Background: There is a need for studies that follow up children and adolescents for many years post disaster since earlier studies have shown that exposure during natural disasters constitutes a risk factor for poor psychological health.Aims: The main aim was to examine whether there was an association between severity of exposures during a natural disaster experienced in childhood or adolescence and posttraumatic stress symptoms, psychological distress, self-rated health, diagnosis of depression, anxiety or worry, thoughts about or attempted suicide, physical symptoms or daily functioning eight years later in young adulthood. A second aim was to compare psychological distress and self-rated health of exposed young adults with a matched population-based sample.Method: Young adults, who experienced the 2004 tsunami as children between 10 and 15 years of age, responded to a questionnaire eight years post disaster. The results were compared to a matched population sample.Results: The results showed that the likelihood for negative psychological outcomes was higher for those who had been exposed to several types of exposures during this natural disaster.Conclusions: The negative psychological impact on children and adolescents can still be present eight years post-disaster and seems to have association with the type of exposure; loss, physical presence and subjective experience. It is important for clinicians, who meet young adults seeking help, to be conscious about the impact as long as eight years post disaster and to be aware of possible clinical implications associated with severity of exposures.

Introduction: To lose a person close suddenly, during childhood or adolescence, can be devastating. Many children or adolescents experienced the 2004 Indonesian tsunami when they were between 10- and 15-years-old. This study, from Stockholm, Sweden, describes the long-term effects of loss, eight- or nine-years post disaster, in young adulthood.

Method: A mixed-method approach was used including statistical analyses (n = 210) and interpretative phenomenological analysis (IPA).

Results: It was shown that there was a significant difference between bereaved (n=34) and nonbereaved (n = 176) respondents concerning, psychological distress, posttraumatic stress symptoms, and self-rated health. Three themes were found by using the IPA approach (n=9): Living in traumas, carrying heavy baggage, and living with change.

Conclusion: The respondents described personal feelings of grief that are not expressed in their outward appearance or behavior in their daily living. When meeting young adults that have lost someone close in childhood or adolescence, this is important to have in mind.

Background: A parental mental illness affects all family members and should warrant a need for support.Aim: To investigate the extent to which psychiatric patients with underage children are the recipients of child-focused interventions and involved in interagency collaboration.Methods: Data were retrieved from a psychiatric services medical record database consisting of data regarding 29,972 individuals in southern Sweden and indicating the patients main diagnoses, comorbidity, children below the age of 18, and child-focused interventions.Results: Among the patients surveyed, 12.9% had registered underage children. One-fourth of the patients received child-focused interventions from adult psychiatry, and out of these 30.7% were involved in interagency collaboration as compared to 7.7% without child-focused interventions. Overall, collaboration with child and adolescent psychiatric services was low for all main diagnoses. If a patient received child-focused interventions from psychiatric services, the likelihood of being involved in interagency collaboration was five times greater as compared to patients receiving no child-focused intervention when controlled for gender, main diagnosis, and inpatient care.Conclusions: Psychiatric services play a significant role in identifying the need for and initiating child-focused interventions in families with a parental mental illness, and need to develop and support strategies to enhance interagency collaboration with other welfare services.

Mental health has become a prominent issue in society. Yet, much remains unknown about the etiology of psychiatric disorders. The aim of the present thesis was to investigate the association between biological, psychological and social factors of risk and resilience and behavioral problems in a birth cohort of Swedish children. 1723 mothers and their children were followed from birth to the age of 12 as part of the South East Sweden Birth Cohort Study (the SESBiC study). Information was gathered through register data, standardized questionnaires and DNA samples.

In study I, stability of maternal symptoms of depression and the impact on child behavior at age 12 were investigated. The prevalence of depressive symptoms was found to be 12.0 % postpartum. Symptoms of postpartum depression significantly increased the risk for subsequent depressive symptoms 12 years later in women. Children whose mothers reported concurrent symptoms of depression and anxiety had an increased risk for both internalizing and externalizing problems at age 12, but no long term effect on child behavior was seen for postpartum depressive symptoms. The greatest risk was seen for children whose mothers reported symptoms of depression on both occasions. In study II, the impact of gene-environment interaction of 5-HTTLPR and BDNF Val66Met and experience of life events together with symptoms of maternal depression and anxiety on child behavior at age 12 was studied. A main effect of 5-HTTLPR was noticed, but no geneenvironment effects were shown. Similarly to study I, concurrent symptoms of maternal depression and anxiety were an important predictor of child behavioral problems. A high degree of psychosocial stress around childbirth was found to have long lasting detrimental effects on child behavior, increasing the risk for internalizing problems at age 12. Study III investigated the impact of geneenvironment interactions of 5-HTTLPR and BDNF Val66Met and life events together with symptoms of maternal depression and birth characteristics on behavioral problems at age 3. Symptoms of postpartum depression were found to predict internalizing as well as externalizing problems in children three years later. Child experience of life events was a stable predictor of behavioral problems across the scales similar to sociodemographic factors such as parental immigration status and unemployment. No gene-environment interaction effects of 5-HTTLPR or BDNF Val66Met were shown. Study IV used the risk factors identified in studies I-III to investigate factors of resilience to behavioral problems at age 12. The l/l genotype of 5-HTTLPR was associated with a lower risk for behavioral problems at age 12, especially for children facing low adversity. Good social functioning was found to be a general resource factor, independent of the level of risk, while an easy temperament was associated with resilience for children with a high degree of adversity. However, effect sizes were small.

In summary, the results from the present thesis emphasize the importance of maternal mental health and sociodemographic factors for child mental health at ages 3 and 12, which must be taken into account in clinical settings. Moreover, it adds to the null-findings of the gene-environment effect of 5-HTTLPR and BDNF Val66Met on behavioral problems in children, but indicates a main effect of 5-HTTLPR on internalizing symptoms at age 12.

Background The influence of maternal temperament on child behavior, and whether maternal temperament impact boys and girls differently is not thoroughly studied. The aim was to investigate the impact of maternal temperament and character on child externalizing and internalizing problems at age 3. Methods A birth-cohort of 1723 mothers and their children were followed from birth to age 3. At the childs age of 3 months, the mothers filled out standardized instruments on their temperament and character using the Temperament and Character Inventory (TCI) and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS). At the childs age of 3 years, the mothers reported on child behavior using the Child Behaviour Checklist (CBCL). Results Maternal temperamental trait novelty seeking was positively associated with externalizing problems in the total population and in girls. Harm avoidance was positively associated with externalizing problems in the total population and in boys, and with internalizing problems in the total population and boys and girls respectively. Maternal character traits of self-directedness and cooperativeness were negatively associated with both externalizing and internalizing problems in the total population and in boys and girls respectively. Conclusions Maternal character traits were more influential on child behavior than were temperamental traits, and thus the opportunities for intervention targeted at parental support are good. Maternal mental health and socioeconomic aspects also increased the risk for child behavior problems, indicating the need for recognition and support in clinical settings.

BACKGROUND: Depression is a common and disabling condition with a high relapse frequency. Maternal mental health problems and experience of traumatic life events are known to increase the risk of behavior problems in children. Recently, genetic factors, in particular gene-by-environment interaction models, have been implicated to explain depressive etiology. However, results are inconclusive.

METHODS: Study participants were members of the SESBiC-study. A total of 889 mothers and their children were followed during the child's age of 3 months to 12 years. Information on maternal depressive symptoms was gathered postpartum and at a 12 year follow-up. Mothers reported on child behavior and traumatic life events experienced by the child at age 12. Saliva samples were obtained from children for analysis of 5-HTTLPR and BDNF Val66Met polymorphisms.

RESULTS: Multivariate analysis showed a significant association between maternal symptoms of depression and anxiety, and internalizing problems in 12-year-old children (OR 5.72, 95% CI 3.30-9.91). Furthermore, carriers of two short alleles (s/s) of the 5-HTTLPR showed a more than 4-fold increased risk of internalizing problems at age 12 compared to l/l carriers (OR 4.73, 95% CI 2.14-10.48). No gene-by-environment interaction was found and neither depressive symptoms postpartum or traumatic experiences during childhood stayed significant in the final model.

CONCLUSIONS: Concurrent maternal symptoms of depression and anxiety are significant risk factors for behavior problems in children, which need to be taken into account in clinical practice. Furthermore, we found a main effect of 5-HTTLPR on internalizing symptoms in 12-year-old children, a finding that needs to be confirmed in future studies.

Objective: Mental illness is increasing among young people and likewise the request for health care services. At the same time, somatic comorbidity is common in children and adolescents with psychiatric disorders. There is a lack of studies on health care use in children and adolescents, and the hypothesis was that children and adolescents with psychiatric disorders use more primary-, and specialized somatic health care compared to children without psychiatric disorders. Methods: In this retrospective population-based register study, all individuals aged 3-17 years living in Vastra Gotaland region in Sweden in 2017 were included (n = 298,877). Linear and Poisson regression were used to compare health care use during 2016-2018 between children with and without psychiatric diagnoses, controlling for age and gender. The results were reported as unstandardised beta coefficient (beta) and adjusted prevalence ratio (aPR) respectively. Results: Having a psychiatric diagnosis was associated with more primary care visits (beta 2.35, 95% CI 2.30-2.40). This applied to most diagnoses investigated. Girls had more primary care visits than boys. Likewise, individuals with psychiatric diagnoses had more specialized somatic outpatient care (beta 1.70, 95% CI 1.67-1.73), both planned and unplanned (beta 1.23, 95% CI 1.21-1.25; beta 0.18, 95% CI 0.17-0.19). Somatic inpatient care was more common in those having a psychiatric diagnosis (aPR 1.65, 95% CI 1.58-1.72), with the diagnoses of psychosis and substance use exerting the greatest risk. Conclusions: Psychiatric diagnoses were associated with increased primary-, somatic outpatient- as well as somatic inpatient care. Increased awareness of comorbidity and easy access to relevant health care could be beneficial for patients and caregivers. The results call for a review of current health care systems with distinct division between medical disciplines and levels of health care.

In the adult population, psychiatric disorders are associated with somatic illness. Explanatory life style factors have been found, but also a failure to recognize somatic illness in this group. Another factor is side effects from long-term use of antipsychotic drugs. Given the psychiatric-somatic comorbidity in the adult population, it is of interest to investigate whether an association exists already during childhood. The aim of the present study was to investigate the frequency of somatic illness in children and adolescents with a psychiatric diagnose. Data were obtained from the regional health care database Vega, Sweden. Psychiatric and somatic diagnoses obtained during 2011-2013 for individuals aged 3-18 years were extracted. Descriptive statistics were used to examine difference in somatic morbidity between children with and without psychiatric diagnoses. Logistic regression was used in age-stratified models to test the association between psychiatric and somatic diagnoses. Anxiety and behavioral disorders were associated with all somatic conditions investigated at nearly all ages. The same applied to substance use, investigated at age 9-18 years. Affective disorders were associated with all somatic conditions at age 12-18 years. Psychotic conditions were associated with asthma, bowel disorders and myalgia in adolescents. Children with psychiatric disorders are at remarkably high risk for concurrent somatic illness. The associations span across many types of conditions and across all ages. The results support the need for awareness of somatic morbidity in child and adolescent psychiatric clinical settings, and the need for coordinated health care for children with comorbid states.

An increasing prevalence of mental health problems calls for more knowledge into factors associated with resilience. The present study used multiple statistical methodologies to examine a biopsychosocial model of risk and resilience on preadolescence behavior. Data from 889 children and mothers from a birth cohort were used. An adversity score was created by combining maternal symptoms of depression, psychosocial risk and childrens experiences of life events. The proposed resilience factors investigated were candidate genetic polymorphisms, child temperament, social functioning, and maternal sense of coherence. The l/ l genotype of the serotonin transporter linked polymorphic region was associated with lower internalizing scores, but not mainly related to the level of adversity. An easy temperament was associated with resilience for children exposed to high adversity. Social functioning was found to be promotive independent of the risk level. The results support a multiple-level model of resilience indicating effects, though small, of both biological and psychosocial factors.

An increasing prevalence of mental health problems calls for more knowledge into factors associated with resilience in the context of child behavior. Biological factors are seldom considered in psychosocial models of resilience. The present study used multiple statistical methodologies to examine a biopsychosocial model of risk and resilience on behavior at preadolescence. Data from 889 children and their mothers were used. A cumulative adversity score was created by combining maternal symptoms of depression, psychosocial risk and children’s experiences of life events. The proposed resilience factors investigated were candidate genetic polymorphisms, child temperament and social functioning, and maternal sense of coherence. Results show that the l/l genotype of the serotonin transporter linked polymorphic region (5-HTTLPR) was associated with lower internalizing scores, especially for children exposed to low adversity. An easy temperament was associated with resilient outcomes for children exposed to high adversity. Child social functioning was found to be more of a general resource variable buffering risk in both high and low adversity groups. The results support a multiple level model of resilience indicating effects, though small, of both biological and psychosocial factors. The present findings call for both preventive actions and further studies on biopsychosocial models in resilience research.

Background: The early environment is important for child development and wellbeing. Gene-by-environment studies investigating the impact of the serotonin transporter genelinked polymorphic region (5-HTTLPR) and the Brain Derived Neurotrophic Factor (BDNF) Val66Met polymorphisms by life events on mental health and behaviour problems have been inconclusive. Methodological differences regarding sample sizes, study population, definitions of adversities and measures of mental health problems obstacle their comparability. Furthermore, very few studies included children. The aim of this study was to examine the associations between a broad range of risk factors covering pregnancy and birth, genetic polymorphism, experience of multiple life events and psychosocial environment, and child behaviour at age three, using a comparably large, representative, population-based sample.

Methods: A total of 1,106 children, and their mothers, were followed from pregnancy to age three. Information on pregnancy and birth-related factors was retrieved from the Medical Birth Register. Questionnaires on depressive symptoms, child behaviour and child experiences of life events were filled in by the mothers. Child saliva samples were used for genotyping the 5-HTTLPR and BDNF Val66Met polymorphisms. Multiple logistic regression was used to investigate the association between psychological scales and genetic polymorphisms.

Results: Symptoms of postpartum depression increased the risk of both internalizing and externalizing problems. Experience of multiple life events was also a predictor of behavioural problems across the scales. No gene-by-environment or gene-bygene-by-environment interactions were found. Children of immigrants had an increased risk of internalizing problems and parental unemployment was significantly associated with both internalizing and externalizing type of problems.

Conclusion: This study shows the importance of the psychosocial environment for psychosocial health in preschool children, and adds to  the literature of null-findings of gene-by-environment effects of 5-HTTLPR and BDNF in children

PurposeEven though the mechanisms behind the development of depression and internalizing problems remains unknown, many different factors have been shown to increase the risk. Longitudinal studies enable the investigation of exposure during different developmental periods during childhood. This study aims to examine factors associated with depressive and internalizing problems at age 20 in terms of sociodemographic factors, previous mental health problems and stressful life events during childhood, adolescence, and early adulthood.MethodsA birth cohort of 1723 children were followed to age 20. At the 20-year follow-up, n = 731 (44%) participated. Standardized instruments were filled out at baseline and the 3-,12- and 20-year follow-ups.ResultsDepressive problems at age 20 were associated with female gender, experience of interpersonal life events reported at age 20, bullying victimization and reports on paternal mental health problems. Participants with depressive problems were also less likely to have experienced adolescence as happy and to report that their father had been a good father. Internalizing problems at age 20 were, in addition, associated with internalizing problems at age 12 and reports on maternal mental health problems. Internalizing problems were associated with a lower likelihood of experiencing adolescence as happy in the final model.ConclusionRecent events (i.e. interpersonal life events and bullying) seemed to be the most influential factors on the development of internalizing and depressive problems. Internalizing problems during childhood increased the risk for internalizing problems in early adulthood, emphasizing the importance of early intervention. Fewer factors were found to increase the risk for depressive problems compared to internalizing problems.

Background Unintentional injuries are a leading cause of morbidity and mortality in children of all ages. Prevention strategies require knowledge of risk factors, and behavior and psychiatric disorders have been suggested to influence the risk of injury during childhood. While externalizing disorders have been found to increase the risk for injuries, results are mixed regarding internalizing disorders, such as affective and anxiety conditions, and Autism Spectrum Disorders (ASD). There is a need for large scale studies relying on robust data sources. The aim of the present study was to examine the association between psychiatric disorders and injuries requiring medical attention, in a large population-based cohort of 350,000 children and adolescents in Sweden. Methods Data were obtained from the regional health care database Vega. Psychiatric diagnoses and injury diagnoses obtained during 2014-2018 for individuals aged 0-17 years in 2016 were extracted. Descriptive statistics were used to examine differences in 5-year injury prevalence between children with and without different psychiatric diagnoses. Logistic regression was used in age-stratified models to test the association between psychiatric diagnoses and injuries requiring medical attention. Results The results show an increased risk for concurrent injuries in general, but the patterns vary by age and psychiatric disorder. Externalizing disorders and anxiety conditions were associated with concurrent injuries, while individuals with ASD had a lower risk for most injuries included. Affective disorders were associated with an increased risk for wounds, concussion, complications and poisoning, while the risk for fractures was decreased. Self-inflicted injury was more common in all psychiatric conditions investigated during adolescence, except for ASD. Children and adolescents with many types of psychiatric disorders were also at increased risk for a concurrent maltreatment diagnosis. Conclusions A general pattern of increased risk for concurrent injuries in children and adolescents with most psychiatric diagnoses was found, but the associations vary by age and type of psychiatric disorder. The results add to the literature on risk factors for injuries in children and adolescents, supporting diagnosis specific patterns. Several psychiatric diagnoses were associated with a marked increase in injury risk, indicating a high burden of disease for affected individuals.

The aim of this thesis was to expand the knowledge of victimization in children and youth in Sweden. Victimization, prevalence, health and peritraumatic reactions were explored in a cross sectional, representative sample of 5,960 second grade high school students in Sweden. A computerized survey was developed and administered in class room setting.

Lifetime victimization was found in 84.1% of the sample (m=83.0%, f=85.2%), and, in relation to the five domains, 66.4% had experienced conventional crime, 24% child maltreatment, 54.4% peer and sibling victimization, 21.8% sexual victimization, and 54% had experienced witness victimization. Females experienced significantly more child maltreatment, peer and sibling victimization, sexual victimization, and witnessed victimization, males more conventional crime (p<0.001). Using logistic regression risk factors for victimization were confirmed by a significant increase OR regarding gender, environment and lack of both parents.

Symptoms (TSCC), were clearly associated with both victimizations per se and the number of victimizations. The results indicated a relatively linear increase in symptoms with an increase in number of events experienced. Mental health of the polyvictimized group was significantly worse than that of the non-polyvictimized group, with significantly elevated TSCC scores (t<0.001). Hierarchical regression analysis resulted in beta value reduction when polyvictimization was introduced supporting the independent effect on symptoms. Social anxiety was found in 10.2 % (n = 605) of the total group (n = 5,960). A significant gender difference emerged, with more females than males reporting social anxiety. Elevated PTSS was found in 14.8 % (n=883). Binary logistic regression revealed the highest OR for having had contact with child and adolescent psychiatry was found for the combined group with social anxiety and elevated PTSS (OR = 4.88, 95 % CI = 3.53–6.73, p<001). Significant associations were also found between use of child and adolescent psychiatry and female gender (OR = 2.05, 95 % CI = 1.70–2.45), Swedish birth origin (OR = 1.68, 95 % CI = 1.16–2.42) and living in a small municipality (OR = 1.33, 95 % CI = 1.02–1.73).

Mediation models used peritraumatic reactions (PT): total, physiological arousal (PA), peritraumatic dissociation (PD), and intervention thoughts (IT) and JVQ and TSCC. Of the n=5,332 cases, a total of n=4,483 (84.1%) reported at least one victimizing event (m = 83.0%, f = 85.2%). Of these, 74.9% (n=3,360) also experienced a PT reaction of some kind. The effect mediated by PT tot was b= 0.479, BCa CI [0.342 – 0.640], representing a relatively small effect of 7.6%, κ2=0.076, 95% BCa CI [0.054- 0.101]. The mediating effect of JVQ on TSCC was mediated by PD more for males (b=0.394 BCa CI [0.170-0.636]) than for females (b=0.247, BCa CI [0.021-0.469]). The indirect effect of the JVQ on the TSCC tot mediated by the different PT reactions was significant for PD (b=0.355, BCa CI [0.199- 0.523]. In males a mediating effect of PD could be seen in the different models, while females had a more mixed result. IT did not show any indirect effect in males, but had a mixed effect for females.

The empirical findings in this thesis lead to the conclusion that victimization is highly prevalent in children and youth and is related to health issues. The association of victimization on symptoms was mediated by peritraumatic reactions. Using a comprehensive instrument such as the JVQ provides the researcher or clinician the opportunity to acquire more complete measurement and also makes it possible to identify polyvictimization, a high-level category of events with severe impact on health.  

Background: Exposure to traumatic events is clearly associated with a diversity of subsequent mental health problems, with posttraumatic stress disorder (PTSD) as the most prevalent disorder. Epidemiologically, trauma exposure rates are more prevalent than PTSD, indicating that most trauma victims do not develop PTSD. More knowledge is needed to understand the development of the different posttraumatic pathways including the significance of pretraumatic, peritraumatic and posttraumatic risk factors. Objective: To study peritraumatic reactions in relation to trauma exposure and symptoms of posttraumatic stress and to enhance our understanding of peritraumatic reactions as mediators between trauma and later symptomatology. Method: The study was composed of a representative community sample of 5332 second year high school students (mean age 17.3 years) who completed the Juvenile Victimization Questionnaire (SAQ/JVQ), Trauma Symptom Checklist for Children (TSCC) and answered questions about peritraumatic reactions. Mediation effects of peritraumatic reactions on the trauma exposure relationship to symptoms was tested using the PROCESS macro for SPSS. Results: Traumatic events are common (84.1%) and are accompanied in three-quarters of the students with at least one form of peritraumatic reaction. Peritraumatic reactions, especially peritraumatic dissociative reactions, mediate the relationship between trauma exposure and symptoms, and gender moderates the effect of peritraumatic dissociation. This moderating effect was found to be larger for boys than for girls, indicating gender differences in response to trauma. Conclusions: The results indicate the need to screen for peritraumatic reactions as early as possible after a traumatic event in order to identify those at risk for PTSD.

The main objective of this article was to study the relationship between the different areas of victimization (eg, sexual victimization) and psychological symptoms, taking into account the full range of victimization domains. The final aim was to contribute further evidence regarding the bias that studies that focus on just one area of victimization may be introduced into our psychological knowledge. The sample included 5,960 second-year high school students in Sweden with a mean age of 17.3 years (range =16–20 years, standard deviation =0.652), of which 49.6% were females and 50.4% males. The Juvenile Victimization Questionnaire and the Trauma Symptom Checklist for Children were used to assess victimization and psychological problems separately. The results show that a majority of adolescents have been victimized, females reported more total events and more sexual victimization and childhood maltreatment, and males were more often victims of conventional crime. The majority of victimization domains as well as the sheer number of events (polyvictimization [PV]) proved to be harmful to adolescent health, affecting females more than males. PV explained part of the health effect and had an impact on its own and in relation to each domain. This suggests the possibility that PV to a large degree explains trauma symptoms. In order to understand the psychological effects of trauma, clinicians and researchers should take into account the whole range of possible types of victimization.

Purpose: Insomnia has adverse effects on people with epilepsy. We aimed to test a novel cognitive behavioral therapy for insomnia (CBT-I) app-based intervention on insomnia symptoms and social psychological factors in people with epilepsy and to examine the possible mechanisms among the factors. Methods: Participants were recruited from neurology clinics in Iran and comprised individuals diagnosed with epilepsy and having moderate to severe insomnia. A two-arm randomized controlled trial design was used, consisting of a treatment group (CBT-I; n = 160) and control group (patient education; n = 160). Primary outcomes were self-reported sleep quality, insomnia severity, and sleep hygiene behavior and objective sleep characteristics measured by actigraphy. Secondary outcomes were attitude, perceived behavioral control, intention, action planning, coping planning, behavioral automaticity, self-monitoring, anxiety, depression, and quality of life (QoL). All outcomes were measured at baseline, and at one, three, and six months postintervention, except objective sleep, which was assessed at baseline, and one and six months postintervention. Data were analyzed using linear mixed models. Results: Current findings showed that sleep quality, insomnia severity, sleep hygiene behavior, and sleep onset latency were significantly improved in the CBT-I group compared with the patient education group at all measurement points. Also, the CBT-I group had significantly improved anxiety, depression, and QoL compared with the patient education group. Mediation analyses showed that attitude, intention, coping planning, self-monitoring, and behavioral automaticity significantly mediated the effect of the intervention on sleep outcomes. Conclusion: Results support the use of the CBT-I app to improve sleep outcomes among people with epilepsy. (C) 2020 Elsevier Inc. All rights reserved.

Purpose of ReviewThe COVID-19 pandemic has promoted behavioral changes and elevated mental distress. Addictive behaviors often increased, generating mental health problems. The present study's primary aim was to investigate associations between different types of behavioral addictions (including behavioral addictions, related conditions, and phenomena) and different types of mental health problems. The secondary aims were: (i) to identify possible sources of heterogeneity and (ii) to explore potential moderators in associations between different types of behavioral addictions (including behavioral addictions, related conditions, and phenomena) and different types of mental health problems.Recent FindingsUsing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), studies from the period between December 2019 and May 2023 were sought from PubMed, Scopus, ISI Web of Knowledge, and Google Scholar in its first ten pages. The articles' relevance was screened and evaluated. The included papers' quality was assessed according to the Newcastle Ottawa Scale. Fisher's Z scores were computed to present magnitudes of associations and I2 indices were used to estimate levels of heterogeneity in the meta-analysis. Among the 85 included studies (N = 104,425 from 23 countries; mean age = 24.22 years; 60.77% female), most were internet-related behavioral addictions, related conditions, and phenomena (28 studies on social media, 25 on internet, 23 on smartphone, and 12 on gaming). The pooled estimation of the associations showed that higher levels of behavioral addictions, related conditions, and phenomena related to internet use (regardless of type) were associated with more mental health problems (regardless of which type). Moderator analyses showed that almost no variables affected heterogeneity for the founded associations.SummaryMost studies of behavioral addictions, related conditions, and phenomena focused on internet-related behaviors, with studies suggesting relationships with specific types of mental health problems during the COVID-19 pandemic. Moreover, associations between behavioral addictions (including behavioral addictions, related conditions, and phenomena) and mental health problems found in the present systematic review and meta-analysis were comparable to the associations identified in studies conducted before the COVID-19 pandemic. How to help people reduce internet-related behavioral addictions, related conditions, and phenomena and address associated mental health concerns are important topics for healthcare providers.

Alexithymia, a difficulty identifying and expressing emotions experienced by oneself or others, measurably harms quality of sleep. Research has observed the association between alexithymia and sleep problems; however, the cumulative effect of this association is still unknown. Therefore, this systematic review and meta-analysis was conducted to present scientific evidence regarding the relationship between alexithymia and sleep quality. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, and using relevant keywords, we searched six databases: Scopus, PubMed Central, ProQuest, ISI Web of Knowledge, EMBASE, and Science Direct. We selected observational studies on the association between alexithymia and sleep. We conducted meta-analysis using a random-effect model to calculate the effect size (ES) with Fishers z transformation. Eligible studies (N = 26) in 24 papers included 7546 participants from 12 countries. The entire ES for the association between alexithymia and sleep was 0.44 (95 % CI: 0.31, 0.56). Additionally, patient populations had a larger ES (ES = 0.55; 95 % CI: 0.30, 0.79) than healthy populations (ES = 0.30; 95 % CI: 0.20, 0.41). The results of the present systematic review and meta-analysis revealed a significant association between alexithymia and sleep problems, especially among people with any medical condition.

The Oslo Chronic Fatigue Consortium consists of researchers and clinicians who question the current narrative that chronic fatigue syndromes, including post-covid conditions, are incurable diseases. Instead, we propose an alternative view, based on research, which offers more hope to patients. Whilst we regard the symptoms of these conditions as real, we propose that they are more likely to reflect the brains response to a range of biological, psychological, and social factors, rather than a specific disease process. Possible causes include persistent activation of the neurobiological stress response, accompanied by associated changes in immunological, hormonal, cognitive and behavioural domains. We further propose that the symptoms are more likely to persist if they are perceived as threatening, and all activities that are perceived to worsen them are avoided. We also question the idea that the best way to cope with the illness is by prolonged rest, social isolation, and sensory deprivation.Instead, we propose that recovery is often possible if patients are helped to adopt a less threatening understanding of their symptoms and are supported in a gradual return to normal activities. Finally, we call for a much more open and constructive dialogue about these conditions. This dialogue should include a wider range of views, including those of patients who have recovered from them.

The COVID-19 pandemic influence mental health in both infected and non-infected populations. In this study we examined if individually tailored internet-based cognitive behavioral therapy (ICBT) could be an effective treatment for psychological symptoms related to the pandemic. Following recruitment we included 76 participants who were randomized to either a treatment group (n = 37) or a waitlist control group (n = 39). The treatment group received 8 modules (out of 16 possible) during 8 weeks with weekly therapist support. We collected data on symptoms of depression, experienced quality of life, anxiety, stress, anger, insomnia, PTSD, and alcohol use before, after the treatment and at one year follow-up. Using multiple regression analysis, group condition was found to be a statistically significant predictor for a decrease, favoring the treatment group, in symptoms of depression, insomnia, and anger with small to moderate effect sizes. The improvements remained at one year follow-up. Group condition did not significantly predict changing symptoms regarding experienced quality of life, anxiety, stress, PTSD and alcohol use. Findings indicate that ICBT is an effective intervention for some psychological symptoms associated with the COVID-19 pandemic. There is a need for further studies on mechanisms of change and on tailored ICBT for problems associated with crises like the pandemic.

AimSeveral studies have suggested that rare copy number variants (CNVs) are an important genetic contributor to autism spectrum disorders. The aims of the study were to use chromosomal microarray to investigate the presence of rare copy number variants in a population-based cohort of well-characterised young children with autism spectrum disorders and to relate the genetic results to neurodevelopmental profiles and medical conditions. MethodsWe performed chromosomal microarray on samples from 162 children who had been referred to the Stockholm Autism Centre for Young Children in Sweden after being diagnosed with autism spectrum disorder between 20 and 54months of age. ResultsPathogenic aberrations were detected in 8.6% of the children and variants of uncertain significance were present in another 8.6%. CNVs were more frequent in children with congenital malformations or dysmorphic features as well as in the subgroup with intellectual disability. ConclusionOur results support the use of chromosomal microarray methods for the first tier genetic analysis of autism spectrum disorder. However, it is likely in the near future that chromosomal microarray methods will probably be replaced by whole-exome and whole-genome sequencing technologies in clinical genetic testing.

Objective: The aims of the present study was to investigate communication impairments in a Norwegian sample of children with ADHD and children with Asperger syndrome (AS) and to explore whether children with ADHD can be differentiated from children with AS in terms of their language profiles on the Norwegian adaptation of the Children’s Communication Checklist Second Edition (CCC-2). Method: The CCC-2 was completed by the parents, and altogether, 77 children aged between 6 and 15 years participated in the study. Results: Communication impairments were as common in a group of children with ADHD as in a group of children with AS. Although a similar pattern appeared on most CCC-2 scales, children with ADHD and children with AS could be distinguished from each other in terms of their language profiles on the subscales assessing stereotyped language and nonverbal communication. Conclusion: Language abilities should be taken into account when standard assessments of ADHD and AS are performed and before therapies are initiated

Objective: This study aimed to explore whether children with specific language impairment (SLI) and children with ADHDcan be differentiated from each other in terms of their language profiles, and also to investigate whether these two clinicalgroups differ regarding mental health problems. Method: A total of 59 children in the age range 6 to 12 years participatedin the study. The parents completed the Children’s Communication Checklist–Second Edition and the Strengths andDifficulties Questionnaire. Results: Communication impairments were as prominent in the ADHD group as in the SLIgroup; however, the groups were separable from each other in terms of their language profiles. Furthermore, the ADHDgroup experienced significantly more mental health problems compared with the SLI group. Conclusion: Language shouldbe assessed in children with ADHD and instruments sensitive to ADHD should be included when assessing children withSLI. Mental health should be an area of concern to be addressed in both groups. (J. of Att. Dis. 2012; XX(X) 1-XX)

Background

Depressive disorders have been associated with a number of co-morbidities, and we   hypothesized that patients with a depression diagnosis would be heavy users of health   care services, not only when first evaluated for depression, but also for preceding   years. The aim of this study was to investigate whether increased health care utilisation   and co-morbidity could be seen during five years prior to an initial diagnosis of   depression.

Methods

We used a longitudinal register-based study design. The setting comprised the general   population in the county of Östergötland, south-east Sweden. All 2470 patients who   were 20 years or older in 2006 and who received a new diagnosis of depression (F32   according to ICD-10) in 2006, were selected and followed back to the year 2001, five   years before their depression diagnosis. A control group was randomly selected among   those who were aged 20 years or over in 2006 and who had received no depression diagnosis   during the period 2001-2006.

Results

Predictors of a depression diagnosis were a high number of physician visits, female   gender, age below 60, age above 80 and a low socioeconomic status.

Patients who received a diagnosis of depression used twice the amount of health care   (e.g. physician visits and hospital days) during the five year period prior to diagnosis   compared to the control group. A particularly strong increase in health care utilisation   was seen the last year before diagnosis. These findings were supported with a high   level of co-morbidity as for example musculoskeletal disorders during the whole five-year   period for patients with a depression diagnosis.

Conclusions

Predictors of a depression diagnosis were a high number of physician visits, female   gender, age below 60, age above 80 and a low socioeconomic status. To find early signs   of depression in the clinical setting and to use a preventive strategy to handle these   patients is important.

IMPORTANCE: It is unclear whether d-cycloserine (DCS), a partial N-methyl-d-aspartate agonist that enhances fear extinction, can augment the effects of exposure-based cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD).

OBJECTIVES: To examine whether DCS augments the effects of CBT for OCD and to explore (post hoc) whether concomitant antidepressant medication moderates the effects of DCS.

DESIGN, SETTING, AND PARTICIPANTS: A 12-week, double-blind randomized clinical trial with 3-month follow-up conducted at an academic medical center between September 4, 2012, and September 26, 2013. Participants included 128 adult outpatients with a primary diagnosis of OCD and a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of 16 or higher. Concurrent antidepressant medication was permitted if the dose had been stable for at least 2 months prior to enrollment and remained unchanged during the trial. The main analysis was by intention-to-treat population.

INTERVENTIONS: All participants received a previously validated Internet-based CBT protocol over 12 weeks and were randomized to receive either 50 mg of DCS or placebo, administered 1 hour before each of 5 exposure and response prevention tasks.

MAIN OUTCOMES AND MEASURES: Clinician-administered Y-BOCS score at week 12 and at 3-month follow-up. Remission was defined as a score of 12 or lower on the Y-BOCS.

RESULTS: In the primary intention-to-treat analyses, DCS did not augment the effects of CBT compared with placebo (mean [SD] clinician-rated Y-BOCS score, DCS: 13.86 [6.50] at week 12 and 12.35 [7.75] at 3-month follow-up; placebo: 11.77 [5.95] at week 12 and 12.37 [6.68] at 3-month follow-up) but showed a significant interaction with antidepressants (clinician-rated Y-BOCS, B = -1.08; Z = -2.79; P = .005). Post hoc analyses revealed that antidepressants significantly impaired treatment response in the DCS group but not the placebo group, at both posttreatment and follow-up (clinician-rated Y-BOCS: t62 = -3.00; P = .004; and t61 = -3.49; P < .001, respectively). In the DCS group, a significantly greater proportion of antidepressant-free patients achieved remission status at follow-up (60% [95% CI, 45%-74%]) than antidepressant-medicated patients (24% [95% CI, 9%-48%]) (P = .008). Antidepressants had no effect in the placebo group (50% [95% CI, 36%-64%] remission rate in both groups).

CONCLUSIONS AND RELEVANCE: The findings suggest that antidepressants may interact with DCS to block its facilitating effect on fear extinction. Use of DCS may be a promising CBT augmentation strategy but only in antidepressant-free patients with OCD.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01649895.

I denna bok omnämns flera olika psykiska ohälsotillstånd och mekanismerna bakom dem. I detta kapitel vill jag ge en översikt med några exempel på metoder för de olika nivåerna i den biopsykosociala modellen. Begreppet consilience, myntat av Edward O. Wilson, introducerades som ett ramverk för hur olika vetenskapstraditioner kan samverka och berika varandra. Jag går igenom olika metoder inom olika forskningstraditioner och avslutar med en diskussion om utmaningar med att förena olika angreppssätt i förståelsen av psykisk sjukdom.

I den här delen av kapitlet går vi igenom psykoterapi och psykologisk behandling. Avsnittet belyser olika terapiformer och format, och en slutsats är att psykologisk behandling fungerar, samt att kombinerad behandling med samtidig läkemedelsbehandling kan vara mer effektiv än att endast erbjuda läkemedel eller psykologisk behandling. Olika psykoterapier har effekt men det finns än så länge mest stöd för kognitiv beteendeterapi.

Background: Internet-delivered cognitive behavior therapy (ICBT) was developed over 20 years ago and has since undergone a number of controlled trials, as well as several systematic reviews and meta-analyses. However, the crucial question of response rates remains to be systematically investigated. The aim of this individual patient meta-analysis (IPDMA) was to use a large dataset of trials conducted in Sweden to determine reliable change and recovery rates across trials for a range of conditions.

Methods: We used previously collected and aggregated data from 2,866 patients in 29 Swedish clinical trials of ICBT for three categories of conditions: anxiety disorders, depression, and others. Raw scores at pre-treatment and post-treatment were used in an IPDMA to determine the rate of reliable change and recovery. Jacobson and Truax’s, (1991) reliable change index (RCI) was calculated for each primary outcome measure in the trials as well as the recovery rates for each patient, with the additional requirement of having improved substantially. We subsequently explored potential predictors using binomial logistic regression.

Results: In applying an RCI of z = 1.96, 1,162 (65.6%) of the patients receiving treatment were classified as achieving recovery, and 620 (35.0%) were classified as reaching remission. In terms of predictors, patients with higher symptom severity on the primary outcome measure at baseline [odds ratio (OR) = 1.36] and being female (OR = 2.22) increased the odds of responding to treatment. Having an anxiety disorder was found to decrease the response to treatment (OR = 0.51). Remission was predicted by diagnosis in the same direction (OR = 0.28), whereas symptom severity was inversely predictive of worse outcome (OR = 0.81). Conclusions: Response seems to occur among approximately half of all clients administered ICBT, whereas about a third reach remission. This indicates that the efficacy of ICBT is in line with that of CBT based in prior trials, with a possible caveat being the lower remission rates. Having more symptoms and being female might increase the chances of improvement, and a small negative effect of having anxiety disorder versus depression and other conditions may also exist. A limitation of the IPDMA was that only studies conducted in Sweden were included.

Internet-delivered cognitive behaviour therapy (ICBT) has existed for 20 years and there are now several controlled trials for a range of problems. In this paper, we focused on recent meta-analytic reviews of the literature and found moderate to large effects reported for panic disorder, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder, and major depression. In total, we reviewed 9 recent meta-analytic reviews out of a total of 618 meta-analytic reviews identified using our search terms. In these selected reviews, 166 studies were included, including overlap in reviews on similar conditions. We also covered a recent review on transdiagnostic treatments and 2 reviews on face-to-face v. internet treatment. The growing number of meta-analytic reviews of studies now suggests that ICBT works and can be as effective as face-to-face therapy.

Intimate partner violence (IPV) is a serious public health concern worldwide and defined as behavior performed by spouses or other intimate partners that causes physical, sexual, or psychological harm. Internet-delivered cognitive-behavioral therapy (ICBT) may be particularly useful for survivors of IPV for several reasons, including barriers pertaining to limited community recourses and treatment availability, safety concerns, and issues of stigma, guilt and shame, which may prevent members of this population from seeking help via face-to face interactions. However, Internet interventions are lacking. The primary aim of the present randomized controlled pilot trial was to explore the feasibility of ICBT as guided self-help individually tailored to the pre dominant symptomatology of PTSD or depression in survivors of IPV. A second aim was to conduct a preliminary evaluation exploring the short-and long-term effects of the treatment in comparison to a waitlist control con-dition. Results showed that the treatment was feasible. Attrition rate was low (9.4%), and participants were satisfied with treatment. However, treatment adherence was moderate in terms of completed modules (62.5%). Results of the preliminary evaluation of treatment effects showed large and statistically significant between-group effect sizes (Cohens d = 0.86-1.08) on some measures of PTSD and depression at post assessment, fa-voring the treatment condition. However, there were no effects on other measures. At follow-up assessment, when the control condition had received delayed treatment, there were large and statistically significant within-group effect sizes (d = 0.96-1.48) on measures of PTSD, depression and anxiety, and small effects (d = 0.48) on a measure of quality of life. The results of the present pilot study are promising and warrant further research on ICBT for this population.

Background: Guided Internet-based cognitive behavior therapy (ICBT) has been tested in many trials and found to be effective in the treatment of anxiety and mood disorders. Generalized anxiety disorder (GAD) has also been treated with ICBT, but there are no controlled trials on guided Internet-based psychodynamic treatment (IPDT). Since there is preliminary support for psychodynamic treatment for GAD, we decided to test if a psychodynamically informed self-help treatment could be delivered via the Internet. The aim of the study was to investigate the efficacy of IPDT for GAD and to compare against ICBT and a waiting list control group. Method: A randomized controlled superiority trial with individuals diagnosed with GAD comparing guided ICBT (n = 27) and IPDT (n = 27) against a no treatment waiting list control group (n = 27). The primary outcome measure was the Penn State Worry Questionnaire. Results: While there were no significant between-group differences immediately after treatment on the main outcome measure, both IPDT and ICBT resulted in improvements with moderate to large within-group effect sizes at 3 and 18 months follow-up on the primary measure in the completer analyses. The differences against the control group, although smaller, were still significant for both PDT and CBT when conforming to the criteria of clinically significant improvement. The active treatments did not differ significantly. There was a significant group by time interaction regarding GAD symptoms, but not immediately after treatment. Conclusions: IPDT and ICBT both led to modest symptom reduction in GAD, and more research is needed.

Internet interventions, and in particular Internet-delivered cognitive behaviour therapy (ICBT), have existed for at least 20 years. Here we review the treatment approach and the evidence base, arguing that ICBT can be viewed as a vehicle for innovation. ICBT has been developed and tested for several psychiatric and somatic conditions, and direct comparative studies suggest that therapist-guided ICBT is more effective than a waiting list for anxiety disorders and depression, and tends to be as effective as face-to-face CBT. Studies on the possible harmful effects of ICBT are also reviewed: a significant minority of people do experience negative effects, although rates of deterioration appear similar to those reported for face-to-face treatments and lower than for control conditions. We further review studies on change mechanisms and conclude that few, if any, consistent moderators and mediators of change have been identified. A recent trend to focus on knowledge acquisition is considered, and a discussion on the possibilities and hurdles of implementing ICBT is presented. The latter includes findings suggesting that attitudes toward ICBT may not be as positive as when using modern information technology as an adjunct to face-to-face therapy (i.e., blended treatment). Finally, we discuss future directions, including the role played by technology and machine learning, blended treatment, adaptation of treatment for minorities and non-Western settings, other therapeutic approaches than ICBT (including Internet-delivered psychodynamic and interpersonal psychotherapy as well as acceptance and commitment therapy), emerging regulations, and the importance of reporting failed trials.

BackgroundNonsuicidal self-injury (NSSI) is common in adolescents. Emotion dysregulation has been identified as a core mechanism in the development and maintenance of NSSI and it is therefore an important target when addressing NSSI. The pathogenic connection between different kinds of childhood abuse, difficulties in emotion regulation and NSSI needs further investigation. The objective of this study was to examine whether difficulties with emotion regulation and trauma symptoms, separately and together, mediate the relationships between sexual, physical and emotional abuse and NSSI. MethodCross-sectional data was collected from 3,169 adolescent high-school students aged 16-19 years (M = 18.12, SD = 0.45). Data from self-reported experiences of childhood abuse, current difficulties with emotion regulation (measured with the Difficulties with Emotion Regulation Scale, DERS-16) and trauma symptoms (measured with the Trauma Symptom Checklist for Children, TSCC), and NSSI were collected. Structural Equation Modeling (SEM) was used to test the proposed relationships between variables. ResultsThe prevalence of life-time NSSI was 27.4%. Prevalence of reported childhood abuse was 9.2, 17.5, and 18.0% for sexual, physical, and emotional abuse, respectively. Childhood abuse, difficulties with emotion regulation and trauma symptoms exhibited significant positive associations with NSSI in adolescents. Emotional dysregulation and trauma symptoms were both found to mediate the relationship between childhood abuse and NSSI. Latent variable models were found to fit data well. ConclusionResults indicate that increased levels of emotional dysregulation and trauma symptoms in relation to childhood abuse contribute to the increased risk of NSSI. Further, results point to some aspects of emotional dysregulation and trauma symptoms being more important in this regard. Clinical implications are discussed.

BackgroundNonsuicidal self-injury (NSSI) is associated with stigma, and negative attitudes among healthcare professionals toward NSSI have been reported. A person-centered approach that focuses on how individuals with lived experience of NSSI perceive the treatment and care they receive is invaluable in reducing barriers to help-seeking and improving treatment and mental healthcare services. The aim of the current qualitative study was to explore the perceptions of young adults when they look back upon their experiences of psychiatric treatment for NSSI during adolescence.MethodsTwenty-six individuals with lived experience of NSSI who were in contact with child and adolescent psychiatry during adolescence were interviewed. The interviews were analyzed using thematic analysis.ResultsThree main themes were developed: Changed perceptions in retrospect, The importance of a collaborative conceptualization and Lasting impression of the relationship. Participants' perception of themselves as well as the treatment changed over time. The importance of a joint understanding of NSSI and an agreed-upon treatment focus was emphasized. The relationship to the mental health professionals, and experiences of how NSSI was communicated, were salient several years later.ConclusionsHealthcare professionals need to communicate about NSSI in a respectful manner and include the perspective of the adolescent with lived experience of NSSI in a joint conceptualization of NSSI and treatment focus.

AimsTo investigate self-reported beliefs and perceived sensitivity to medicines and their effects in relation to self-reported use of medicines and herbal remedies. MethodsA survey sent to 13,931 randomly selected Swedish adults included the Beliefs about Medicines Questionnaire-General (BMQ-General) Questionnaire and the Perceived Sensitivity to Medicines Scale (PSM). The survey also asked about individuals use of prescribed and over-the-counter (OTC) medicines and herbal remedies in the past month. We examined all associations between scores on the BMQ-General subscales and PSM in relation to the use of medicines and herbal remedies, using analysis of covariance adjusted for potential confounders. ResultsAmong 7099 respondents, those using herbal remedies exclusively believed strongly that prescription and OTC medicines are harmful and overprescribed. Respondents using prescription and OTC medicines reported more positive beliefs [coefficient 0.67 (95% CI 0.47-0.87) and 0.70 (95% CI 0.51-0.90)] on the benefits of medicines compared with those using herbal remedies [-0.18 (95% CI -0.57-0.20)]. Perceived sensitivity to medicines was higher among those using herbal remedies only [1.25 (95% CI 0.46-2.03)] compared with those using no medicines (reference 0) or prescription [-0.44 (95% CI -0.84 to -0.05)] or OTC [-0.27 (95% CI -0.66-0.12)] medicines alone. ConclusionRespondents using prescription and/or OTC medicines reported stronger positive beliefs about the benefits of medicines in general, supporting the hypothesis that beliefs influence medicine use. Therefore, addressing beliefs and concerns about medicines during patient counselling may influence medicine use, particularly regarding unintentional non-adherence.

Introduction: The Reading the Mind in the Eyes Test is a widely used test for measuring aspects of social cognition. The aim of the present study was to provide results from a group of typically developing Swedish children (age 9-12) and to compare these results with children and adults in other Swedish and English studies, as well as results from a group of children with Asperger syndrome. Method: A Swedish version of the child version of the test was completed by 83 controls and by six children with Asperger syndrome. Results were compared between the two groups and with data from other studies. Results: The children in the current study did not differ on scores compared to children in the same age group in other studies. The children in the current study scored significantly lower than adults in an earlier study. The results from the children with Asperger syndrome did not differ significantly to the results from the controls.

Parents experience many stressful situations when their child is ill and needs medical care, irrespective of the child’s age, diagnosis or the severity of the illness. Poor sleep quality and negative mood decrease the parents’ ability to sustain attention and focus, to care for their ill child, and to cope with the challenges they face.

The overall aim of this thesis was to evaluate sleep, mood, cortisol response, and sense of coherence (SOC) in parents caring for children in need of medical care, and to identify factors that may influence parents’ sleep.

This thesis includes four original studies; two of these are quantitative, prospective, descriptive and comparative studies including parents (n=82) accommodated in six pediatric wards with their ill child, using questionnaires and sleep logs to measure sleep, mood and SOC, and saliva cortisol to measure cortisol response. A follow-up was performed four weeks later at home, after hospital discharge. The other two studies are qualitative, inductive and explorative interview studies, including parents (n=12) staying overnight with their preterm and/or ill infant in three neonatal intensive care units, and parents (n=15) with a child receiving hospital-based home care in two pediatric outpatient clinics. The interviews were analyzed with a phenomenographic method.

Being together with one’s family seems beneficial for sleep and may decrease stress. The ability to stay with the child, in the hospital or at home, was highly appreciated by the parents. When caring for a child with illness, parents’ sleep quality was sufficient in the hospital; however, sleep quality improved further (p<0.05) at home after discharge. The parents reported frequent nocturnal awakenings in the hospital caused by the child, medical treatment and hospital staff. Concern and anxiety about the child’s health, and uncertainty about the future were stressors affecting the parents’ sleep and mood negatively. The parents had lower (p=0.01) morning awakening cortisol levels in the pediatric ward compared to at home, and parents accommodated for more than one night had lower (p<0.05) post-awakening cortisol levels compared to parents staying their first night.

The findings of this thesis conclude that being together as a family is important for the parents’ sleep. The ability to be accommodated in the hospital and gather the family around the child may have given the parents time for relaxation and recovery, that in turn may lead to a less stressful hospital stay. When it is beneficial for the child, the whole family should be included in the pediatric care. Moreover, pediatric nurses must acknowledge parents’ sleep, in hospital and at home. Medical treatment and care at night should be scheduled and sleep promoted for the parents in order to maintain health and well-being in the family.

Background

Child physical abuse (CPA) is an extensive public health problem because of its associations with poor health outcomes. The aim of this study was to examine which of the background factors of CPA committed by a parent or other caregiver relates to self-reported poor health among girls and boys (13; 15 and 17 years old): perpetrator, last year exposure; severity and frequency; socioeconomic load and foreign background.

Methods

In a cross-sectional study in a Swedish county (n = 8024) a path analysis was performed to evaluate a model where all background variables were put as predictors of three health-status variables: mental; physical and general health problems. In a second step a log linear analysis was performed to examine how the distribution over the health-status categories was different for different combinations of background factors.

Results

Children exposed to CPA reported poor health to a much higher extent than those who were not exposed. In the path analysis it was found that frequency and severity of abuse (boys only) and having experienced CPA during the last year, was significantly associated with poor health as well as socioeconomic load in the families. Foreign background was significantly negatively associated with all three health indicators especially for girls. Neither mother nor father as perpetrator remained significant in the path analysis, while the results from the log linear analyses showed that mother-abuse did in fact relate to poor general health and mental as well as physical health problems among boys and girls. Father-abuse was associated with poor mental health if severe abuse was reported. Poor mental health was also associated with mild father-abuse if exposure during the last year was reported.

Conclusion

Despite the limitations that cross-sectional studies imply, this study provides new knowledge about factors associated with poor health among physically abused children. It describes details of CPA that have significant associations to different aspects of poor health and thus what needs to be addressed by professionals within mental health providers and social services. Understanding how different factors may contribute to different health outcomes for exposed children is important in future research and needs further studies.

Decades of research have revealed numerous risk factors for mental disorders beyond genetics, but their consistency and magnitude remain uncer-tain. We conducted a "meta-umbrella" systematic synthesis of umbrella reviews, which are systematic reviews of meta-analyses of individual studies, by searching international databases from inception to January 1, 2021. We included umbrella reviews on non-purely genetic risk or protective factors for any ICD/DSM mental disorders, applying an established classification of the credibility of the evidence: class I (convincing), class II (highly suggestive), class III (suggestive), class IV (weak). Sensitivity analyses were conducted on prospective studies to test for temporality (reverse causation), TRANSD criteria were applied to test transdiagnosticity of factors, and A Measurement Tool to Assess Systematic Reviews (AMSTAR) was employed to address the quality of meta-analyses. Fourteen eligible umbrella reviews were retrieved, summarizing 390 meta-analyses and 1,180 associations between putative risk or protective factors and mental disorders. We included 176 class I to III evidence associations, relating to 142 risk/protective factors. The most robust risk factors (class I or II, from prospective designs) were 21. For dementia, they included type 2 diabetes mellitus (risk ratio, RR from 1.54 to 2.28), depression (RR from 1.65 to 1.99) and low frequency of social contacts (RR=1.57). For opioid use disorders, the most robust risk factor was tobacco smoking (odds ratio, OR=3.07). For non-organic psychotic disorders, the most robust risk factors were clinical high risk state for psychosis (OR=9.32), cannabis use (OR=3.90), and childhood adversities (OR=2.80). For depressive disorders, they were widowhood (RR=5.59), sexual dysfunction (OR=2.71), three (OR=1.99) or four-five (OR=2.06) metabolic factors, childhood physical (OR=1.98) and sexual (OR=2.42) abuse, job strain (OR=1.77), obesity (OR=1.35), and sleep disturbances (RR=1.92). For autism spectrum disorder, the most robust risk factor was maternal overweight pre/during pregnancy (RR=1.28). For attention-deficit/hyperactivity disorder (ADHD), they were maternal pre-pregnancy obesity (OR=1.63), maternal smoking during pregnancy (OR=1.60), and maternal overweight pre/during pregnancy (OR=1.28). Only one robust protective factor was detected: high physical activity (hazard ratio, HR=0.62) for Alzheimers disease. In all, 32.9% of the associations were of high quality, 48.9% of medium quality, and 18.2% of low quality. Transdiagnostic class I-III risk/protective factors were mostly involved in the early neurodevelopmental period. The evidence-based atlas of key risk and protective factors identified in this study represents a benchmark for advancing clinical characterization and research, and for expanding early intervention and preventive strategies for mental disorders.

Introduction Anxiety disorders have a high lifetime prevalence, early-onset and long duration or chronicity. Exposure therapy is considered one of the most effective elements in cognitive behavioural therapy (CBT) for anxiety, but in vivo exposure can be challenging to access and control, and is sometimes rejected by patients because they consider it too aversive. Virtual reality allows flexible and controlled exposure to challenging situations in an immersive and protected environment. Aim The SoREAL-trial aims to investigate the effect of group cognitive behavioural therapy (CBT-in vivo) versus group CBT with virtual reality exposure (CBT-in virtuo) for patients diagnosed with social anxiety disorder and/or agoraphobia, in mixed groups. Methods and analysis The design is an investigator-initiated randomised, assessor-blinded, parallel-group and superiority-designed clinical trial. Three hundred two patients diagnosed with social anxiety disorder and/or agoraphobia will be included from the regional mental health centres of Copenhagen and North Sealand and the Northern Region of Denmark. All patients will be offered a manual-based 14-week cognitive behavioural group treatment programme, including eight sessions with exposure therapy. Therapy groups will be centrally randomised with concealed allocation sequence to either CBT-in virtuo or CBT-in vivo. Patients will be assessed at baseline, post-treatment and 1-year follow-up by treatment blinded researchers and research assistants. The primary outcome will be diagnosis-specific symptoms measured with the Liebowitz Social Anxiety Scale for patients with social anxiety disorder and the Mobility Inventory for Agoraphobia for patients with agoraphobia. Secondary outcome measures will include depression symptoms, social functioning and patient satisfaction. Exploratory outcomes will be substance and alcohol use, working alliance and quality of life. Ethics and dissemination The trial has been approved by the research ethics committee in the Capital Region of Denmark. All results, positive, negative as well as inconclusive, will be published as quickly as possible and still in concordance with Danish law on the protection of confidentially and personal information. Results will be presented at national and international scientific conferences. The trial has obtained approval by the Regional Ethics Committee of Zealand (H-6-2013-015) and the Danish Data Protection Agency (RHP-2014-009-02670). The trial is registered at ClinicalTrial.gov as NCT03845101. The patients will receive information on the trial both verbally and in written form. Written informed consent will be obtained from each patient before inclusion in the trial. The consent form will be scanned and stored in the database system and the physical copy will be destroyed. It is emphasised that participation in the trial is voluntary and that the patient can withdraw his or her consent at any time without consequences for further and continued treatment.

Social anxiety disorder (SAD) is a highly prevalent and impairing disorder. Current bestpractice is cognitive behavioral therapy (CBT), but there are several challenges associatedwith performing exposure therapy. Virtual reality exposure (VRE) may improvetreatment efficacy of SAD in a group therapy context, because it allows for greatercontrol, flexibility, and individualization of the exposure stimuli. However, to date nostudy has investigated the use of VRE for SAD in a group context. In the present study,nine patients who had undergone group CBT with VRE for SAD and three therapistsresponsible for the treatment were interviewed about their experiences. The objective ofthe study was to investigate the practical and therapeutic challenges of using VRE in agroup therapy context. Thematic analysis was used to analyze the data. The resultsshowed that it was difficult for the patients to engage with the VRE in a group therapycontext and that there were several practical challenges. However, all participants foundthe VRE exercises to be meaningful, because it gave them a medium to practice andunderstand typically avoided social situations. The latter has not previously beendescribed as a treatment mechanism for anxiety through virtual reality. However, theappropriateness of VRE in group therapy remains unclear. Implications are discussed.

Artificial intelligence as a medical device is increasingly being applied to healthcare for diagnosis, risk stratification and resource allocation. However, a growing body of evidence has highlighted the risk of algorithmic bias, which may perpetuate existing health inequity. This problem arises in part because of systemic inequalities in dataset curation, unequal opportunity to participate in research and inequalities of access. This study aims to explore existing standards, frameworks and best practices for ensuring adequate data diversity in health datasets. Exploring the body of existing literature and expert views is an important step towards the development of consensus-based guidelines. The study comprises two parts: a systematic review of existing standards, frameworks and best practices for healthcare datasets; and a survey and thematic analysis of stakeholder views of bias, health equity and best practices for artificial intelligence as a medical device. We found that the need for dataset diversity was well described in literature, and experts generally favored the development of a robust set of guidelines, but there were mixed views about how these could be implemented practically. The outputs of this study will be used to inform the development of standards for transparency of data diversity in health datasets (the STANDING Together initiative). A systematic review, combined with a stakeholder survey, presents an overview of current practices and recommendations for dataset curation in health, with specific focuses on data diversity and artificial intelligence-based applications.

We mapped the evidence on the type and strength of associations between a broad range of mental and physical conditions in children and adolescents, by carrying out an umbrella review, i.e., a quantitative synthesis of previous systematic reviews and meta-analyses. We also assessed to which extent the links between mental and physical conditions vary across disorders or, by contrast, are transdiagnostic. Based on a pre-established protocol, we retained 45 systematic reviews/meta-analyses, encompassing around 12.5 million of participants. In analyses limited to the most rigorous estimates, we found evidence for the following associations: ADHD-asthma, ADHDobesity, and depression-asthma. A transdiagnostic association was confirmed between asthma and anxiety/ASD/depression/bipolar disorder, between obesity and ADHD/ASD/depression, and between dermatitis and ASD/ADHD. We conclude that obesity and allergic conditions are likely to be associated with mental disorders in children and adolescents. Our results can help clinicians explore potential links between mental and physical conditions in children/adolescent and provide a road map for future studies aimed at shading light on the underlying factors.

Background: Depressed suicide attempters are, according to some earlier studies, treated more often with antipsychotics than depressive non-suicide attempters. Cluster B personality disorders, especially borderline personality disorder, are associated with a high suicide risk, and antipsychotics are commonly used for the reduction of symptoms. However, no previous study has taken comorbid personality disorders into account when assessing the use of antipsychotics in patients with unipolar depression. Therefore, the aim of this study was to investigate the clinical selection of pharmacotherapy in unipolar depression with and without a previous suicide attempt, taking into account potential confounders such as cluster B personality disorders. Methods: The study sample consisted of 247 patients with unipolar depression. The study was approved by the Regional Ethical Review Board in Lund, Sweden. Study participants were recruited from 4 different secondary psychiatric care clinics in Sweden and were diagnosed according to the DSM-IV-TR with the MINI and SCID II. Previous and ongoing psychiatric treatments were investigated in detail and medical records were assessed. Results: Thirty percent of the patients had made previous suicide attempts. Depressed suicide attempters underwent both lifetime treatment with antipsychotics and an ongoing antipsychotic treatment significantly more often than non-attempters. Significances remained after a regression analysis, adjusting for cluster B personality disorders, symptom severity, age at the onset of depression, and lifetime psychotic symptoms. Conclusions: This is the first study to consider the effect of comorbidity with cluster B personality disorders when comparing treatment of depressive suicide and non-suicide attempters. Our findings suggest that suicide attempters are more frequently treated with antipsychotics compared to non-suicide attempters, regardless of cluster B personality disorder comorbidity. These findings are important for clinicians to consider and would also be relevant to future studies evaluating reduction of suicide risk with antipsychotics in patients with psychiatric comorbidity and a history of attempted suicide.