Vol. 5, No. 4, 1970 B. Rorsman: Disability of Psychiatric Patients 219

Disability of Psychiatric Patients BIRGITTA RORSMAN

Psychiatric Research Center, University of Lund, Sweden

Summary. In Sweden, all inhabitants over 16 years of age are covered by compulsory insurance and registered by the public insurance funds. Earlier investigations of Swedish Na- tional Health Insurance materials have shown that mental disorder is a common cause of disability pension and long term sickness benefit. The purpose of the present study was to estimate the magnitude of disability in persons with a history of psychiatric contact. - - The material consisted of a geo- graphically defined subsample of a randomized series of psy- chiatric patients. The local National Health Insurance records were used for estimating the rate of sickness. The amount of sickness benefit given to 194 patients (74 men and 120 women) treated at a department of psychiatry in 1962 was studied during the subsequent four years. Controls matched for sex, age and domicile were obtained from the local branches of the National Health Insurance Service. Disability pension was granted to 9 men and 15 women in the patient group, and to 4 men and 1 women in the control group. The average number of sickness benefit days per year was 4.9 times larger for male patients and 3.4 times larger for female patients, than for the corresponding controls. The higher sickness reporting in men was due to both psychiatric and physical illness. In women only si&ness reporting because of psychiatric illness was sig- nificantly increased.

R~surnd. En Su6de, tousles habitants de plus de 16 ans sont couverts par une assurance obligatoire et sont inscrits au fonds d'assurance publique. Des investigations ant6rieures dans les dossiers de l'Assurance maladie nationale su6doise ont montr6 que les troubles psychiques sont une cause fr6quente de rente invalidit~ et d'indemnit6 pour maladie ~ long terme. La pr&ente &ude se propose d'estimer le degr6 d'invalidit6 des personnes prdsentant une anamnhse psychiatrique. - - Le matt- riel de l'&ude consiste en un &hantillon g6ographiquement d6fini de patients psychiatriques choisis au hasard. On a utilis6 les dossiers du bureau local de l'Assurance maladie nationale pour ~valuer le taux de maladie. On a &udi~ pendant 4 ann~es cons~cutives le montant des indemnitds vers&s ~ 194 patients (74 hommes et 120 femmes) soignds dans un service psychia- trique en 1962. Des cas contr61es quant au sexe, h l'fige et au domicile ont &6 obtenus dans les agences locales de l'Assurance

maladie nationale. Une rente invalidit6 a dtd accordde ~t 9 hom- mes et 15 femmes du groupe des patients, et ~i 4 hommes et 1 femme du groupe de contr61e. Le hombre moyen de journdes

p , p p �9 de maladie par annee s est avere 4,9 fols plus grand chez les patients hommes, et 3,4 fois plus grand chez les patientes fern- rues que dans les groupes de contr61e correspondants. Chez les hommes, le plus grand hombre de ddclarations de maladie &aient dues ~t la fois ~ des affections psychiatriques et ~t des affections physiques. Chez les femmes, seules les d&larations de maladie pour affections psychiatriques avaient augmentd de facon significative.

Zusarnrnenfassung. In Schweden werden alle Einwohner fiber 16 Jahre durch eine Pflichtversicherung erfaf~t und durch die 6ffentlichen Versicherungsfonds registriert. Frfihere Unter- suchungen des Materials aus der staatlichen schwedischen Ge- sundheitsversicherung haben gezeigt, dat~ seelische St6rungen ein i.iblicher Grund ffir eine Rente wegen Arbeitsunf~ihigkeit und ffir langdauernden Krankheitsgewinn sind. Das Ziel der gegenw~irtigen Untersuchung war es, den Umfang der Unfiihig- keit yon Personen mit l~.ngerem psychiatrischen Kontakt einzu- sch~itzen. - - Das Material bestand aus einer geographisch deft- nierten Untergruppe einer randomisierten Serie psychiatrischer Patienten. Die Berichte der lokalen staatlichen Gesundheitsver- sicherung werden ffir die Einsch~itzung des Krankheitsausmages benutzt. Der Umfang der Krankenunterstiitzung, den 194 Pa- tienten (74 M~inner und 120 Frauen) bekamen, die 1962 in einer psychiatrischen Einrichtung behandelt wurden, wurde wiihrend der darauffolgenden 4 Jahre untersucht. Kontrollgruppen, die in bezug auf Geschle&t, Alter und Wohngegend zusammen- gestellt wurden, erhielt man yon den lokalen Zweigstellen des staatlichen Gesundheitsversicherungsdienstes. Krankenrenten wurden 9 M~innern und 15 Frauen in der Patientengruppe und 4 Miinnern und 1 Frau in der Kontrollgruppe gew~ihrt. Die durchschnittli&e Anzahl yon Krankenurlaubstagen pro Jahr war bei den m~innlichen Patienten 4,9real und bei den weib- lichen Patienten 3,4mal gr~Sger als fiir die entsprechenden Kon- trollf~ille. Die h~iufigere Krankmeldung bei Miinnern war so- wohl psychischer wie k6rperlicher Krankheit zuzuschreiben. Bei Frauen war nut die Krankmeldung wegen psychischer Krank- heit signifikant h~iufiger.

In Sweden, about 40% of the disability pensions are paid on account of mental illness, mental retar- dation and psychosis being the main cause (Inghe, 1967). Investigations of Swedish National Health Insurance materials have also shown that mental disorder is a common cause of prolonged sickness (Giilich, 1963; Areschoug et al., 1962). Further defi- nition of the relative importance of various psychi- atric diseases as causes for reporting sick seems to be of importance. The purpose of the present study was to measure the disability of patients previously treated at a psychiatric department of a university hospital where the majority of the patients treated suffered from milder nervous diseases.

Material and Methods

The material consisted of 194 patients--74 men and 120 women--treated at Psychiatric Depart- ment I, the Lasarett in Lund. It is a university de- partment attached to a general hospital and has 105 beds, as well as an out-patient clinic, and is

primarily intended for treatment of minor mental conditions, such as neurosis, depression, and mild forms of alcoholism. No special formality is required for admission and discharge and the department has no "'right of retention". The city has a mental hospi- tal with a research clinic especially concerned with schizophrenic disorders. Psychoses and other severe mental conditions therefore constitute quite a small part of the present patient sample.

In Sweden, all inhabitants over 16 years of age are covered by compulsory insurance and registered by the public insurance funds. Sickness benefits com- prise medical benefits payable to all insured persons and a daily allowance payable to certain insured persons (for further details, see National Insurance, The Official Statistics of Sweden, summary in En- glish). In the present investigation, the local Na- tional Health Insurance records, where reports of si&ness and the examining doctor's diagnosis are noted, were used for estimating the rate of sickness.

220 B. Rorsman: Disability of Psychiatric Patients Social Psychiatry

Table 1. Age and diagnosis of the men

Age (1963) Psychoses Depressive Mixed Alco- Organic Per- Mental No Total neuroses neuroses holism brain sonality retar- psychiatric

syndrome disorder dation illness b

17--19 2 1 3 20--24 4 3 ~ 1 8 25--29 1 2 1 4 30--34 2 3 5 35--39 1 2 5 6 ~ 14 40--44 1 ~ 2 4 1 8 45--49 2 2 3 ~ 7 50--54 1 1 4 1 7 55--59 1 5 1 3 1 11 6O--63 I 3 1 2 7

Total 3 12 23 26 6 1 3 74

One of these patients died. b Patients with various physical conditions, sent for psychiatric assessment.

Table 2. Age and diagnosis of the women

Age (1963) Psychoses Depressive Mixed Alco- Organic Per- Mental No Total neuroses neuroses holism brain sonality retar- psychiatric

syndrome disorder dation illness b

17--19 1 2 1 4 20--24 3 3 2 2 10 25--29 1 4 1 1 7 30--34 1 11 3 15 35--39 4 12 1 1 4 22 4O--44 8 ~ 5 1 14 45--49 4 10 5 1 20 50--54 7 3 1 2 13 55--59 1 3 3 2 9 60--63 6 6

Total 5 44 48 1 4 5 13 120

a One of these patients died. b Problems of termination of pregnancy and various physical diseases, sent for psychiatric assessment.

Out of 3,653 patients, constituting all patients who were treated at the Psychiatric Out-patient Department of the Lasarett in Lund or were admit- ted as in-patients during 1962, a sample was chosen whose birth date ended in 2. Of these, patients who were born between 1900 and 1946 and who lived in MalmShus County were investigated concerning sickness records during the period 1963 up to and including 1966. The object of using only those born between 1900 and 1946 was to obtain a patient sample all of whom were included in the National Insurance Scheme and none of whom was in receipt of an old age pension.

Information about the patient's sickness records, pension if any, civil status, and income was obtained through the Central National Health Insurance Of- fice in Lund. Each patient was matched by a control registered in the same local branch of the National Health Insurance Service, with the same sex and age (within a few days), and similar information was obtained for the controls concerning sickness record and socio-economic condition.

Of the 74 male patients, 19 were bachelors, 49 were married, 5 divorced, and 1 a widower; corre- sponding figures for the male controls were 16, 51, 5 and 2. For the 120 female patients, the figures were 24, 78, 11, and 7; for the female controls 20, 93, 1, and 6.

Based on information about class of daily allow- ance, the average annual income was calculated dur- ing the four years for patients and their controls. During the observation period, 19 patients and 11 controls were periodically "'0-classed", which means an annual income less than 1800 Sw. Kronor. 0-classification involves no daily allowance, which means that only illness resulting in hospitalization could be taken into account for these persons. The average income when 0-class time was deducted was similar for patients and their controls. Grouping of the sickness diagnoses was done according to the International Classification of Diseases, seventh edition.

The psychiatric diagnoses were based on the records of the hospital. The largest group, mixed neuroses, is naturally very heterogeneous, anxiety and asthenia being the main symptoms of illness. The depressive group contains only non-psychotic depression. Those in whom alcoholism was the main cause for contact with the psychiatric clinic were diagnosed as alcoholics. The term "'no psychiatric illness" was used mainly for patients with various somatic diseases referred for psychiatric assessment, and to problems connected with termination of preg- nancy.

Table 1 and 2 give the psychiatric diagnoses and age distribution of the male and female patients.

Vol. 5, No. 4, 1970 B. Rorsman: Disability of Psychiatric Patients 221

As can be seen from the tables, one woman and four men died during the observation period. All were out-patients. Cardiac insufficiency caused the death of one man; suicide accounted for the others. Thus 189 patients (70 men and 119 women) re- mained in the sample; of these, 32 were in-patients and 157 out-patients.

Results

The average survival t i m e - - f r o m 1 January 1 9 6 3 - of the patients who died during the obser- vation period was two years and eleven months, and their average sick record period was seven months. The average sick record period of the control persons during the corresponding period was twelve days.

Of the 189 patients who survived the entire ob- servation period, 9 men and 15 women were, or became, during the observation period disability pensioned. Among the controls, disability pensions were awarded to 4 men and 1 woman.

The age distribution of those pensioned accord- ing to age when the pension was granted is given in table 3.

The psychiatric diagnoses among the pensioned patients were: Psychosis, 1 man and 2 women; De- pression, 2 men and 5 women; Mixed-neuroses, I man and 4 women; Organic brain syndrome, 3 men and 1 woman; Personality disorders, Intellectual reduc- tion, and No psychiatric illness, each 1 woman; Alco- holism, 2 men.

Reason for pension for the men: one was based on the psychiatric condition, one on the physical, and seven were due to combined psychiatric and physical conditions. For the women: eleven were based solely on mental disorder, two solely on physi- cal, and two on combined psychiatric and physical conditions. Two of the five persons in the control group who were granted disability pensions had psychiatric diagnoses: one schizophrenia and one intellectual defect. Disability pensioned patients and those whose controls were pensioned during the ob- servation period were not included in the following calculations.

For comparison between sickness reporting by patients and their controls, the annual average sick record time was calculated. Wilcoxon's signed Rank test was used in the statistical processing (Dixon and Massey). At the first working up of the sickness record conditions, an investigation was carried out concerning whether any difference existed between the various years 1963 to 1966. No difference was revealed; all calculations were therefore made on the total sickness records 1963 to 1966.

Table 4 shows the distribution of sickness report- ing by patients and controls. During the four years, 44 of the male patients had reported sick on one or more occasions, whereas 13 had not. Corresponding figures for the male control persons were 31 and 26. Of the female patients, 79 had reported sick on some occasion during the four years, 24 had not. Corre-

Table 3. Patients and controls with disability pension. Age when pension began

Patients Controls Age Men Women Men Women

16--19 1 20--24 1 25--29 30--34 1 1 35--39 1 1 4O--44 3 1 45--49 1 2 50--54 1 3 1 55--59 5 3 1 60--63 1 1

Total 9 15 4 1

Table 4. Patients and controls grouped according to average number of sickness benefit days per year

Number of subjects Number Men Women of days Patients Controls Patients Controls

0 13 26 24 39 i - - 7 10 17 19 32 8--28 19 9 24 23

~ 2 8 15 5 36 9

Table 5. Average number of sickness benefit clays per year for patients and controls

Diagnosis Average annual number of sickness benefit days

Men Women Patients Controls Patients Controls

Psychosis 83 4 102 Depressive

neuroses 16 3 37 11 Mixed neuroses 43 5 28 9 Alcoholism 28 10 Organic brain

syndrome 61 5 Personality

disorder 15 23 78 16 Mental

retardation 20 1 No psychiatric

illness 9 0 23 13

Total 34 7 34 10

sponding figures for the female control persons were 64 and 39. Among the male patients 15 had more than 28 sickness benefit days per year compared to 5 of the male controls. 36 female patients had more than 28 sickness benefit days per year compared to 9 female controls.

Table 5 shows the average number of sickness benefit days per year for patients in the various psychiatric diagnosis groups and their controls. The number was 4.9 times larger for male patients and 3.4 times larger for female patients than for the cor- responding controls. Wilcoxon's signed Rank test showed that sick reporting was more extensive by the patients than by the controls (p<0.001).

222 B. Rorsman: Disability of Psychiatric Patients Social Psychiatry

Table 6. Average number of sickness benefit days per year caused by different diseases. (Number o[ patients in parentheses)

Sick-report diagnoses Men Women Mixed Controls Alco- Controls Depressive Controls Mixed neuroses holism neuroses neuroses (20) (21) (38) (45)

Controls

Mental disorders 14 0 5 0 13 0 11 2 Diseases of respiratory system 11 1 2 5 2 1 2 1 Diseases of digestive system 7 2 4 1 1 1 0 1 Diseases of bones and

organs of movement 5 0 2 1 9 1 4 2 Accidents 4 1 6 3 2 3 2 1 Others 2 1 9 0 10 5 8 2

Total 43 5 28 10 37 11 27 9

At the statistical analysis of various psychiatric diagnosis groups, it appeared that men with depres- sive neurosis showed a slightly increased sick report- ing (p<0.05). Men with mixed-neuroses, and men with alcoholism had a significantly increased sick reporting (p<0.001). Concerning the men with de- pressive neurosis, it must be observed that the differ- ence between patients and controls is largely deter- mined by remarkably low sickness reporting by the controls (cf. National Insurance 1966). Women with depressive neuroses and women with mixed-neuro- ses had a significantly increased sick reporting (p <0.001); other groups were too small for statisti- cal analysis.

Table 6 shows sickness reporting because of psy- chiatric disorder and because of the quantitatively most important organic disorders in the patient groups large enough to allow an analysis. Both men- tal and organic disorders caused more sick reporting among the patients than among the controls. Statis- tical analysis showed a significant tendency for sick- ness reporting of both psychiatric and physical dis- orders among male patients with mixed-neuroses and among alcoholics (p<0.01). However, among women, only the tendency for sickness reporting of mental disorders was significant (p<0.001 in de- pressive neuroses, p < 0.05 in mixed-neuroses).

Discussion

The investigation has revealed a high degree of disability in "minor" psychiatric illness. Disability pension was often granted to people in the sample; particularly in age groups where the disability required pension for many years. Also disorders causing shorter periods of disability proved to be overrepresented in the patient sample.

The higher sickness reporting of mental disorders by patients with previous psychiatric contact could be an expression of chronicity or of a tendency to recurrence. The sickness reporting in this study, how- ever, was only to an insignificant extent a direct continuation of sickness reporting in 1962 and no difference existed between the individual years 1963 to 1966. Patients with a chronic disease and with

prolonged sickness reporting were mainly repre- sented in the group who received disability pension.

Several workers have suggested that psychiatric patients suffer more physical illness than other people. The literature has recently been reviewed by Shephard et al., who in an investigation of patients in a general practice found a positive association be- tween psychiatric disturbance and physical illness. In this study the higher sickness reporting was due to both psychiatric and organic illness in men, where- as in women only sickness reporting because of psy- chiatric illness was significantly increased.

The present investigation naturally reflects the occurrence of reduced capacity for work on account of illness but several factors influence the sick record frequency in any study: e. g., the state of the labour market, the social welfare system of the country, and the attitudes of the physicians. From a purely medical point of view, an investigation based on sickness reported days is of limited value. One and the same illness causes different degrees of disability in different persons and under different conditions. In addition, the sickness reporting certificates do not require defined diagnoses, and information obtained about the illness is often vague. The present study was carried out in order to estimate the magnitude of disability in persons with a history of psychiatric contact and illustrates the problem primarily from the socio-medical aspect. A further definition of the importance of the minor mental insufficiencies for disability could be obtained by an investigation of a total population previously studied with regard to psychiatric symptoms (Essen-M611er, 1956; Hagnell, 1966).

Medicine is becoming increasingly concerned with the long-term functioning of "the chronic-sick" in the community. The need for rehabilitation is generally accepted, but resources are still limited and the indications and methods are not generally agreed upon. The results of this study can be helpful in planning investigations into the rehabilitation of psychiatric patients. The size of the present patient material made it possible to obtain certain significant results, but it is also evident that the number of

I1ol. 5, No. 4, 1970 B. Rorsman: Disability of Psychiatric Patients 223

patients must be considerably increased if the effects of different rehabilitation procedures are to be com- pared.

R e f e r e n c e s

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Dixon, W. J., Massay, F. J.: Introduction to Statistical Analy- sis. 2nd ed. New York: McGraw Hill 1957.

Essen-MBller, E.: Individual traits and morbidity in a Swedish rural population. Acta psychiat, et neurolog, scand suppl. 100. Copenhagen: Munksgaard 1956.

Giilich, T.: En granskning av 90-dagars sjukfall. Tidskrift f~r allmiin fSrs~ikring 56, 170--184 (1963).

Giilich, T.: Sjukm~Snstret inom Malm6hus liin. L~ikartidningen 66, 1127--1133 (1969).

Hagnell, O.: A prospective study of the incidence of mental disorder. Lund: Scandinavian University Books, Stockholm 1966. In USA: Humanities Press. Inc. Park Ave. South, New York.

Inghe, G.: Problemets omfattning. Socialmed. T. 44, 55 (1967). Shepherd, M., Cooper, A., Brown, C., Kalton, G. W.: Psychi-

atric Illness in General Practice. London: Oxford Univer- sity Press 1966.

Sveriges officiella statistik. Allm~in F/Srsakring 1966. Stock- holm: RiksfBrs~ikringsverket 1968.

W. H. O.: International classification of diseases. Geneva 1957. Birgitta Rorsman Psychiatric Research Center University of Lund S:t Lars Hospital Lund, Sweden