The interplay between mental wellbeing and socioeconomic factors is complex. Over forty years ago, William Eaton (1980) identified what he termed “social drift” whereby the onset of severe mental illness, which led to a loss of employment and hospitalisation, resulted in lower socioeconomic status. More recently, work led by Michael Marmot (2010) and Kate Karban (2016) has positioned mental illness as part of wider health and social inequalities; highlighting that many of the issues that we now classify as mental illness fundamentally have their roots in poverty, social inequality and injustice. The impact of austerity policies introduced by the UK Coalition Government in 2010 was two-fold in the area of mental health. Firstly, there was a reduction in services, but at the same time, pressures on individuals also led to poorer mental health.
This blog considers the findings of a recent study that examined the potential impact of experiencing mental disorders on individual participation in the labour market (Plana-Ripoll et al, 2023). The cohort study was carried out in Denmark. There are clearly significant differences between the welfare and health systems in Denmark and the UK. This means that not all the findings necessarily transfer easily from Denmark to the UK (or other countries). However, the key message is that mental disorders have a substantial impact on workforce participation and there is a wider need to invest in social programmes to mitigate this.
The onset of severe mental health difficulties can lead to hospitalisation and loss of employment.
Methods
The Danish Civil Registration System (DCRS) was established in 1968. Since then, it has kept information on all Danish residents. The DCRS includes demographic details such as date of birth and gender. Each person on the register has a unique personal identification number. This number can then be used to link to other Danish national registers, including the Danish Psychiatric Central Research Register (DPCRR). The DPCRR has details of all admissions to psychiatric inpatient units since 1969 and visits to outpatients and emergency departments since 1995.
This cohort study examined the records for 5,163,321 individuals on the DCRS. The cohort included all 18-65 year-olds living in Denmark between 1/1/1995 and 31/12/2016. The cohort did not include anyone who had taken early retirement before 1/1/1995. Individuals were included in the cohort from their 18th birthday or the date of immigration to Denmark if they did not appear on the DCRS on 1/1/1995. The tracking period ended on an individual’s 65th birthday, death, emigration, voluntary early retirement or the payment of disability pension if any of these took place before 31/12/2016. All data studied as part of this project was deidentified so that it was not possible to recognise individuals.
The retirement age in Denmark is 65. However, individuals who have paid state employment insurance for at least 30 years can take early retirement. Denmark also has a system of disability pensions. The study assumed all individuals were in the workforce until their 65th birthday unless they had died, taken voluntary early retirement or were being paid a disability pension. To estimate periods of absence from the labour market, individuals were classified as working (employed or self-employed), on an educational programme, unemployed or receiving sickness benefits. In the results, total working years lost is the average number of years people with mental disorders are not working or in education compared with the general population of the same sex and age.
The Danish system used the International Classification of Diseases (8th revision) until 31/12/93 and the 10th revision from 1/1/1994. The authors used the following categories: organic disorders, substance use disorders, schizophrenia-spectrum disorders, mood disorders, neurotic disorders, eating disorders, personality disorders, intellectual disabilities, and behavioural disorders.
Results
The study followed 2,642,383 men and 2,520,938 women for a combined total of 65.4 million person years. One person was followed for the whole length of the study: 22 years. Overall 9.47% were diagnosed with a mental disorder; 8.63% of men (n=228,054) and 10.34% of women (n=260,721).
The study highlighted the impact on involvement in the labour market. 20.71% of the cohort (n=1, 069,165) left the labour market before the age of 65 – the retirement age in Denmark. Of this group, 6.46% left due to obtaining a disability pension, 12.05% took voluntary early retirement and 2.19% died. The paper demonstrates that those with mental health diagnoses were actively working or enrolled on an educational programme for 12.79 years after diagnosis. This is compared with a figure of 23.31 years for the general population of the same sex and age. This results in a total of 10.52 working years lost.
The authors’ approach highlighted significant differences between the average working years lost and within categories of mental disorders. The overall average was 10.52 years. If one drills down, the average for substance use disorder was 14.99 years. Further analysis shows that the average for alcohol use disorder was 12.81 compared to 21.78 years for cannabis use disorder. For mood disorders, the overall average was 10.34 years. Bipolar disorder had a higher rate at 11.89. Intellectual disabilities had the highest rate at 25.55 years. For schizophrenia, the average was 24.03 years – more than double the overall average. The variation in the rates reflects both the nature of the disorder but also the wider social and cultural barriers that stigma creates.
The authors note that all types of mental disorders included in the study were associated with shorter working life. The study notes that a large proportion of people with mental disorders remained in the workforce. Changes to the Danish system, similar to those introduced in the UK and other countries, from 1998 onwards made it more difficult to access the disability pension.
The authors conclude that all mental health disorders based on ICD-10 included in the study were associated with shorter working life.
Conclusions
This study uses a range of measures to demonstrate the potential impact of a diagnosis of a mental disorder on an individual’s involvement in the labour market. In addition to the impact of mental illness itself, it is well-documented that individuals continue to face stigma when seeking employment. This study looks at exclusion from the labour market. It notes that the workplace environment itself is increasingly a source of mental distress and burnout. This trend was exacerbated by the pandemic. To tackle these issues, as well as interventions that promote employees’ mental health, a shift in focus is required so that mental health and broader welfare services address structural issues rather than focusing on individualised models of mental distress.
New employment and welfare policies are required to tackle stigma and create healthier workplace environments.
Strengths and limitations
The results from this study are in line with previous work that demonstrates the impact of mental disorders on an individual’s patterns of employment.
The authors note that there are limitations:
- The first is that the study is based on the DPCRR (Danish Psychiatric Central Research Register). This register only records those who are treated in secondary care. Those who are undiagnosed or treated solely by a GP would be misclassified as not experiencing a mental disorder.
- The length of the study is one of its strengths. However, the registers do not contain any information about remission or recovery so that the diagnosis lasts across the study.
- The final area to consider is that the Danish welfare system, though it came under pressure in this period, is generally more generous than other models. This is certainly the case when compared to the UK. Universal coverage reduces inequalities in healthcare access and provides greater economic security during periods of illness.
The study focused on secondary mental health services, so people who are undiagnosed or treated by a GP were not included.
Implications for practice
The study highlights the significant impact that a mental health diagnosis can have on employment. As well as the economic impact, there are broader considerations such as the impact on an individual’s self-esteem and the risks of social isolation. For practitioners, the study emphasizes the importance of broader support for those experiencing mental health difficulties. In the UK, these would include recognising the legal protections that the Equality Act and employment law can offer. It is important to look at other ways that professionals can support individuals including their colleagues. These include advocacy, peer mentoring and challenging stigmatising public attitudes.
Mental health practitioners should advocate for systemic support including employment and benefits.
Statement of interests
None.
Links
Primary paper
Plana-Ripoll, O., Weye, N., Knudsen, A.K., Hakulinen, C., Madsen, K.B., Christensen, M.K., Agerbo, E., Laursen, T.M., Nordentoft, M., Timmermann, A. and Whiteford, H., 2023. The association between mental disorders and subsequent years of working life: a Danish population-based cohort study. The Lancet Psychiatry, 10(1), pp.30-39. https://doi.org/10.1016/S2215-0366(22)00376-5
Other references
Eaton, W. (1980). A formal theory of selection for schizophrenia. American Journal of Sociology, 86, 149–158.
Karban, K., (2016). Developing a health inequalities approach for mental health social work. British Journal of Social Work, 47(3), pp.885-992.
Marmot, M. (Chair) (2010) Fair society, healthy lives, The Marmot Review, London: Department of Health.
