Unemployment and Early Cause-Specific Mortality: A Study Based on the Swedish Twin Registry

Margaretha Voss, PhD, MPH; Lotta Nylén, MPH; Birgitta Floderus, PhD; Finn Diderichsen, MD, PhD; Paul D. Terry, PhD


Am J Public Health. 2004;94(12) 

In This Article

Abstract and Introduction

Objectives: We investigated the association between unemployment and early cause-specific mortality to determine whether the relationship was modified by other risk indicators.
Methods: Female and male twins (n=20632) were followed with regard to mortality from 1973 through 1996. Questionnaire data from 1973 were used to obtain information on experience of unemployment and on social, behavioral, health, and personality characteristics.
Results: Unemployment was associated with an increased risk of suicide and death from undetermined causes. Low education, personality characteristics, use of sleeping pills or tranquilizers, and serious or long-lasting illness tended to strengthen the association between unemployment and early mortality.
Conclusions: An increased risk of death from external causes implies a need for support for those experiencing unemployment, particularly susceptible individuals.

Loss of a job has pronounced negative effects on an individual's life situation.[1,2,3,4,5,6,7,8,9,10] Several studies have shown an increased risk of early mortality among the unemployed, but the nature of this association is not clear.[1,2,6,7,8,11,12,13,14,15,16,17] To better understand the relationship between unemployment and mortality, one should consider the meaning of employment beyond earning a living, including the impact on lifestyle, self-image, social integration, and psychological well-being.[3,18] Unemployment entails an increase in general distress, anxiety, and depression and a decrease in activity,[4,7,8,17] which in the long run may increase the risk of early death.

The excess risk of mortality associated with unemployment has been attributed mainly to external causes of death, including suicide and undetermined causes[1,2,4,5,7,8,9,12,13,16,19,20]; diseases of the circulatory system[1,21,22,23]; and lung cancer.[2,10,12,21,24]

Mortality rates seem to increase with the duration of unemployment[1,12,17] and are higher for the unemployed than the employed in all social classes.[6,20] Several studies have suggested that unemployment has a direct effect on health over and above the effects of socioeconomic status, poverty, risk behaviors, or prior ill health.[1,2,3,6,16,20,21,25] Unemployment has also been suggested as more important than other socioeconomic variables as a risk factor for premature death.[20]

It has been suggested that when unemployment rates are low, those with impaired health status are more likely than healthy people to become unemployed.[1,26,27] In Sweden, unemployment was by all international standards low (2%-4%) between 1950 and 1990 but increased to about 8% during the1990s.[18]

Individuals actively employed may have better health status on average than those outside the workforce because healthy individuals are more likely to enter the workforce. Employees with impaired health or certain risk indicators, such as high alcohol consumption, may also be more likely to lose their jobs. The effect of unemployment on mortality could therefore also be attributable to confounding from other risk factors.[11,12,21,24,25,28] In earlier studies, analyses took into account demographic and social characteristics to some extent,[2,11,16,21,29] while adjustment for potential confounding from other factors was limited.

We have previously shown an increased risk of overall early mortality (i.e., before 70 years of age) among individuals who experienced unemployment.[29] The results were similar for women and men, which could reflect that losing or holding a job is equally important among both Swedish men and women. In Denmark, which has a similar labor market, relative risks of about the same magnitude among unemployed men and women were reported.[9]

In our study, we extended the analyses to specific causes of death, accounting for potential confounding from social, behavioral, health, and personality characteristics. We also studied the relation between unemployment and total mortality using pairs of twins, one of whom had experienced employment while the other had not, thus controlling for genetic factors and for social and environmental conditions during childhood and youth. An additional aim was to analyze to what extent the effect of unemployment was modified by the presence of other risk indicators of early mortality. The study was performed with information from the Swedish twin registry.[30]


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