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Factors associated with being granted a pension among psychiatric outpatients with major depression
Journal of Affective Disorders 75 (2003) 43–48 www.elsevier.com / locate / jad
Research report
Factors associated with being granted a pension among psychiatric outpatients with major depression a, b c Marko Sorvaniemi *, Hans Helenius , Raimo K.R. Salokangas a
Psychiatric Policlinic of Rauma, Satakunta Hospital District, Steniuksenkatu 2, 26100 Rauma, Finland b ¨ 1, 20520 Turku, Finland Department of Biostatistics, University of Turku, Lemminkaisenkatu c Department of Psychiatry, University of Turku, Turku University Central Hospital, Kiinamyllynkatu 4 -8, 20520 Turku, Finland Received 1 August 2000; received in revised form 17 January 2002; accepted 18 January 2002
Abstract Background: Little is known about factors associated with early retirement due to major depression in naturalistic settings. We examined to what extent major depression leads to disability pension and whether there are any associated factors with being granted a pension. Methods: In our retrospective document-based cohort study of 213 adult psychiatric outpatients with first-time documented DSM-III-R major depression, several sociodemographic, clinical and treatment characteristics were detected during the follow-up time of 3 months of medical care in Finland. This information was related to official registers of granted pensions with a follow-up time of 30 months. Results: Forty-six (21.6%) patients were granted a pension during the follow-up period. Greater age, comorbidity and lowered self-esteem were strongly associated with being granted a pension. Discussion: Some risk factors associated with subsequent retirement could be identified at the early phase of the illness. 2002 Elsevier Science B.V. All rights reserved. Keywords: Major depression; Disability pension; Retirement; Psychiatric care
1. Introduction Persons with major depression have an almost five times greater risk of disability compared with asymptomatic individuals, (Broadhead et al., 1990). Also, milder forms of depression or subclinical depression have been related to decrements in job performance *Corresponding author. Fax: 1 358-2-835-5709. E-mail address: [email protected] (M. Sorvaniemi).
(Wells et al., 1992; Sherbourne et al., 1994; Judd et al., 1996; Martin et al., 1996). The poor functioning due to depressive symptoms, with or without depressive disorder, is comparable to or worse than that associated with a major chronic medical conditions (Wells et al., 1989; Hays et al., 1995). The economic consequences of major depression have been considered almost incalculable. This is related to the short-term effects of illness, and the consequences of permanent disability and premature
0165-0327 / 02 / $ – see front matter 2002 Elsevier Science B.V. All rights reserved. doi:10.1016/S0165-0327(02)00034-4
44
M. Sorvaniemi et al. / Journal of Affective Disorders 75 (2003) 43–48
¨ death (Jonsson and Bebbington, 1993). In the Global Burden of Disease Study, unipolar major depression was fourth among leading specific causes of global disability in terms of permanent disability and premature death (Murray and Lopez, 1997). Since 1994, major depressive disorders have overtaken schizophrenia as the most common mental disorders leading to the granting of a pension in Finland. During recent years, over 10% of all the new pensions granted have named depression as the main cause. Today, depression is the commonest illness leading to permanent disability in Finland (Salminen et al., 1997). In Finland, local communities are obliged by the mental health law to organize specialized mental health services. Approximately 3–4% of the population use these services yearly, while about 70% have contact with primary care (Salokangas et al., 1995). The private sector plays a minor role and is concentrated only in the few larger cities. We investigated patients with first-time documented major depression seeking help from psychiatric policlinics focusing on two questions. First, to what extent does major depression lead to disability pension? Second, are there any sociodemographic, clinical or treatment factors which may be associated with early retirement among the patients with major depression seen in psychiatric policlinics?
2. Methods Our study was carried out in the hospital district of Satakunta on the west coast of Finland, which has a total population of more than 240 000. The hospital district provides an average sociodemographic profile of the population and mental health services compared with other hospital districts (National Agency for Medicines, 1996). Our study is based on all the patients (N 5 1919) who sought treatment for any reason at four psychi¨ ¨ and atric policlinics (Pori, Rauma, Kankaanpaa Harjavalta) in the years 1989, 1992 and 1995 in Satakunta, and who met the DSM-III-R criteria for major depression. Patients included in the study had no previously documented episodes of major depression or contact with psychiatric care. They had to be non-retired and aged between 18 and 64 years. They
had to have visited the policlinic at least twice during the depressive episode. Altogether 213 out of the 1919 patients (11.1%) fulfilled the final study criteria. The retrospective diagnosis for the study made by the first author was based on a review of the clinical records and all the other documents that had been available in the actual diagnostic and therapeutic process (Sorvaniemi et al., 1998a). The documents for 1919 patients were checked at least four times. Detailed data were collected from the 213 patients fulfilling the criteria. Information was gathered on sociodemographic and clinical variables, target symptoms of major depression, diagnostic proposals and the treatment carried out by the treating physicians as seen in Table 1. The follow-up time of the medical care process was set at 3 months from entering the study. Two psychiatrists independently re-evaluated a randomly selected sample of 160 documents to give diagnoses according to the DSM-III-R-criteria. The reliability achieved for major depression was excellent: k 5 0.92–0.95. The levels of adequate pharmacotherapy were based on several guidelines, comparative studies and consultations with authoritative psychopharmacologists (Bech, 1993; Goodnick, 1994; Montgomery and Johnson, 1995). All antidepressant drug compounds available on the Finnish market during the study years were categorized into three levels according to both given dosage and duration of medication (Sorvaniemi et al., 1998b). In Finland, the final decisions on benefits to be granted are made, on the basis of certificates and statements by treating physicians, by the Social Insurance Institution. These data are gathered in the central data system of the Social Insurance Institution. The month, year and type of pension, along with main diagnoses of all the 213 study patients were obtained with the permission of the Social Insurance Institution. The follow-up time of being pensioned off was set at 30 months from entering the study. Our study was approved by the ethics committee in psychiatry in the Satakunta hospital district. The data were analyzed using version 6.10 of the SAS-software package. Chi-square tests for categorical variables and one-way analyses of variance for
M. Sorvaniemi et al. / Journal of Affective Disorders 75 (2003) 43–48
45
Table 1 Sociodemographic, clinical and treatment characteristics a of the 213 patients with first-time documented major depression in the study years 1989, 1992 and 1995 in psychiatric outpatient care in Finland
Table 1. Continued
Current alcohol abuse Current major somatic diseases
35 46
19 19
Characteristics
N
Female gender
124
58
Marital status Single Married or living together Widowed or divorced
Treating physician Psychiatrist Resident Other physician
73 44 81
40 20 40
59 116 36
31 51 18
Proposed diagnoses by treating physician Major depression Other depressive disorder Non-depressive disorder No diagnosis
86 63 21 43
34 34 13 25
Adequacy levels of pharmacotreatment Probably inadequate Possibly adequate Probably adequate
86 106 21
56 41 3
Living arrangement With someone else
%
167
80
Level of education Elementary school Grade or middle school High school or more
78 75 50
45 39 16
Socio–economic status Entrepreneurs Management employees Manual workers Not in the labour force
26 52 100 35
13 18 56 13
65 63 38 47
33 25 20 22
Duration of current episode before entry to study 2 weeks–3 months Over 3 months
53 156
24 76
Assessed severity of episode ( DSM-III-R) 2961B (mild) 2961C (moderate) 2961D (severe) 2961 (psychotic)
1 166 43 3
1 73 24 2
Documented target symptoms ( DSM-III-R) Depressed mood Anhedonia Appetite or weight changes Sleep changes Psychomotor changes Fatigue Lowered self-esteem Cognitive dysfunction Suicidal thoughts
213 150 85 191 64 162 110 130 107
100 65 36 86 32 75 53 57 47
Psychiatric policlinic location Pori Rauma ¨¨ Kankaapaa Harjavalta
Characteristics
a
N
%
Some data missing.
continuous variables were used in the statistical analyses. Differences in survival times for being pensioned off between groups of patients were tested by the log-rank ( x 2 ) method. Survival time was measured from the first day a patient fulfilled the study criteria. All times were allocated to the monthly interval in which they fell. Multivariate survival analysis of age, education, duration and severity of symptoms, comorbidity and lowered self-esteem as a predictor of being pensioned off was performed using stepwise Cox’s regression analysis (Collett, 1994). Tests were based on the number of subjects for whom data on each characteristic were available. In all tests, P-values of less than 0.05 were interpreted as statistically significant.
3. Results The mean (S.D.) age of the patients at intake was 40.8 (11.7) years with no statistically significant differences between the study years. During the 3month treatment follow-up, the study patients had a mean of personal appointments with the mental health workers of 7.4 (S.D. 5 4.1, median 5 6) and of contacts with physicians 2.4 (S.D. 5 2.1,
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M. Sorvaniemi et al. / Journal of Affective Disorders 75 (2003) 43–48
median 5 2). The other sociodemographic, clinical and treatment characteristics of the 213 patients are presented in Table 1. During the 30-month follow-up, 46 (21.6%) patients were granted a permanent disability pension, all the pensions being granted due to a major depressive disorder. Age was clearly associated with being granted a pension. Twenty-four (39%) patients in the upper median ( $ 43 years) and only 4 (5%) patients in the lower median ( , 43 years) were pensioned off ( x 2 5 19.4, df 5 1, P 5 0.0001). The level of basic education of the patients was associated with being granted a pension. Fifteen (19%) patients with only elementary school education versus 10 (8%) with higher basic education were granted a pension ( x 2 5 6.2, df 5 1, P 5 0.046). The duration of the symptoms of the current illness episode before the study criteria were fulfilled had a statistically significant association with being granted a pension. If the symptoms had lasted over 3 months before entry into the study, 27 (17%) versus none with a shorter duration of symptoms were granted a pension ( x 2 5 9.52, df 5 2, P 5 0.009). Also, the severity of the depressive episode was associated with being pensioned off. Eleven (24%) severely depressed patients versus 17 (10%) were granted a pension ( x 2 5 5.69, df 5 1, P 5 0.017). Of the patients, 16 (42%) with a concomitant major somatic disease and 12 (7%) without comorbidity were granted a pension ( x 2 5 40, df 5 1, P , 0.001). The documented symptoms of lowered self-esteem had a strong association with being pensioned off ( x 2 5 12.3, df 5 1, P , 0.001). Twenty-three (21%) patients with this target symptom and only 5 (5%) patients without it were granted pensions. In a multivariate study, age (P 5 0.01), comorbidity (P , 0.001) and lowered self-esteem (P 5 0.008) were all clearly associated with being granted a pension. Risk ratios (95% confidence intervals) for predictive factors derived from Cox’s model were: age ( $ 43 / , 43 years), 6.2 (1.3–28.3); comorbidity (yes / no), 5.0 (1.9–13.0) and lowered self-esteem (yes / no), 4.2 (1.4–12.6). Neither basic education of the patients, nor the duration or severity of the current episode contributed independently. Crosstabulations showed that they were strongly associ-
ated with at least one of the significant variables in the model (age, comorbidity, lowered self-esteem). No other sociodemographic, clinical or treatment characteristics presented in Table 1 revealed any statistically significant associations with being granted a pension
4. Discussion Our study shares the limitations common to the retrospective method in general. First of all, the study relies on case note reviews for determination of sociodemographic, clinical and treatment characteristics. We may not have recognized some cases of true major depression because of the limitations of our documented information. Even so, we wanted to avoid an intervention effect and so chose the retrospective method to gather information on the careprocess in a naturalistic setting. Also, the study population represents a selected group of depressive patients met in psychiatric outpatient care. Contrary to other studies, we related the study patients with major depression to official—both reliable and valid—registers of granted pensions. In a relatively short follow-up time, over one-fifth of the patients with first-time documented depression permanently lost their ability to cope with their jobs. This emphasizes the need to evaluate possible risk factors for being pensioned off later at an early phase of treatment in the first-time detected depressive patient. Also, it stresses the socio–economic burden of a major depressive disorder (Hays et al., 1995). The connection between greater age and functional impairment may be related to previous findings that greater age increases the risk of chronicity and recurrence of the illness (Mann et al., 1981; Kessing et al., 1998). Our results support the importance of comorbidity as a predictive factor for being granted a pension. An association between depression and major physical diseases has been reported in the clinical studies of patients with specific medical disorders, as well as among patients being treated for depression (Wells et al., 1991; Moldin et al., 1993; Stevens et al., 1995). Also, chronicity in depression has been found to correlate with concurrent incapacitating medical diseases (Akiskal, 1982). According to the impressive study by Judd et al.
M. Sorvaniemi et al. / Journal of Affective Disorders 75 (2003) 43–48
(2000), psychosocial disability in major depression is pervasive and chronic, but it seems to be statedependent and varies with the level of depressive symptom severity during the course of the illness. However, functional status may not always parallel general symptom severity (Goethe and Fischer, 1995). In our study lowered self-esteem at an early phase of the care process was strongly associated with the later inability to work. This target symptom may be of a more hidden nature (Domken et al., 1994) and may persist for longer, thus partly explaining why work recovery takes longer than general symptom relief (Mintz et al., 1992; Shapira et al., 1999). Also, this is a good reason for more individually deliberated treatment. Achieving good job performance may have become more difficult for depressive patients because in the work place an individual is usually a member of a complicated psychosocial network and is, therefore, more easily exposed to negative affective feedback. Several randomized, controlled trials have reported improved functional outcomes in experimental treatment groups relative to the usual care (Ormel and Von Korff, 2000). Efficacy studies have their limitations, too. In our study, using a more naturalistic approach, we did not find any statistically significant association between the adequacy of the early phase pharmacotherapy and subsequently being retired due to the illness. Several factors may be behind this finding. Our treatment follow-up time was not long enough to rule out possible chronicity or recurrence(s) of major depression. More interestingly, this may be related to well-documented difficulties in the long-term treatment of major depression in clinical practice. Selfperceived need of help is surprisingly low among depressive patients (Isometsa¨ et al., 1997), and noncompliance is common for many reasons (Ramana et al., 1999). Effectiveness studies on the long-term treatment of major depression with work ability as an outcome measure in a naturalistic setting are still needed.
References Akiskal, H.S., 1982. Factors associated with incomplete recovery in primary depressive illness. J. Clin. Psychiatry 43, 266–271.
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Bech, P., 1993. Acute therapy of depression. J. Clin. Psychiatry 54 (Suppl. 8), 18–27. Broadhead, W., Blazer, D., George, L., Tse, C., 1990. Depression, disability days, and days lost from work in a prospective epidemiologic survey. J. Am. Med. Assoc. 264, 2524–2528. Collett, D., 1994. Modelling Survival Data in Medical Research. Chapman & Hall, London. Domken, M., Scott, J., Kelly, P., 1994. What factors predict discrepancies between self and observer ratings of depression? J. Affect. Disord. 31, 253–259. Goethe, J., Fischer, E., 1995. Functional impairment in depressed inpatients. J. Affect. Disord. 33, 23–29. Goodnick, P., 1994. Pharmacokinetic optimisation of therapy with newer antidepressants. Clin. Pharmacokinet. 27 (Suppl 4.), 307–330. Hays, R., Wells, K., Sherbourne, C., Rogers, W., Spritzer, K., 1995. Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch. Gen. Psychiatry 52, 11–19. ¨ E., Aro, S., Aro, H., 1997. Depression in Finland: a Isometsa, computer assisted telephone interview study. Acta Psychiatr. Scand. 96, 122–128. ¨ Jonsson, B., Bebbington, P., 1993. Economic studies of the ¨ treatment of depressive illness. In: Jonsson, B., Rosenbaum, J. (Eds.), Health Economics of Depression. John Wiley & Sons, Chichester, UK, pp. 35–48. Judd, L., Akiskal, H., Zeller, P., Paulus, M., Leon, A., Maser, J., Endicott, J., Coryell, W., Kunovac, J., Mueller, T., Rice, J., Keller, M., 2000. Psychosocial disability during the long-term course of unipolar major depressive disorder. Arch. Gen. Psychiatry 57, 375–380. Judd, L., Paulus, M., Wells, K., Rapaport, M., 1996. Socio– economic burden of subsyndromal depressive symptoms and major depression in a sample of general population. Am. J. Psychiatry 153, 1411–1417. Kessing, L., Andersen, P., Mortensen, P., 1998. Predictors of recurrence in affective disorder. A case register study. J. Affect. Disord. 49, 101–108. Mann, A., Jenkins, R., Belsey, E., 1981. The 12-month outcome of patients with neurotic illness in general practice. Psychol. Med. 11, 531–550. Martin, J., Blum, T., Beach, S., Roman, P., 1996. Subclinical depression and performance to work. Soc. Psychiatry Psychiatr. Epidemiol. 31, 3–9. Mintz, J., Mintz, L., Arruda, M., Hwang, S., 1992. Treatments of depression and the functional capacity of work. Arch. Gen. Psychiatry 49, 761–768. Moldin, S., Scheftner, W., Rice, J., Nelson, E., Knesevich, M., Akiskal, H., 1993. Association between major depressive disorder and physical illness. Psychol. Med. 23, 755–761. Montgomery, S., Johnson, F., 1995. Citalopram in the treatment of depression. Rev. Contemp. Pharmacother. 6, 297–306. Murray, C., Lopez, A., 1997. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 349, 1436–1442. National Agency for Medicines, 1996. Finnish Statistics On Medicines 1995. Social Insurance Institution, Helsinki. Ormel, J., Von Korff, M., 2000. Synchrony of change in depression and disability. Arch. Gen. Psychiatry 57, 381–382.
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Ramana, R., Paykel, E., Surtees, P., Melzer, D., Mehta, M., 1999. Medication received by patients with depression following the acute episode: adequacy and relation to outcome. Br. J. Psychiatry 174, 128–134. ¨ Salminen, J., Saarijarvi, S., Raitasalo, R., 1997. Depression and disability pension in Finland. Acta Psychiatr. Scand. 95, 242– 243. ˚ Salokangas, R.K.R., Poutanen, O., Stengard, E., 1995. Screening for depression in primary care. Acta Psychiatr. Scand. 92, 10–16. Shapira, B., Zislin, J., Osher, Y., Gorfine, M., Souery, D., Mendlewicz, J., Lerer, B., 1999. Social adjustment and selfesteem in remitted patients with unipolar and bipolar affective disorder: a case-control study. Compr. Psychiatry 40, 24–30. Sherbourne, C., Wells, K., Hays, R., Rogers, W., Burnam, A., Judd, L., 1994. Subthreshold depression and depressive disorder: clinical characteristics of general medical and mental health specialty outpatients. Am. J. Psychiatry 151, 1777– 1784. Sorvaniemi, M., Helenius, H., Alho, A., Kesti, S., Salokangas,
R.K.R., 1998a. Improved diagnostic assessment of major depression in psychiatric outpatient care in Finland. Psych. Services 49, 384–386. Sorvaniemi, M., Helenius, H., Salokangas, R.K.R., 1998b. Improved pharmacotherapy of major depression in psychiatric outpatient care. Nord. J. Psychiatry 52, 155–161. Stevens, D., Merikangas, K., Merikangas, J., 1995. Comorbidity of depression and other medical conditions. In: Beckham, E., Leber, W. (Eds.), Handbook of Depression, 2nd Edition. The Guilford Press, New York, pp. 147–202. Wells, K., Stewart, A., Hays, R., Burnam, A., Rogers, W., Daniels, M., Berry, S., Greenfield, S., Ware, J., 1989. The functioning and well-being of depressed patients. J. Am. Med. Assoc. 262, 914–919. Wells, K., Rogers, W., Burnam, A., Greenfield, S., Ware, J., 1991. How the medical comorbidity of depressed patients differs across health care settings. Am. J. Psychiatry 148, 1688–1696. Wells, K., Burnam, M., Rogers, W., Hays, R., Camp, P., 1992. The course of depression in adult outpatients. Arch. Gen. Psychiatry 49, 788–794.
Research report
Factors associated with being granted a pension among psychiatric outpatients with major depression a, b c Marko Sorvaniemi *, Hans Helenius , Raimo K.R. Salokangas a
Psychiatric Policlinic of Rauma, Satakunta Hospital District, Steniuksenkatu 2, 26100 Rauma, Finland b ¨ 1, 20520 Turku, Finland Department of Biostatistics, University of Turku, Lemminkaisenkatu c Department of Psychiatry, University of Turku, Turku University Central Hospital, Kiinamyllynkatu 4 -8, 20520 Turku, Finland Received 1 August 2000; received in revised form 17 January 2002; accepted 18 January 2002
Abstract Background: Little is known about factors associated with early retirement due to major depression in naturalistic settings. We examined to what extent major depression leads to disability pension and whether there are any associated factors with being granted a pension. Methods: In our retrospective document-based cohort study of 213 adult psychiatric outpatients with first-time documented DSM-III-R major depression, several sociodemographic, clinical and treatment characteristics were detected during the follow-up time of 3 months of medical care in Finland. This information was related to official registers of granted pensions with a follow-up time of 30 months. Results: Forty-six (21.6%) patients were granted a pension during the follow-up period. Greater age, comorbidity and lowered self-esteem were strongly associated with being granted a pension. Discussion: Some risk factors associated with subsequent retirement could be identified at the early phase of the illness. 2002 Elsevier Science B.V. All rights reserved. Keywords: Major depression; Disability pension; Retirement; Psychiatric care
1. Introduction Persons with major depression have an almost five times greater risk of disability compared with asymptomatic individuals, (Broadhead et al., 1990). Also, milder forms of depression or subclinical depression have been related to decrements in job performance *Corresponding author. Fax: 1 358-2-835-5709. E-mail address: [email protected] (M. Sorvaniemi).
(Wells et al., 1992; Sherbourne et al., 1994; Judd et al., 1996; Martin et al., 1996). The poor functioning due to depressive symptoms, with or without depressive disorder, is comparable to or worse than that associated with a major chronic medical conditions (Wells et al., 1989; Hays et al., 1995). The economic consequences of major depression have been considered almost incalculable. This is related to the short-term effects of illness, and the consequences of permanent disability and premature
0165-0327 / 02 / $ – see front matter 2002 Elsevier Science B.V. All rights reserved. doi:10.1016/S0165-0327(02)00034-4
44
M. Sorvaniemi et al. / Journal of Affective Disorders 75 (2003) 43–48
¨ death (Jonsson and Bebbington, 1993). In the Global Burden of Disease Study, unipolar major depression was fourth among leading specific causes of global disability in terms of permanent disability and premature death (Murray and Lopez, 1997). Since 1994, major depressive disorders have overtaken schizophrenia as the most common mental disorders leading to the granting of a pension in Finland. During recent years, over 10% of all the new pensions granted have named depression as the main cause. Today, depression is the commonest illness leading to permanent disability in Finland (Salminen et al., 1997). In Finland, local communities are obliged by the mental health law to organize specialized mental health services. Approximately 3–4% of the population use these services yearly, while about 70% have contact with primary care (Salokangas et al., 1995). The private sector plays a minor role and is concentrated only in the few larger cities. We investigated patients with first-time documented major depression seeking help from psychiatric policlinics focusing on two questions. First, to what extent does major depression lead to disability pension? Second, are there any sociodemographic, clinical or treatment factors which may be associated with early retirement among the patients with major depression seen in psychiatric policlinics?
2. Methods Our study was carried out in the hospital district of Satakunta on the west coast of Finland, which has a total population of more than 240 000. The hospital district provides an average sociodemographic profile of the population and mental health services compared with other hospital districts (National Agency for Medicines, 1996). Our study is based on all the patients (N 5 1919) who sought treatment for any reason at four psychi¨ ¨ and atric policlinics (Pori, Rauma, Kankaanpaa Harjavalta) in the years 1989, 1992 and 1995 in Satakunta, and who met the DSM-III-R criteria for major depression. Patients included in the study had no previously documented episodes of major depression or contact with psychiatric care. They had to be non-retired and aged between 18 and 64 years. They
had to have visited the policlinic at least twice during the depressive episode. Altogether 213 out of the 1919 patients (11.1%) fulfilled the final study criteria. The retrospective diagnosis for the study made by the first author was based on a review of the clinical records and all the other documents that had been available in the actual diagnostic and therapeutic process (Sorvaniemi et al., 1998a). The documents for 1919 patients were checked at least four times. Detailed data were collected from the 213 patients fulfilling the criteria. Information was gathered on sociodemographic and clinical variables, target symptoms of major depression, diagnostic proposals and the treatment carried out by the treating physicians as seen in Table 1. The follow-up time of the medical care process was set at 3 months from entering the study. Two psychiatrists independently re-evaluated a randomly selected sample of 160 documents to give diagnoses according to the DSM-III-R-criteria. The reliability achieved for major depression was excellent: k 5 0.92–0.95. The levels of adequate pharmacotherapy were based on several guidelines, comparative studies and consultations with authoritative psychopharmacologists (Bech, 1993; Goodnick, 1994; Montgomery and Johnson, 1995). All antidepressant drug compounds available on the Finnish market during the study years were categorized into three levels according to both given dosage and duration of medication (Sorvaniemi et al., 1998b). In Finland, the final decisions on benefits to be granted are made, on the basis of certificates and statements by treating physicians, by the Social Insurance Institution. These data are gathered in the central data system of the Social Insurance Institution. The month, year and type of pension, along with main diagnoses of all the 213 study patients were obtained with the permission of the Social Insurance Institution. The follow-up time of being pensioned off was set at 30 months from entering the study. Our study was approved by the ethics committee in psychiatry in the Satakunta hospital district. The data were analyzed using version 6.10 of the SAS-software package. Chi-square tests for categorical variables and one-way analyses of variance for
M. Sorvaniemi et al. / Journal of Affective Disorders 75 (2003) 43–48
45
Table 1 Sociodemographic, clinical and treatment characteristics a of the 213 patients with first-time documented major depression in the study years 1989, 1992 and 1995 in psychiatric outpatient care in Finland
Table 1. Continued
Current alcohol abuse Current major somatic diseases
35 46
19 19
Characteristics
N
Female gender
124
58
Marital status Single Married or living together Widowed or divorced
Treating physician Psychiatrist Resident Other physician
73 44 81
40 20 40
59 116 36
31 51 18
Proposed diagnoses by treating physician Major depression Other depressive disorder Non-depressive disorder No diagnosis
86 63 21 43
34 34 13 25
Adequacy levels of pharmacotreatment Probably inadequate Possibly adequate Probably adequate
86 106 21
56 41 3
Living arrangement With someone else
%
167
80
Level of education Elementary school Grade or middle school High school or more
78 75 50
45 39 16
Socio–economic status Entrepreneurs Management employees Manual workers Not in the labour force
26 52 100 35
13 18 56 13
65 63 38 47
33 25 20 22
Duration of current episode before entry to study 2 weeks–3 months Over 3 months
53 156
24 76
Assessed severity of episode ( DSM-III-R) 2961B (mild) 2961C (moderate) 2961D (severe) 2961 (psychotic)
1 166 43 3
1 73 24 2
Documented target symptoms ( DSM-III-R) Depressed mood Anhedonia Appetite or weight changes Sleep changes Psychomotor changes Fatigue Lowered self-esteem Cognitive dysfunction Suicidal thoughts
213 150 85 191 64 162 110 130 107
100 65 36 86 32 75 53 57 47
Psychiatric policlinic location Pori Rauma ¨¨ Kankaapaa Harjavalta
Characteristics
a
N
%
Some data missing.
continuous variables were used in the statistical analyses. Differences in survival times for being pensioned off between groups of patients were tested by the log-rank ( x 2 ) method. Survival time was measured from the first day a patient fulfilled the study criteria. All times were allocated to the monthly interval in which they fell. Multivariate survival analysis of age, education, duration and severity of symptoms, comorbidity and lowered self-esteem as a predictor of being pensioned off was performed using stepwise Cox’s regression analysis (Collett, 1994). Tests were based on the number of subjects for whom data on each characteristic were available. In all tests, P-values of less than 0.05 were interpreted as statistically significant.
3. Results The mean (S.D.) age of the patients at intake was 40.8 (11.7) years with no statistically significant differences between the study years. During the 3month treatment follow-up, the study patients had a mean of personal appointments with the mental health workers of 7.4 (S.D. 5 4.1, median 5 6) and of contacts with physicians 2.4 (S.D. 5 2.1,
46
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median 5 2). The other sociodemographic, clinical and treatment characteristics of the 213 patients are presented in Table 1. During the 30-month follow-up, 46 (21.6%) patients were granted a permanent disability pension, all the pensions being granted due to a major depressive disorder. Age was clearly associated with being granted a pension. Twenty-four (39%) patients in the upper median ( $ 43 years) and only 4 (5%) patients in the lower median ( , 43 years) were pensioned off ( x 2 5 19.4, df 5 1, P 5 0.0001). The level of basic education of the patients was associated with being granted a pension. Fifteen (19%) patients with only elementary school education versus 10 (8%) with higher basic education were granted a pension ( x 2 5 6.2, df 5 1, P 5 0.046). The duration of the symptoms of the current illness episode before the study criteria were fulfilled had a statistically significant association with being granted a pension. If the symptoms had lasted over 3 months before entry into the study, 27 (17%) versus none with a shorter duration of symptoms were granted a pension ( x 2 5 9.52, df 5 2, P 5 0.009). Also, the severity of the depressive episode was associated with being pensioned off. Eleven (24%) severely depressed patients versus 17 (10%) were granted a pension ( x 2 5 5.69, df 5 1, P 5 0.017). Of the patients, 16 (42%) with a concomitant major somatic disease and 12 (7%) without comorbidity were granted a pension ( x 2 5 40, df 5 1, P , 0.001). The documented symptoms of lowered self-esteem had a strong association with being pensioned off ( x 2 5 12.3, df 5 1, P , 0.001). Twenty-three (21%) patients with this target symptom and only 5 (5%) patients without it were granted pensions. In a multivariate study, age (P 5 0.01), comorbidity (P , 0.001) and lowered self-esteem (P 5 0.008) were all clearly associated with being granted a pension. Risk ratios (95% confidence intervals) for predictive factors derived from Cox’s model were: age ( $ 43 / , 43 years), 6.2 (1.3–28.3); comorbidity (yes / no), 5.0 (1.9–13.0) and lowered self-esteem (yes / no), 4.2 (1.4–12.6). Neither basic education of the patients, nor the duration or severity of the current episode contributed independently. Crosstabulations showed that they were strongly associ-
ated with at least one of the significant variables in the model (age, comorbidity, lowered self-esteem). No other sociodemographic, clinical or treatment characteristics presented in Table 1 revealed any statistically significant associations with being granted a pension
4. Discussion Our study shares the limitations common to the retrospective method in general. First of all, the study relies on case note reviews for determination of sociodemographic, clinical and treatment characteristics. We may not have recognized some cases of true major depression because of the limitations of our documented information. Even so, we wanted to avoid an intervention effect and so chose the retrospective method to gather information on the careprocess in a naturalistic setting. Also, the study population represents a selected group of depressive patients met in psychiatric outpatient care. Contrary to other studies, we related the study patients with major depression to official—both reliable and valid—registers of granted pensions. In a relatively short follow-up time, over one-fifth of the patients with first-time documented depression permanently lost their ability to cope with their jobs. This emphasizes the need to evaluate possible risk factors for being pensioned off later at an early phase of treatment in the first-time detected depressive patient. Also, it stresses the socio–economic burden of a major depressive disorder (Hays et al., 1995). The connection between greater age and functional impairment may be related to previous findings that greater age increases the risk of chronicity and recurrence of the illness (Mann et al., 1981; Kessing et al., 1998). Our results support the importance of comorbidity as a predictive factor for being granted a pension. An association between depression and major physical diseases has been reported in the clinical studies of patients with specific medical disorders, as well as among patients being treated for depression (Wells et al., 1991; Moldin et al., 1993; Stevens et al., 1995). Also, chronicity in depression has been found to correlate with concurrent incapacitating medical diseases (Akiskal, 1982). According to the impressive study by Judd et al.
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(2000), psychosocial disability in major depression is pervasive and chronic, but it seems to be statedependent and varies with the level of depressive symptom severity during the course of the illness. However, functional status may not always parallel general symptom severity (Goethe and Fischer, 1995). In our study lowered self-esteem at an early phase of the care process was strongly associated with the later inability to work. This target symptom may be of a more hidden nature (Domken et al., 1994) and may persist for longer, thus partly explaining why work recovery takes longer than general symptom relief (Mintz et al., 1992; Shapira et al., 1999). Also, this is a good reason for more individually deliberated treatment. Achieving good job performance may have become more difficult for depressive patients because in the work place an individual is usually a member of a complicated psychosocial network and is, therefore, more easily exposed to negative affective feedback. Several randomized, controlled trials have reported improved functional outcomes in experimental treatment groups relative to the usual care (Ormel and Von Korff, 2000). Efficacy studies have their limitations, too. In our study, using a more naturalistic approach, we did not find any statistically significant association between the adequacy of the early phase pharmacotherapy and subsequently being retired due to the illness. Several factors may be behind this finding. Our treatment follow-up time was not long enough to rule out possible chronicity or recurrence(s) of major depression. More interestingly, this may be related to well-documented difficulties in the long-term treatment of major depression in clinical practice. Selfperceived need of help is surprisingly low among depressive patients (Isometsa¨ et al., 1997), and noncompliance is common for many reasons (Ramana et al., 1999). Effectiveness studies on the long-term treatment of major depression with work ability as an outcome measure in a naturalistic setting are still needed.
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