Abstract
Background
Mental disorders and low socioeconomic status (SES) drive premature mortality. Disentangling clinical severity from behavioural and structural pathways requires robust longitudinal data. We developed an administrative database and population-based survey linkage model to analyse these associations in Slovenia.
Methods
This retrospective cohort study linked the 2014 and 2019 Slovenian European Health Interview Surveys (EHIS) to national hospital, prescription, sick leave, and mortality registries (follow-up to 2023; N = 13,737). A composite Mental Disorder (MD) Severity Index (None to Severe) was engineered using ICD-10 codes, ATC codes, and PHQ-8. Hierarchical Time-Dependent Cox regression evaluated mortality across structural (SES), clinical (somatic comorbidities, MH), and behavioural pathways, adjusting for the COVID-19 pandemic.
Results
During follow-up (912 deaths), profound structural inequalities emerged: unemployment carried a 2.11-fold higher mortality hazard (95% CI, 1.40–3.21) than employment. Clinically, a dose-response was observed; Severe MD showed a 68% higher mortality risk (HR 1.68, 95% CI, 1.17–2.40) adjusting for SES and somatic health. The HR for Severe MD was attenuated to 1.33 (95% CI, 0.92–1.92) after adjusting for lifestyle mediators. The mortality penalty of unemployment was additive, not synergistic, for those with Severe MD.
Conclusions
Triangulating administrative registries with population-based health surveys provides a highly robust methodology for mental health epidemiology. Excess mortality in severe mental disorders is heavily mediated by modifiable behaviours rather than inevitable clinical decline. Furthermore, unemployment exerts a profound, independent mortality penalty across all mental health severities.
Key messages
• Excess mortality in severe mental disorders is not inevitable; it is driven by modifiable behaviours, requiring integrated lifestyle interventions in psychiatric care.
• Unemployment acts as a potent, independent driver of mortality regardless of psychiatric status, suggesting that social protection is as critical to survival as clinical treatment.