
causes of morbidity and mortality; factors influencing health status and contact with health services.
b
34
610
Table 4. Crude and Adjusted Hazard Ratios (HR) and 95% Confidence Intervals (CI) for Suicide, following Sick-Leave Spell in 2005 in General,
611
due to Different Sick-leave Diagnoses (ICD-10) and in Different Sick-leave Duration, Women.
612
Sick-leave, diagnostic categories
Model 0a
Model 1b
Model 2c
All
Suicide
N
N (%)
All-cause sickness absence, 2005d
250,351
174 (0.1)
2.63 (2.22 to 3.11)
2.76 (2.32 to 3.29)
1.91 (1.60 to 2.29)
Mental and behavioral disorders
44,702
79 (0.2)
6.69 (5.29 to 8.46)
6.69 (5.26 to 8.49)
2.74 (2.12 to 3.53)
Musculoskeletal system/connective tissue
47,387
22 (0.05)
1.75 (1.14 to 2.68)
1.76 (1.15 to 2.70)
1.58 (1.03 to 2.43)
All other disordersd,e
158.262
73 (0.05)
1.75 (1.37 to 2.23)
1.88 (1.47 to 2.41)
1.56 (1.22 to 2.00)
1-14
35,509
16 (0.05)
1.68 (1.02 to 2.75)
1.97 (1.20 to 3.25)
1.64 (0.99 to 2.70)
15-90
150,461
87 (0.1)
2.19 (1.74 to 2.74)
2.26 (1.80 to 2.85)
1.74 (1.38 to 2.19)
91-180
25,460
20 (0.1)
2.99 (1.91 to 4.67)
3.13 (2.00 to 4.90)
1.98 (1.26 to 3.10)
181-365
14,902
25 (0.2)
6.48 (4.34 to 9.68)
6.60 (4.41 to 9.87)
3.55 (2.36 to 5.34)
> 365
24,019
26 (0.1)
4.14 (2.79 to 6.13)
4.16 (2.80 to 6.18)
1.91 (1.27 to 2.86)
2,086,944
585 (0.03)
1
1
Hazard ratios (95% CI)
Sick-leave duration (days)
No sickness absence (reference group)
1
35
613
614
615
616
617
618
619
620
a
Model 0: Crude.
Model 1: Adjusted for age, educational level, area of residence, country of birth and family situation.
c
Model 2: Adjusted for age, educational level, area of residence, country of birth and family situation, previous in- and outpatient care due to mental disorders, previous
suicide attempt from inpatient care and antidepressants in 2005.
d
Including sick-leave spells for which diagnoses were missing (20% of all the sick-leave spells).
e
Including all other diagnoses in ICD-10 categories, except for mental and behavioral disorders and diseases of the musculoskeletal system and connective tissue.
b
36
621
Table 5. Crude and Adjusted Hazard Ratios (HR) and 95% Confidence Intervals (CI) for Suicide, following Sick-Leave Spell in 2005 in General,
622
due to Different Sick-leave Diagnoses (ICD 10) and in Different Sick-leave Duration, Men.
Sick-leave, Diagnostic Categories
Model 0a
Model 1b
Model 2c
All
Suicide
N
N (%)
All-cause sickness absence, 2005d
166,370
404 (0.2)
2.92 (2.63 to 3.25)
2.65 (2.38 to 2.96)
1.92 (1.71 to 2.14)
Mental and behavioral disorders
22,164
156 (0.7)
8.48 (7.20 to 9.97)
7.88 (6.69 to 9.28)
2.96 (2.48 to 3.54)
Musculoskeletal system/ connective tissue
37,833
63 (0.2)
1.99 (1.55 to 2.56)
1.78 (1.38 to 2.29)
1.66 (1.29 to 2.14)
Injury and poisoninge
25,566
46 (0.2)
2.15 (1.61 to 2.89)
1.91 (1.43 to 2.56)
1.76 (1.32 to 2.36)
All other disordersd,f
80,807
139 (0.2)
2.08 (1.75 to 2.47)
1.89 (1.59 to 2.45)
1.55 (1.30 to 1.84)
1-14
21,425
38 (0.2)
2.08 (1.51 to 2.87)
1.96 (1.42 to 2.70)
1.60 (1.16 to 2.20)
15-90
101,914
218 (0.2)
2.57 (2.24 to 2.96)
2.33 (2.03 to 2.69)
1.86 (1.61 to 2.15)
91-180
16,678
52 (0.3)
3.80 (2.89 to 5.00)
3.43 (2.61 to 4.53)
2.25 (1.70 to 2.97)
181-365
10,619
39 (0.4)
4.57 (3.33 to 6.28)
4.10 (2.98 to 5.63)
2.34 (1.70 to 3.23)
> 365
15,734
57 (0.4)
4.43 (3.41 to 5.76)
3.87 (2.97 to 5.05)
1.94 (1.48 to 2.54)
2,419,739
2,193 (0.1)
1
1
1
Hazard ratios (95% CI)
Sick-leave duration (days)
No sickness absence (reference group)
37
623
624
625
626
627
628
629
630
631
632
633
634
a
Model 0: Crude.
Model 1: Adjusted for age, educational level, area of residence, country of birth and family situation.
c
Model 2: Adjusted for age, educational level, area of residence, country of birth and family situation, previous in- and outpatient care due to mental disorders, previous
suicide attempt from inpatient care and antidepressants in 2005.
d
Including sick-leave spells for which diagnoses are missing (20% of all the sick-leave spells).
e
Including certain other consequences of external causes.
f
Including all other diagnoses in ICD-10 categories except for mental and behavioral disorders, diseases of the musculoskeletal system and connective tissue, and injury,
poisoning and certain other consequences of external causes.
b