School dropout and mental illness. Cause, effect, or both? Arnstein Mykletun Norwegian Institute of Public Health

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1 School dropout and mental illness. Cause, effect, or both? Arnstein Mykletun Norwegian Institute of Public Health

2 Well established associaiton between educational level and mental disorder Bjelland, Krokstad, Mykletun, Dahl, Tell, Tambs. Soc Sci Med 2008.

3 First onset of mental disorders usually occurs in childhood or adolescence Kessler et al. Curr Opin Psychiatry 2008.

4 Adolescent emotional symptoms (youth reports) ES = 0.36; p <.001 ES = 0.13; p =.06 Collishaw et al (2010). Trends in adolescent emotional problems in England. J Child Psychol Psych, 51,

5 School dropout and mental illness: Cause, effect or both? Intervention? Lessons from occupational mental health

6 The two competing paradigms in occupational mental health

7 Traditional perspective Mental disorder Sickness absence (and treatment) Cure and return to work

8 Symptoms of common mental disorder predict sickness absence and disability beneftis Population based health study Registry of disability pension award during follow-up Mykletun et al. Amercian Journal of Psychiatry, Knudsen et al. Acta Psych Scand Mykletun et al. Psychosomatic Medicine Øverland et al. Sleep, Sivertsen et al. American Journal of Epidemiology, 2006.

9 Treatment and under-treatment According to medical records One attempt, one drug only Isometsa et al. Am J Psychiatry, Honkonen et al. J Clinical Psychiatry, Self-report after disability pension is award 32% claimed no treatment ever Overland et al. Psychiatric Services, 2007.

10 There is good quality evidence that universally delivered workplace mental health interventions can reduce the level of depression symptoms among workers.

11 Work-place risk factors for mental disorder: The Karasek & Theorell model

12 The Karasek og Theorell model Demand low high Control low high

13 The Karasek og Theorell model Demand low high Control low high

14 The Karasek og Theorell model Demand low High Control low high Strain

15 CMD and job strain high low control low high demand Sanne, Mykletun, Dahl, Moen, Tell. Occup Med 2005.

16 CMD and later sickness absence Wang, Mykletun, Møyner et al. PLoS One. 2014

17 Challenging the traditional perspective Mental disorder Sickness absence (and treatment) Cure and return to work

18 Calling upon clinical solutions may become an Achilles heel The majority with common mental disorders are actually at work Under-treatment will not find a solution soon Symptom reduction following treatment does not translate into return to work The most common GP response to CMD is sickness absence

19 Supported Employment (SE) Individual Placement and Support (IPS) «Train-and-place»versus «Place and train»

20 Relative risk of competitive employment within months of receiving IPS compared to standard vocational rehabilitation % Author Year Country RR (95% CI) Weight Non-USA Studies Burns et al England Germany Italy Switzerland Netherlands Bulgaria Heslin et al. Hoffmann et al United Kingdom Switzerland Tsang et al. Wong et al Hong Kong Hong Kong Subtotal (I-squared = 37.7%, p = 0.108). USA Studies Bond et al USA Drake et al USA Drake et al USA Lehman et al. Mueser et al USA USA Subtotal (I-squared = 76.3%, p = 0.002). Overall (I-squared = 58.1%, p = 0.003) NOTE: Weights are from random effects analysis 3.00 (1.12, 8.05) 1.27 (0.72, 2.26) 2.00 (1.04, 3.84) 6.00 (1.49, 24.20) 1.29 (0.56, 2.93) 2.00 (1.23, 3.26) 1.91 (0.98, 3.74) 2.26 (1.36, 3.78) 7.37 (2.78, 19.52) 2.00 (1.05, 3.79) 2.14 (1.61, 2.83) 2.23 (1.64, 3.02) 1.94 (1.41, 2.66) 6.60 (3.18, 13.69) 4.15 (1.91, 9.03) 4.19 (2.46, 7.12) 3.18 (2.06, 4.90) 2.50 (1.97, 3.18) Mondini et al. Under review Lancet Psychiatry

21 Total sickness absence Kilde: Tall hentet fra NAVs notatserie. Kun legemeldt sykefravær inngår. Tall i prosent.

22 Part time sickness absence Total sickness absence Mykletun et al. FHI report 2013.

23 Kilde: Markussen, Mykletun, Røed. IZA DP No 5343 Senere publisert som Markussen, Mykletun, Røed (2012). The Case for Presenteeism. Journal of Public Economics, 96( ),

24 Total sickness absence Kilde: Markussen, Mykletun, Røed. IZA DP No 5343 Senere publisert som Markussen, Mykletun, Røed (2012). The Case for Presenteeism. Journal of Public Economics, 96( ),

25 Proportion still holding a job t+2 years Kilde: Markussen, Mykletun, Røed. IZA DP No 5343 Senere publisert som Markussen, Mykletun, Røed (2012). The Case for Presenteeism. Journal of Public Economics, 96( ),

26

27 CMD and school dropout Cause, effect, or both?

28 About 46% of high school noncompletion in the US may be attributed to psychiatric disorders Vander Stoep et al. J Beh Health Serv & Res. 2003

29 Preliminary findings Linkge study between health survey and registry data As expected: We find increased CMD related to educational attainment (n=7968, age 30-46) Melkevik et al. In prep.

30 Does mental disorder predict dropout? Record linkage, data from n=8113, age Registry information on later educational attainment

31 Does mental disorder predict dropout? Record linkage, data from n=8113, age Registry information on later educational attainment No effect of internalizing problems (HSCL-5) Effects as expected of attention problems and conduct problems Evensen et al. Under review.

32 Externalizing problems are well established risk factor for school dropout Galera et al. Psychological Med Van Der Kolk et al. J Ment H Policy and Economics 2011.

33 Systematic review CMD and dropout We found 4 prospective studies 3 trajectory studies 7 retrospective Limited support for an effect of CMD on school dropout Melkevik et al. Under review.

34 Implications for interventions? George Patton ( ): Late development of impulse control Prevention of CMD and dropout simply by preventing school absence?

35 Thank

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