All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996-2019: a register study.

BACKGROUND: All-cause and suicide mortalities of gender-referred adolescents compared with matched controls have not been studied, and particularly the role of psychiatric morbidity in mortality is unknown. OBJECTIVE: To examine all-cause and suicide mortalities in gender-referred adolescents and the impact of psychiatric morbidity on mortality. METHODS: Finnish nationwide cohort of all <23 year-old gender-referred adolescents in 1996-2019 (n=2083) and 16 643 matched controls. Cox regression models with HRs and 95% CIs were used to analyse all-cause and suicide mortalities. FINDINGS: Of the 55 deaths in the study population, 20 (36%) were suicides. In bivariate analyses, all-cause mortality did not statistically significantly differ between gender-referred adolescents and controls (0.5% vs 0.3%); however, the proportion of suicides was higher in the gender-referred group (0.3% vs 0.1%). The all-cause mortality rate among gender-referred adolescents (controls) was 0.81 per 1000 person-years (0.40 per 1000 person-years), and the suicide mortality rate was 0.51 per 1000 person-years (0.12 per 1000 person-years). However, when specialist-level psychiatric treatment was controlled for, neither all-cause nor suicide mortality differed between the two groups: HR for all-cause mortality among gender-referred adolescents was 1.0 (95% CI 0.5 to 2.0) and for suicide mortality was 1.8 (95% CI 0.6 to 4.8). CONCLUSIONS: Clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for. CLINICAL IMPLICATIONS: It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide.

Have the psychiatric needs of people seeking gender reassignment changed as their numbers increase? A register study in Finland.

BACKGROUND: The number of people seeking gender reassignment (GR) has increased everywhere and these increases particularly concern adolescents and emerging adults with female sex. It is not known whether the psychiatric needs of this population have changed alongside the demographic changes. METHODS: A register-based follow-up study of individuals who contacted the nationally centralized gender identity services (GIS) in Finland in 1996-2019 (gender dysphoria [GD] group, n = 3665), and 8:1 age and sex-matched population controls (n = 29,292). The year of contacting the GIS was categorized to 5-year intervals (index periods). Psychiatric needs were assessed by specialist-level psychiatric treatment contacts in the Finnish Care Register for Hospital Care in 1994-2019. RESULTS: The GD group had received many times more specialist-level psychiatric treatment both before and after contacting specialized GIS than had their matched controls. A marked increase over time in psychiatric needs was observed. Among the GD group, relative risk for psychiatric needs after contacting GIS increased from 3.3 among those with the first appointment in GIS during 1996-2000 to 4.6 when the first appointment in GIS was in 2016-2019. When index period and psychiatric treatment before contacting GIS were accounted for, GR patients who had and who had not proceeded to medical GR had an equal risk compared to controls of needing subsequent psychiatric treatment. CONCLUSION: Contacting specialized GIS is on the increase and occurs at ever younger ages and with more psychiatric needs. Manifold psychiatric needs persist regardless of medical GR.

Schizophrenia among young people first admitted to psychiatric inpatient care during early and middle adolescence.

OBJECTIVE: This study explored the incidence and stability of schizophrenia in a large national register data of all adolescents first admitted to psychiatric inpatient care at ages 13-17 in Finland 1980-2010. METHODS: The study population (N 17,112) comprised all Finnish citizens aged 13-17 receiving their first ever psychiatric inpatient treatment between 1980 and 2010 in Finland. To explore incidence and stability of schizophrenia, the diagnostic information on inpatient care or disability pension was obtained from the appropriate registers. RESULTS: The incidence of schizophrenia disorders (F20 + F25) during adolescence was higher in the study population for those admitted to psychiatric inpatient care 1980-1989 than in other decades examined. Overall, psychiatric inpatient care during adolescence was a risk factor for subsequent schizophrenia, especially if a diagnosis of F20-29 was set although a considerable share of those with psychotic disorders other than schizophrenia diagnosis did not subsequently convert to schizophrenia. The stability of adolescent onset schizophrenia diagnosis was high. CONCLUSION: Adolescents requiring psychiatric inpatient care have a higher later rate of schizophrenia diagnosis than prevalence at community level. Whereas adolescent onset schizophrenia diagnosis is a fairly stable diagnosis, there are other adolescent psychotic disorders which are more transient in nature.

Educational attainment of adolescents treated in psychiatric inpatient care: a register study over 3 decades.

Mental disorders may for various reasons impair educational attainment, and with far-reaching consequences given the impact of education on subsequent employment, social life, life choices and even health and mortality. This register-based study addresses trends in educational attainment among Finnish adolescents aged 13-17 with mental disorders severe enough to necessitate inpatient treatment between 1980 and 2010. Our subjects (N = 14,435), followed up until the end of 2014, were at greater risk of discontinuing education beyond compulsory comprehensive school or of lower educational attainment than their age-peers in general population. Only 50.0% had completed any post-comprehensive education compared to 84.9% in same-aged general population. Those at highest risk were males and those with organic, intellectual disabilities and developmental, externalizing disorders or schizophrenia group diagnoses. Despite improvements in adolescent psychiatric care, school welfare services and pedagogical support, risks have remained high. Greater effort in psychiatric treatment, school welfare and pedagogy are needed to combat this severe inequality.

Sex offending among adolescents and young men with history of psychiatric inpatient care in adolescence.

BACKGROUND: Some mental disorders have been associated with increased likelihood of sexual offending in adolescents (and adults), but relevant studies tend to be of established sex offenders. AIMS: To examine relationships between adolescent mental disorders and subsequent involvement in sex offending and to explore any predictive value of primary diagnoses for subsequent interpersonal offending, whether sexual or violent. METHODS: We analyse national register-based longitudinal data on males in Finland admitted for their first psychiatric inpatient treatment between the ages of 13-17 in the period 1980-2010 (N = 6749). Cox regression was used for the analysis of multivariate associations. RESULTS: A subsequent criminal record for sex crime in the 10-year follow up was rare among former child and adolescent psychiatric (CAP) inpatient males (1.5%). Having a subsequent criminal record for non-sex-related violent crime was more common (25%). Time to either sex crimes or non-sex-related violent crimes after a first CAP inpatient treatment was 3-4 years. Whilst the risk of committing non-sex-related violent crimes was elevated in all diagnostic groups compared to those with schizophrenia spectrum disorders, the risk of committing subsequent sex crimes was elevated only in the group with substance use, conduct or personality disorders. Among those with pre-existing criminal history of sex crime, the risk of a subsequent criminal record for sex crime after CAP treatment was increased 11-fold, but the risk for later non-sex-related violent crimes was not increased compared to the rest of the male adolescent CAP population. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: In this first longitudinal study of criminal convictions for sex offending after a period of inpatient psychiatric treatment as an adolescent such convictions were rare, but the difference in post discharge risk of further convictions for sexual offending and non-sexual violent offending raises questions about whether more attention and specific treatment for aberrant sexual behaviours is needed for male adolescents with severe mental disorders.

Factors behind a remarkable increase in adolescent psychiatric inpatient treatment between 1980 and 2010 - a nationwide register study.

PURPOSE: This register-based study aimed to evaluate trends in adolescent psychiatric inpatient care using nationwide data from three consecutive decades. METHODS: The study population (N 17,112) comprised all Finnish citizens aged 13-17 receiving their first-ever psychiatric inpatient treatment between 1980 and 2010 in Finland. Information on inpatient care in the psychiatric hospital was obtained from the Hospital Discharge Register and the Care Register for Health Care, which contains data on all patients discharged from all Finnish inpatient psychiatric health services. RESULTS: Inpatient admissions remained relatively stable until the early 1990s, after which a steady increase was seen, peaking in 2008 and more marked among females than males. In males, there was an increase in inpatient care episodes for externalizing disorder or mood disorder, and in females for mood disorder. Duration of first inpatient care decreased over time, but level of functioning on admission remained stable or even deteriorated. Females, patients first admitted in the 1980s or diagnosed with schizophrenia were more likely to be re-hospitalized during adolescence. CONCLUSIONS: We reported an increase in adolescent psychiatric inpatient care from the latter half of the 1990s up to 2010, which could be explained by societal and policy changes. In particular, as the study period progressed a significant increase was seen in admissions of females and a global reduction of length of stay (LOS) with no concomitant increase in re-hospitalizations.