Labour market marginalisation in young refugees and their majority peers in Denmark and Sweden: The role of common mental disorders and secondary school completion

Christopher Jamil de Montgomery; Marie Norredam; Allan Krasnik; Jørgen Holm Petersen; Emma Björkenstam; Lisa Berg; Anders Hjern; Marit Sijbrandij; Peter Klimek; Ellenor Mittendorfer-Rutz

doi:10.1371/journal.pone.0263450

Peer Review History

Original SubmissionJune 15, 2021
30 Dec 2021 Decision Letter - Gerard Hutchinson, Editor PONE-D-21-19639Labour market marginalisation in young refugees and their majority peers in Denmark and Sweden: The role of common mental disorders and secondary school completionPLOS ONE Dear Dr. Jamil de Montgomery Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Plaease address the points raised by the reviewer particularly the rigour of detrmining the influence of mental health issues in the analysis. Please submit your revised manuscript by Feb 13, 2022 If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Well written paper on an important topic. Minor suggestions to consider. 1) Rationale for using dichotomous indicators for labour market marginalisation is missing. Authors refer to the paper by Bäckman et al, but it would important to explain to readers why certain cut-offs (e.g., "labour market income of less than 12.5% of the median") were chosen. 2) Although common mental disorders typically refer to anxiety and depressive disorders, did authors consider also analysing substance abuse or psychotic disorders? 3) Was there any systematic difference in results between inpatient or outpatient versus antidepressants? I would assume that antidepressant would capture also less severe cases. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. 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Revision 1
7 Jan 2022 Author Response Response to reviewers related to manuscript PONE-D-21-19639 Dear Editor and Reviewer, Thank you for taking the time to process and review our manuscript and for the comments provided. In the following, we respond to each comment. 1. Rationale for using dichotomous indicators for labour market marginalisation is missing. Authors refer to the paper by Bäckman et al, but it would important to explain to readers why certain cut-offs (e.g., "labour market income of less than 12.5% of the median") were chosen. Response: Thank you for this comment. We agree these methodological choices could be made more transparent to the reader. We have therefore added the following sentences to the methods section (new text in italics): “In Bäckman et al.’s definition, 12.5% of the median labour market income is a pragmatic cut-off between labour market positions defined as no or negligible labour market participation and part-time or unstable work. While a full-time income at a low salary corresponds approximately to 87.5% of the median labour market income, 12.5% represents an annual income below what would be earned in 2 months in such a position. Additionally, those with an income from disability pensions of at least 25% of the median labour market income (which corresponds to approximately half a year of full-time disability pension) and those registered as unemployed for at least 180 days during the year (more than half the year) were also included in the LMM category. Although the precise cut-off values to a certain extent are arbitrary, these definitions have been used in several other Nordic comparative studies of labour market marginalization (31,33,34) and aligning the definitions across studies facilitates comparisons.” Reference 31 was already included on the list of references, while references 33 and 34 have been added: “33. Lorentzen T, Bäckman O, Ilmakunnas I, Kauppinen T. Pathways to adulthood: Sequences in the school-to-work transition in Finland, Norway and Sweden. Soc Indic Res. 2019;141(3):1285–305. 34. Jakobsen V, Korpi T, Lorentzen T. Immigration and integration policy and labour market attainment among immigrants to Scandinavia. Eur J Popul. 2019;35(2):305–28.” 2. Although common mental disorders typically refer to anxiety and depressive disorders, did authors consider also analysing substance abuse or psychotic disorders? Response: It is very probable that the trends would be different for other disorders. As our project was originally conceived (and funded!), our focus was on common mental disorders specifically, and our study is one among several using this definition (including depressive disorders and purchases of anti-depressives, anxiety disorders, obsessive-compulsive disorders, and disorders related to severe stress). Our findings have however led us to extend our focus to other disorders, such as psychotic disorders, for future papers. Care pathways are plausibly different for psychotic disorders due to severity, and we do observe higher rates of contact among young refugees for psychosis-related disorders than among their peers. We do not find it feasible to include an analysis of psychotic disorders in the present manuscript as it, to us, represents another research question that we want to explore in its own right. But we have added the following sentence to the discussion (page 18): “Trends may also be different for other kinds of disorders, e.g. psychotic disorders, which are less common and may entail different healthcare pathways than the disorders included in this study.” 3. Was there any systematic difference in results between inpatient or outpatient versus antidepressants? I would assume that antidepressant would capture also less severe cases. Response: This is a good point. We write in the discussion that 90% of youth with a CMD contact had purchased antidepressant medication, except for refugees in Sweden for whom it was 70% (page 17). On the one hand, this means that the results, largely, were driven by youth who had purchased antidepressant medication. On the other hand, it means that youth who had a hospital contact but had not purchased antidepressant medication were a very small sub-group. So even if they did have higher risks of marginalization (as more severe cases) and even if the pattern of utilization was different among refugees and majority youth, their contribution to the overall inequality in labor market marginalization would be small. We have in fact checked to see whether the distribution of CMD contacts indicated through the patient registry (in and outpatient contacts) and through the pharmaceutical registry (anti-depressants) differed for refugees and majority youth. For all three variables, the original composite variable used in the manuscript, the hospital contact variable and the anti-depressants variable, the proportion with a contact was larger in the majority population than in the refugee population. We have added this information to the methods and results sections: Methods section (page 7): “As a sensitivity analysis, we also investigated whether contact patterns differed between the populations when considering hospital contacts (in- or outpatient) and antidepressant purchases separately.” Results section (page 10): “In both Denmark and Sweden, the proportion of youth with CMD was larger in the majority population than in the refugee population. This pattern was consistent whether CMD was defined based on hospital contacts alone, purchases of antidepressants alone, or both combined (not shown). The difference was larger among girls than boys in both countries.” As we conclude that our registry-based CMD variable does not capture the higher mental health vulnerability of refugees as compared with their peers, it does not seem relevant to add further sub-analyses to the study as neither definition singles out refugees as particularly vulnerable. However, we do find this “non-finding” of the explanatory power of a registry-based CMD variable very relevant to the field as such variables are often used. Indeed, having a CMD-related contact (hospital or medicine) does have explanatory power in terms of labor market marginalization in both the refugee and the majority population; but given differences in utilization of psychiatric services, it does not contribute to explain socio-economic inequality between the two groups of young individuals, even though we know from a host of other studies that refugees are particularly vulnerable to mental distress and disorders. Other changes To align with journal requirements, we have also made the following changes to the manuscript: • Formatting of headings • Correction of title page formatting • Key words removed from abstract page • Funding and competing interests information moved • Reference style updated • Figure references updated • Naming of supplementary files updated and captions added at the end of manuscript • The ethics statement has been updated to include information about anonymization and informed consent Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0263450.r002
20 Jan 2022 Decision Letter - Gerard Hutchinson, Editor Labour market marginalisation in young refugees and their majority peers in Denmark and Sweden: The role of common mental disorders and secondary school completion PONE-D-21-19639R1 Dear Dr. Jamil de Montgomery We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Gerard Hutchinson, MD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for answering all my comments. I have no further comments. Thank you for answering all my comments. I have no further comments. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No https://doi.org/10.1371/journal.pone.0263450.r003
Formally Accepted
25 Jan 2022 Acceptance Letter - Gerard Hutchinson, Editor PONE-D-21-19639R1 Labour market marginalisation in young refugees and their majority peers in Denmark and Sweden: The role of common mental disorders and secondary school completion Dear Dr. de Montgomery: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Gerard Hutchinson Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0263450.r004

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