Identifying predictors of adverse outcomes after termination of seclusion in psychiatric intensive care units.

BACKGROUND: Seclusion is a restrictive practice that many healthcare services are trying to reduce. Previous studies have sought to identify predictors of seclusion initiation, but few have investigated factors associated with adverse outcomes after seclusion termination. AIMS: To assess the factors that predict an adverse outcome within 24 h of seclusion termination. METHOD: In a cohort study of individuals secluded in psychiatric intensive care units, we investigated factors associated with any of the following outcomes: actual violence, attempted violence, or reinitiation of seclusion within 24 h of seclusion termination. Among the seclusion episodes that were initiated between 29 March 2018 and 4 March 2019, we investigated the exposures of medication cooperation, seclusion duration, termination out of working hours, involvement of medical staff in the final seclusion review, lack of insight, and agitation or irritability. In a mixed-effects logistic regression model, associations between each exposure and the outcome were calculated. Odds ratios were calculated unadjusted and adjusted for demographic and clinical variables. RESULTS: We identified 254 seclusion episodes from 122 individuals (40 female, 82 male), of which 106 (41.7%) had an adverse outcome within 24 h of seclusion termination. Agitation or irritability was associated with an adverse outcome, odds ratio 1.92 (95% CI 1.03 to 3.56, P = 0.04), but there was no statistically significant association with any of the other exposures, although confidence intervals were broad. CONCLUSIONS: Agitation or irritability in the hours preceding termination of seclusion may predict an adverse outcome. The study was not powered to detect other potentially clinically significant factors.

Exploring causal mechanisms of psychosis risk.

Robust epidemiological evidence of risk and protective factors for psychosis is essential to inform preventive interventions. Previous evidence syntheses have classified these risk and protective factors according to their strength of association with psychosis. In this critical review we appraise the distinct and overlapping mechanisms of 25 key environmental risk factors for psychosis, and link these to mechanistic pathways that may contribute to neurochemical alterations hypothesised to underlie psychotic symptoms. We then discuss the implications of our findings for future research, specifically considering interactions between factors, exploring universal and subgroup-specific factors, improving understanding of temporality and risk dynamics, standardising operationalisation and measurement of risk and protective factors, and developing preventive interventions targeting risk and protective factors.

PsyCog: A computerised mini battery for assessing cognition in psychosis.

Despite the functional impact of cognitive deficit in people with psychosis, objective cognitive assessment is not typically part of routine clinical care. This is partly due to the length of traditional assessments and the need for a highly trained administrator. Brief, automated computerised assessments could help to address this issue. We present data from an evaluation of PsyCog, a computerised, non-verbal, mini battery of cognitive tests. Healthy Control (HC) (N = 135), Clinical High Risk (CHR) (N = 233), and First Episode Psychosis (FEP) (N = 301) participants from a multi-centre prospective study were assessed at baseline, 6 months, and 12 months. PsyCog was used to assess cognitive performance at baseline and at up to two follow-up timepoints. Mean total testing time was 35.95 min (SD = 2.87). Relative to HCs, effect sizes of performance impairments were medium to large in FEP patients (composite score G = 1.21, subtest range = 0.52-0.88) and small to medium in CHR patients (composite score G = 0.59, subtest range = 0.18-0.49). Site effects were minimal, and test-retest reliability of the PsyCog composite was good (ICC = 0.82-0.89), though some practice effects and differences in data completion between groups were found. The present implementation of PsyCog shows it to be a useful tool for assessing cognitive function in people with psychosis. Computerised cognitive assessments have the potential to facilitate the evaluation of cognition in psychosis in both research and in clinical care, though caution should still be taken in terms of implementation and study design.

The prevalence of premenstrual dysphoric disorder: Systematic review and meta-analysis.

BACKGROUND: Premenstrual dysphoric disorder is characterised by symptoms confined to the premenstrual phase of the menstrual cycle. Confirmed diagnosis requires prospective monitoring of symptoms over two cycles, otherwise the diagnosis is provisional. We aimed to measure the point prevalence of premenstrual dysphoric disorder. METHODS: We searched for studies of prevalence using MEDLINE, EMBASE, PsycINFO and PubMed. For each study, the total sample size and number of cases were extracted. The prevalence across studies was calculated using random effects meta-analysis with a generalised linear mixed model. Potential sources of heterogeneity were explored by meta-regression and subgroup analyses. Pre-registration was with PROSPERO (CRD42021249249). RESULTS: 44 studies with 48 independent samples met inclusion criteria, consisting of 50,659 participants. The pooled prevalence was 3.2 % (95 % confidence intervals: 1.7 %-5.9 %) for confirmed and 7.7 % (95 % confidence intervals: 5.3 %-11.0 %) for provisional diagnosis. There was high heterogeneity across all studies (I2 = 99 %). Sources of heterogeneity identified by meta-regression were continent of sample (p < 0.0001), type of sample (community-based, university, high school) (p = 0.007), risk of bias (p = 0.009), and method of diagnosis (p = 0.017). Restricting the analysis to community-based samples using confirmed diagnosis resulted in a prevalence of 1.6 % (95 % confidence intervals: 1.0 %-2.5 %), with low heterogeneity (I2 = 26 %). LIMITATIONS: A small number of included studies used full DSM criteria in community settings. CONCLUSIONS: The point prevalence of premenstrual dysphoric disorder using confirmed diagnosis is lower compared with provisional diagnosis. Studies relying on provisional diagnosis are likely to produce artificially high prevalence rates.

The Translational Future of Stress Neurobiology and Psychosis Vulnerability: A Review of the Evidence.

Psychosocial stress is a well-established risk factor for psychosis, yet the neurobiological mechanisms underlying this relationship have yet to be fully elucidated. Much of the research in this field has investigated hypothalamic-pituitary-adrenal (HPA) axis function and immuno-inflammatory processes among individuals with established psychotic disorders. However, as such studies are limited in their ability to provide knowledge that can be used to develop preventative interventions, it is important to shift the focus to individuals with increased vulnerability for psychosis (i.e., high-risk groups). In the present article, we provide an overview of the current methods for identifying individuals at high-risk for psychosis and review the psychosocial stressors that have been most consistently associated with psychosis risk. We then describe a network of interacting physiological systems that are hypothesised to mediate the relationship between psychosocial stress and the manifestation of psychotic illness and critically review evidence that abnormalities within these systems characterise highrisk populations. We found that studies of high-risk groups have yielded highly variable findings, likely due to (i) the heterogeneity both within and across high-risk samples, (ii) the diversity of psychosocial stressors implicated in psychosis, and (iii) that most studies examine single markers of isolated neurobiological systems. We propose that to move the field forward, we require well-designed, largescale translational studies that integrate multi-domain, putative stress-related biomarkers to determine their prognostic value in high-risk samples. We advocate that such investigations are highly warranted, given that psychosocial stress is undoubtedly a relevant risk factor for psychotic disorders.

Risk of unemployment and work disability among refugee and non-refugee migrants with incident psychotic disorders in Sweden and Denmark.

BACKGROUND: Unemployment and work disability are common among individuals with non-affective psychotic disorders (NAPDs) but it is unknown whether rates differ among migrants and native-born individuals. The present study aimed to compare the risk of these outcomes during the first 5 years of illness in non-refugee migrants, refugees and native-born individuals with NAPDs in Sweden and Denmark-two countries with different immigration policies and models of early psychosis care. METHODS: Using national registers, we identified all individuals aged 18-35 years in Sweden and Denmark who received an incident NAPD diagnosis between 2006 and 2013 (N = 6750 and 8320, respectively). Cohorts were followed for 5 years to determine the days of unemployment and sickness absence (analyzed using zero-inflated negative binomial models) and the time to receipt of disability pension (analyzed using complementary log-log models). RESULTS: Relative to their native-born peers, refugees and non-refugee migrants in Sweden and non-refugee migrants in Denmark were significantly less likely to have zero unemployment days (OR range: 0.54-0.72) and all migrant groups experienced more unemployment days (IRR range: 1.26-1.37). Results were largely unchanged after adjustment for sociodemographic and clinical factors. In the adjusted model, both Swedish migrant groups and refugees in Denmark were more likely to experience zero sickness absence days than native-born individuals (OR range: 1.48-1.56). Only refugees in Denmark were at greater risk of disability pension. CONCLUSIONS: Non-refugee migrants and refugees with NAPDs in both Sweden and Denmark are particularly vulnerable to experiencing unemployment. Targeted interventions may help to reduce these disparities and promote long-term work ability among migrant groups.

Incidence of non-affective psychotic disorders in refugees and peers growing up in Denmark and Sweden: a registry linkage study.

PURPOSE: Higher rates of non-affective psychotic disorders (NAPD) in minority groups have been reported in many countries. However, few studies have explored how rates differ between refugees and other minority groups and none with an international comparative angle. A comparative perspective makes it possible to relate group differences to aspects national context that underpin the social determinants of disease. METHODS: We compared the incidence of treated NAPD among youth born in or who immigrated to Denmark/Sweden before turning 18. Youth aged 18-35 during 2006-2018 were included (NDenmark/NSweden = 1,606,423/2,614,721) and were followed until first NAPD treatment (cases [Denmark/Sweden] = 12,193/9,641), 36th birthday, emigration or death. Incidence rates (IR) and ratios (IRR) comparing refugees, non-refugee migrants, descendants of non-refugee migrants and majority youth were obtained through Poisson regression on data aggregated by country, sex and age, contrasted by sex and country. Complementary analyses on individual-level data adjusting for further socio-demographic factors were conducted in each country separately. RESULTS: Incidence rates were higher in all groups compared with the majority group (IRRrange = 1.4-2.9, 95% CI[min, max] = 1.2-3.1). Relative differences between the three minority groups were smaller (IRRrange = 0.7-1.0, 95% CI[min, max] = 0.5-1.2). Although incidence rates were higher in Denmark than Sweden, relative group differences were similar. CONCLUSION: Exposures shared between young refugees and other minority groups growing up in Denmark and Sweden may be especially important for their excess risk of NAPD. Further studies should investigate the mechanisms behind the elevated rates in minority groups with special paid attention to factors such as discrimination, social exclusion and acculturation stress.

Comparison of Hospitalization for Nonaffective Psychotic Disorders Among Refugee, Migrant, and Native-Born Adults in Sweden and Denmark.

Importance: Determining whether migrants with nonaffective psychotic disorders (NAPDs) experience poorer outcomes after illness onset is essential to ensure adequate health care provision to these disadvantaged populations. Objective: To compare cumulative hospital days for NAPDs during the first 5 years of illness among refugee, nonrefugee, and second-generation migrants and their Swedish and Danish peers. Design, Setting, and Participants: This was a prospective cohort study of individuals treated for incident NAPDs in inpatient or outpatient settings between January 1, 2006, and December 31, 2013, and followed up for 5 years. This population-based study used Swedish and Danish national registries. Included participants were individuals in Sweden and Denmark, aged 18 to 35 years, treated for incident NAPDs. Data analyses were conducted from November 2022 to August 2023. Exposures: Population group (determined according to residency in either country, not both countries), categorized as refugee (migrants whose residence in Sweden or Denmark was registered as refugee status or family reunification with a refugee), nonrefugee (all other individuals born outside Sweden and Denmark), second generation (individuals born in Sweden or Denmark with at least 1 parent born abroad), or native born (individuals born in Sweden or Denmark with both parents born in these countries). Main Outcome and Measures: Total hospital days for NAPDs during the first 5 years of illness, analyzed using a hurdle model. Among those ever admitted, total number of admissions and mean admission length were examined. Results: In total, 7733 individuals in Sweden (mean [SD] age, 26.0 [5.1] years; 4919 male [63.6%]) and 8747 in Denmark (mean [SD] age 24.8 [5.0] years; 5324 male [60.9%]) were followed up for 5 years or until death or emigration. After adjusting for a range of sociodemographic and clinical factors, the odds of experiencing any hospital days for NAPD were significantly higher among migrant groups compared with their native-born peers (Sweden: second generation, odds ratio [OR], 1.17; 95% CI, 1.03-1.33; P = .01; nonrefugee migrant, OR, 1.45; 95% CI, 1.21-1.73; P < .001; refugee, OR, 1.25; 95% CI, 1.06-1.47; P = .009; Denmark: second generation, OR, 1.21; 95% CI, 1.05-1.40; P = .01; nonrefugee migrant, OR, 1.33; 95% CI, 1.14-1.55; P < .001). These odds were highest among nonrefugee (Sweden: OR, 2.53; 95% CI, 1.59-4.03; P < .001; Denmark: OR, 2.61; 95% CI, 1.70-4.01; P < .001) and refugee (Sweden: OR, 1.96; 95% CI, 1.43-2.69; P < .001; Denmark: OR, 2.14; 95% CI, 1.42-3.21; P < .001) migrants from Africa and those who had arrived within 3 to 5 years (Sweden: nonrefugee migrants, OR, 1.93; 95% CI, 1.26-2.95; P = .002; refugees, OR, 2.38; 95% CI, 1.46-3.88; P < .001; Denmark: nonrefugee migrants, OR, 1.66; 95% CI, 0.96-2.85; P = .07; refugees, OR, 3.40; 95% CI, 1.13-10.17; P = .03). Among those ever hospitalized, refugees in both countries (Sweden, incidence rate ratio [IRR], 1.30; 95% CI, 1.12-1.51; P < .001; Denmark, IRR, 1.47; 95% CI, 1.24-1.75; P < .001) and second-generation migrants in Denmark (IRR, 1.22; 95% CI, 1.07-1.39; P = .003) experienced more days hospitalized for NAPDs than native-born individuals. Conclusions and Relevance: In this prospective cohort study of individuals with NAPDs, results suggest that refugee, nonrefugee, and second-generation migrants experience more days hospitalized for these disorders than their native-born peers. Patterns were consistent across 2 countries with different models of psychosis care and immigration and integration policies.

Predictors of positive patient-reported outcomes from 'Early Intervention in Psychosis': a national cross-sectional study.

BACKGROUND: The components of care delivered by Early Intervention in Psychosis (EIP) services vary, but the impact on patient experience is unknown. OBJECTIVE: To investigate associations between components of care provided by EIP services in England and patient-reported outcomes. METHODS: 2374 patients from EIP services in England were surveyed during the National Clinical Audit of Psychosis. Participants were asked about the care they received, and completed the 'Patient Global Impressions' Scale (rating whether their mental health had improved), and 'Friends and Family Test' (rating whether they would recommend their service). Information about service structure was obtained from service providers. We analysed associations between outcomes and components of care using multilevel regression. FINDINGS: The majority of participants were likely to recommend the treatment they had received (89.8%), and felt that their mental health had improved (89.0%). Participants from services where care coordinators had larger case loads were less likely to recommend their care. Participants were more likely to recommend their care if they had been offered cognitive behavioural therapy for psychosis, family therapy or targeted interventions for carers. Participants were more likely to report that their mental health had improved if they had been offered cognitive behavioural therapy for psychosis or targeted interventions for carers. CONCLUSIONS: Specific components of EIP care were associated with improved patient reported outcomes. Psychosocial interventions and carer support may be particularly important in optimising outcomes for patients. CLINICAL IMPLICATIONS: These findings emphasise the need for small case load sizes and comprehensive packages of treatment in EIP services.

Stressful life events and relapse of psychosis: analysis of causal association in a 2-year prospective observational cohort of individuals with first-episode psychosis in the UK.

BACKGROUND: Despite accumulating evidence of an association between stressful life events and psychosis relapse, the extent to which this is a causal relationship remains unclear. We aimed to examine the association between exposure to, and number of, stressful life events after initial psychosis onset and psychosis relapse. METHODS: In this 2-year prospective observational study, we recruited individuals with first-episode psychosis, aged 18-65 years, who presented to psychiatric services in south London, UK. Participants were assessed via interview, with additional data obtained from electronic clinical records. Stressful life events were recorded at psychosis onset and during the 2-year follow-up using a brief questionnaire that assesses 12 major life events. Psychosis relapse was defined as inpatient admission because of symptom exacerbation within 2 years from psychosis onset. We examined the time to first psychosis relapse and the number and length of relapses using survival and binomial regression analyses. We used fixed-effects regression and cross-lagged path analysis to examine the directionality of effects and control for unmeasured confounders. FINDINGS: Between April 12, 2002, and July 26, 2013, 256 individuals with first-episode psychosis (100 [39%] female and 156 [61%] male; 16 [6%] Asian, 140 [55%] Black African or Caribbean, 86 [34%] White, and 14 [6%] mixed ethnicity) were recruited, with a mean age of onset of psychosis of 28·06 years (SD 8·03; range 17·21-56·03). 93 (36%) participants experienced at least one relapse during the 2-year follow-up. 253 individuals had all relevant data and were included in analyses. For people exposed to stressful life events after the onset of psychosis, the adjusted hazard (hazard ratio [HR] 2·60, 95% CI 1·63-4·16, p<0·0001), incidence (incidence rate ratio [IRR] 1·87, 1·24-2·80, p=0·0026), and length (IRR 2·53, 1·40-4·67, p=0·0011) of relapse were greater than for those who were unexposed. These relationships were dose dependent (HR 1·36; 1·09-1·69, p=0·0054; incidence IRR 1·26, 1·02-1·53, p=0·023; length IRR 1·52, 1·12-2·12, p=0·0028). Adjusted fixed-effects models showed a higher (odds ratio [OR] 3·82, 1·82-8·00, p=0·0004) and dose-dependent (OR 1·62, 1·18-2·21, p=0·0028) risk of relapse when stressful life events preceded relapse compared with the period when they did not. Cross-lagged path analysis confirmed an effect of stressful life events on the number of subsequent relapses (ß=0·66, p=0·0055) that was dose dependent (ß=0·29, p=0·029), but it did not show an effect of relapses on subsequent risk or number of stressful life events. INTERPRETATION: These results provide converging evidence of a causal effect of stressful life events on the risk of relapse in psychosis. They suggest that there is a need to develop interventions at the individual and health-service level that could mitigate the harmful effects of stressful life events. FUNDING: National Institute for Health Research, UK.

Systematic review of the association between adverse life events and the onset and relapse of postpartum psychosis.

Postpartum psychosis is defined as a psychotic episode occurring within 4 to 6 weeks of childbirth. While there is robust evidence that adverse life events are associated with the onset and relapse of psychosis outside the postpartum period, the extent to which these contribute to postpartum psychosis is less clear. This systematic review examined whether adverse life events are associated with an increased likelihood of developing postpartum psychosis or subsequent relapse in women diagnosed with postpartum psychosis. The following databases were searched from inception to June 2021: MEDLINE, EMBASE, PsycInfo. Study level data were extracted including setting, number of participants, type of adverse event, and differences between groups. A modified version of the Newcastle-Ottawa Quality Assessments Scale was used to assess risk of bias. In total, 1933 records were identified, of which 17 met the inclusion criteria, comprising nine case-control studies and eight cohort studies. Most studies (16/17) examined the association between adverse life events and the onset of postpartum psychosis, with only in which the outcome was relapse of psychosis. Overall, there were 63 different measures of adversity examined (most of which were examined in a single study only) and 87 associations between these measures and postpartum psychosis tested across the studies. In terms of statistically significant associations with onset/relapse of postpartum psychosis, 15 (17%) were positive (i.e., the adverse event increased the risk of onset/relapse), 4 (5%) were negative, and 68 (78%) were not statistically significant. Our review highlights the diversity of risk factors examined in this field, with few attempts at replication, hence limiting the ability to conclude that any single risk factor is robustly associated with the onset of postpartum psychosis. Further large-scale studies, that attempt to replicate earlier studies, are urgently needed to determine whether adverse life events play a role in the onset and exacerbation of postpartum psychosis. Systematic review registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=260592], identifier [CRD42021260592].

Antipsychotic treatment patterns in refugees and their Swedish-born peers with first-episode non-affective psychosis: findings from the REMAIN study.

BACKGROUND: Previous studies suggest that migrants tend to utilise antipsychotics less often than their native-born peers. However, studies examining antipsychotic use among refugees with psychosis are lacking. AIMS: To compare the prevalence of antipsychotic drug use during the first 5 years of illness among refugees and Swedish-born individuals with a newly diagnosed non-affective psychotic disorder, and to identify sociodemographic and clinical factors associated with antipsychotic use. METHOD: The study population included refugees (n = 1656) and Swedish-born persons (n = 8908) aged 18-35 years during 2007-2018, with incident diagnosis of non-affective psychotic disorder recorded in the Swedish in-patient or specialised out-patient care register. Two-week point prevalence of antipsychotics use was assessed every 6 months in the 5 years following first diagnosis. Factors associated with antipsychotic use (versus non-use) at 1 year after diagnosis were examined with modified Poisson regression. RESULTS: Refugees were somewhat less likely to use antipsychotics at 1 year after first diagnosis compared with Swedish-born persons (37.1% v. 42.2%, age- and gender-adjusted risk ratio 0.88, 95% CI 0.82-0.95). However, at the 5-year follow-up, refugees and Swedish-born individuals showed similar patterns of antipsychotic use (41.1% v. 40.4%). Among refugees, higher educational level (>12 years), previous antidepressant use and being diagnosed with schizophrenia/schizoaffective disorder at baseline were associated with an increased risk of antipsychotics use, whereas being born in Afghanistan or Iraq (compared with former Yugoslavia) was associated with decreased risk. CONCLUSIONS: Our findings suggest that refugees with non-affective psychotic disorders may need targeted interventions to ensure antipsychotic use during the early phase of illness.

Patient factors associated with receipt of psychological and pharmacological treatments among individuals with common mental disorders in a Swedish primary care setting.

BACKGROUND: Psychological and pharmacological therapies are the recommended first-line treatments for common mental disorders (CMDs) but may not be universally accessible or utilised. AIMS: To determine the extent to which primary care patients with CMDs receive treatment and the impact of sociodemographic, work-related and clinical factors on treatment receipt. METHOD: National registers were used to identify all Stockholm County residents aged 19-64 years who had received at least one CMD diagnosis (depression, anxiety, stress-related) in primary care between 2014 and 2018. Individuals were followed from the date of their first observed CMD diagnosis until the end of 2019 to determine treatment receipt. Associations between patient factors and treatment group were examined using multinomial logistic regression. RESULTS: Among 223 271 individuals with CMDs, 30.6% received pharmacotherapy only, 16.5% received psychological therapy only, 43.1% received both and 9.8% had no treatment. The odds of receiving any treatment were lower among males (odds ratio (OR) range = 0.76 to 0.92, 95% CI[minimum, maximum] 0.74 to 0.95), individuals born outside of Sweden (OR range = 0.67 to 0.93, 95% CI[minimum, maximum] 0.65 to 0.99) and those with stress-related disorders only (OR range = 0.21 to 0.51, 95% CI[minimum, maximum] 0.20 to 0.53). Among the patient factors examined, CMD diagnostic group, prior treatment in secondary psychiatric care and age made the largest contributions to the model (R2 difference: 16.05%, 1.72% and 1.61%, respectively). CONCLUSIONS: Although over 90% of primary care patients with CMDs received pharmacological and/or psychological therapy, specific patient groups were less likely to receive treatment.

Period effects in the risk of labour market marginalization among refugees in Sweden: a register-based cohort study.

BACKGROUND: Changes in Swedish national insurance policies over time and/or migration-related health inequalities may influence the risk for labour market marginalization (LMM) in refugees as compared to the Swedish-born host population. This study aimed to investigate potential period effects in the association between refugee status and the risk of LMM and explore any differences by country of birth, age and duration of residence. METHODS: Using national registers, three cohorts including all Swedish residents during 1999, 2004 and 2009 were followed for 4 years (cohort 2000, 2005 and 2010). Cox regression models were used to examine associations between refugee status and LMM defined as long-term unemployment (>180 days annually) and disability pension. The analyses were adjusted for socio-demographic factors, morbidities and labour market-related factors. Stratified analyses were run for age, country of birth and duration of residence. RESULTS: Across the cohorts, hazard ratios (HRs) were higher for long-term unemployment [2000: HR = 1.98; 95% confidence interval (CI): 1.96-2.01; 2005: HR = 2.30; 95% CI: 2.27-2.33; 2010: HR = 2.78; 95% CI: 2.75-2.81] for refugees compared to Swedish-born but not for disability pension. HRs for long-term unemployment were highest among refugees aged 25-34 and 35-44 years, from Somalia, Afghanistan and Iraq and refugees with a shorter duration of residence. CONCLUSIONS: The risk of long-term unemployment appears to have increased for refugees over time. Particularly some refugee subgroups experienced more difficulties. These findings highlight ongoing disparities for refugees and implicate on a broader scale that changes in policies such as stricter regulations in the insurance or healthcare system might adversely affect them.

Differences in all-cause and cause-specific mortality due to external causes and suicide between young adult refugees, non-refugee immigrants and Swedish-born young adults: The role of education and migration-related factors.

BACKGROUND: International migration has increased during the past years and little is known about the mortality of young adult immigrants and refugees that came to Sweden as children. This study aimed to investigate 1) the risk of all-cause and cause-specific mortality in young accompanied and unaccompanied refugees and non-refugee immigrants compared to Swedish born individuals; and 2) to determine the role of educational level and migrations-related factors in these associations. METHODS: This register linkage study is based on 682,358 individuals (633,167 Swedish-born, 2,163 unaccompanied and 25,658 accompanied refugees and 21,370 non-refugee immigrants) 19-25 years old, who resided in Sweden 31.12.2004. Outcomes were all-cause mortality and mortality due to suicide and external causes. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox regression models with a maximum follow-up to 2016. RESULTS: After adjusting for covariates, all-cause mortality was significantly lower in non-refugee immigrants (aHR 0.70, 95% CI 0.59-0.84) and refugees (aHR 0.76, 95% CI 0.65-0.88) compared to Swedish-born individuals. The same direction of association was observed for mortality due to suicide and external causes. No differences between accompanied and unaccompanied refugees were found. Risk estimates for all migrant groups varied with educational level, duration of residency, age at arrival and country of birth. Further, the mortality risk of migrants arriving in Sweden before the age of 6 years did not significantly differ from the risk of their Swedish-born peers. Low education was a considerable risk factor. CONCLUSION: In general, young adult refugees and non-refugee immigrants have a lower risk of all-cause and cause-specific mortality than Swedish-born individuals. The identified migrant groups with higher mortality risk need specific attention.

Dissociable impairments of verbal learning differentiate childhood risk profiles for schizophrenia.

Poor verbal learning and memory function is well-documented among individuals with schizophrenia and those at clinical high-risk for psychosis. This study aimed to identify these impairments among children aged 9-12 years with different schizophrenia risk profiles (family history or antecedents of schizophrenia, each of higher[H] or lower[L] risk load) relative to typically developing peers. These three groups were recruited via community-screening, and differentiated for analysis into: typically developing children (TD = 45); children who had 1 first- or ≥2 second-degree affected relatives (FHxH = 16) or one second-degree relative (FHxL = 15); and children presenting multiple replicated antecedents of schizophrenia whose clinical symptoms persisted at 2- and/or 4-year follow-up (ASzH = 16) or remitted during follow-up (ASzL = 16). Verbal learning/memory measures assessed at baseline (age 9-12 years) included: (i) total recall; (ii) trial 1 recall; (iii) learning score; (iv) intrusions; (v) total words lost; and (vi) serial position patterns. Analyses of variance indicated that FHxH and ASzH youth demonstrated impaired total recall compared to TD and ASzL children and lost significantly more words between trials than TD and FHxL children. Learning score was impaired among both FHxH and FHxL relative to TD and ASzL children. Thus, among putatively at-risk children, total words recalled and lost distinguished those with higher risk load (by family history or persistent antecedent symptomology), whereas learning score indexed familial vulnerability. Follow-up of the sample is needed to determine the capacity of verbal learning deficits to predict later illness and provide a potential avenue for early remediation to improve clinical or functional outcomes.

Cortisol Levels in Childhood Associated With Emergence of Attenuated Psychotic Symptoms in Early Adulthood.

BACKGROUND: In individuals at clinical high-risk for psychosis, elevated cortisol levels predict subsequent onset of psychotic disorder. However, it is unclear whether cortisol alterations are evident at an earlier clinical stage and promote progression of psychosis expression. This study aimed to address this issue by investigating whether cortisol levels in childhood were associated with the emergence of attenuated psychotic symptoms in early adulthood. In exploratory analyses, we examined whether cortisol and psychosocial stress measures interacted in predicting attenuated psychotic symptoms. METHODS: A sample of children (N = 109) enriched for psychosis risk factors were recruited at age 9-12 years and assessed at age 11-14 years (T1) and 17-21 years (T2). Measures of psychopathology, psychosocial stressors, and salivary cortisol were obtained at T1. Attenuated psychotic symptoms were assessed at T2 using the Prodromal Questionnaire. RESULTS: Diurnal cortisol (ß = 0.915, 95% CI: 0.062-1.769) and daily stressors (ß = 0.379, 95% CI: 0.034-0.723) at T1 were independently associated with total Prodromal Questionnaire scores at T2 after accounting for demographic factors and T1 psychopathology. Exploratory analyses indicated a significant interaction between T1 diurnal cortisol and daily stressors (ß = 0.743, 95% CI: 0.081-1.405), with the highest predicted T2 total Prodromal Questionnaire scores occurring when both diurnal cortisol and daily stressors were increased. CONCLUSIONS: Our findings suggest that daily stressors and elevations in diurnal cortisol in late childhood/early adolescence increases risk for developing attenuated psychotic symptoms. These findings emphasize the importance of assessing environmental and biological risk factors for psychosis during neurodevelopmentally vulnerable time periods.