The length of unemployment predicts mortality, differently in men and women, and by cause of death: a six year mortality follow-up of the Swedish 1992-1996 recession

This study examines the relationship between the total amount of accumulated unemployment during the deep Swedish recession of 1992-1996 and mortality in the following 6 years. Nearly 3.4 million Swedish men and women, born between 1931 and 1965 who were gainfully employed at the time of the 1990 census were included. Almost 23% of these individuals were unemployed at some point during the recession. We conduct a prospective cohort study utilizing Cox proportional hazard regression with a mortality follow-up from January 1997 to December 2002. We adjust for health status (1982-1991), baseline (1991) social, family, and employer characteristics of individuals before the recession. The findings suggest that long-term unemployment is related to elevated all-cause mortality for men and women. The excess mortality effects were small for women and attributable to a positive, linear increase in the hazard of alcohol disease-related mortality and external causes-of-death not classified as suicides or transport accidents. For men, the excess hazard of all-cause mortality was best represented by a cubic, non-linear shape. The predicted hazard increases rapidly with the shortest and longest accumulated levels of unemployment. However, the underlying pattern differed by cause-of-death. The cancer, circulatory, and alcohol disease-related analyses suggest that mortality peaks with mid-levels of accumulated unemployment and then declines with longer duration unemployment. For men, we observed a positive, linear increase in the hazard ratios associated with transport and suicide mortality, and a very steep non-linear increase in the excess hazard ratio associated with other external causes of death that were not classified as suicide or transport accidents. In conclusion, mortality risk increases with the duration of unemployment among men and women. This was best described by a cubic function for men and a linear function for women. Behind this pattern, different causes-of-death varied in their relation to the accumulation of unemployment.