Therapeutic alliance in guided internet therapy programs for depression and anxiety disorders - A systematic review.

OBJECTIVE: The role of internet therapy programs for mental disorders is growing. Those programs employing human support yield better outcomes than do those with no such support. Therapeutic alliance may be a critical element in this support. Currently, the significance of therapeutic alliance in guided, internet-delivered cognitive behavioral therapy programs (iCBT) remains unknown. This review aims to determine whether the therapeutic alliance influences outcome of iCBTs and if it does, what plausible factors underlie this association. METHOD: Towards that goal searches were made in PubMed, PsycINFO, SCOPUS, The Cochrane Library and CINAHL in May 2016 and January 2017. RESULTS: From the 1658 relevant studies, only six studied the relationship of therapeutic alliance and outcome. All six studies showed a high level of client-therapist alliance; in the three most recent studies, the alliance was directly associated with outcome. No studies reported alliance-adherence associations. CONCLUSIONS: Alliance research in iCBT for mental disorders is scarce. Therapeutic alliance seems to associate with outcomes. More studies are necessary to define the optimal support to strengthen alliance. iCBT is a feasible environment for alliance research both practically and theoretically. The impact of alliance on adherence to iCBT requires study.

Multiple physical healthcare needs among outpatients with schizophrenia: findings from a health examination study.

BACKGROUND: Despite the abundant literature on physical comorbidity, the full range of the concurrent somatic healthcare needs among individuals with schizophrenia has rarely been studied. AIMS: This observational study aimed to assess the distressing somatic symptoms and needs for physical health interventions in outpatients with schizophrenia, and factors predicting those needs. METHODS: A structured, comprehensive health examination was carried out, including a visit to a nurse and a general practitioner on 275 outpatients with schizophrenia. The required interventions were classified by type of disease. Logistic regression was used to assess the influence of sociodemographic factors, lifestyle, functional limitations, factors related to psychiatric disorder, and healthcare use on the need for interventions. RESULTS: In total, 44.9% of the patients (mean age 44.9 years) reported somatic symptoms affecting daily life; 87.6% needed specific interventions for a disease or condition, most commonly for cardiovascular, dermatological, dental, ophthalmological, and gastrointestinal conditions, and for altered glucose homeostasis. Smoking and obesity predicted significantly a need of any intervention, but the predictors varied in each disease category. Strikingly, use of general practitioner services during the previous year did not reduce the need for interventions. CONCLUSIONS: Health examinations for outpatients with schizophrenia revealed numerous physical healthcare needs. The health examinations for patients with schizophrenia should contain a medical history taking and a physical examination, in addition to basic measurements and laboratory tests. Prevention and treatment of obesity and smoking should be given priority in order to diminish somatic comorbidities in schizophrenia.

A longitudinal study of educational differences in antidepressant use before and after hospital care for depression.

BACKGROUND: Despite social inequalities in depression various studies report small or even reversed social gradients for antidepressant treatment, suggesting unmet need for treatment among those with low social position. However, few studies assess need for treatment or compare longitudinal antidepressant use patterns between socioeconomic groups. METHODS: We used a nationally representative register cohort of Finnish adults with hospital care for depression in 1998-2007 (n = 7249). We compared the prevalence of any use and daily use of antidepressants across educational groups in consecutive 3-month periods up to 5 years before admission and 5 years after discharge, adjusting for important confounders. RESULTS: We found no educational differences in any antidepressant use in the 5 years leading to hospital care for depression but a 3-4 percentage-point higher prevalence among those with high education in the 3-month periods immediately preceding and following hospital care for depression. Furthermore, decline in the prevalence of antidepressant use after discharge was more rapid in low education resulting in a significant 4-6 percentage-point higher prevalence among the highly educated lasting until 2.5 years after discharge. Daily use was significantly more common among the highly educated for a year before admission, immediately after discharge and for 2.5 years thereafter, the excess being 3-8 percentage-points. CONCLUSION: Our results suggest rather equitable access to antidepressant treatment at the time of evident need, i.e. immediately after discharge from hospital care for depression. However, early discontinuation of treatment as well as below guideline use of antidepressants were more common among the low educated.

The effectiveness of email-based exercises in promoting psychological wellbeing and healthy lifestyle: a two-year follow-up study.

BACKGROUND: Web-based interventions provide a possibility to enhance well-being in large groups of people. Only a few studies have studied the effectiveness of the interventions and there is no information on the sustainability of the effects. Study aims were to investigate both the short (2-month) and long-term (2-year) effects of email-based training for mental health and lifestyle. METHODS: Persons who completed an 'Electronic Health Check', as advertised in a TV program, were offered a chance to participate in email-based interventions. The baseline questionnaire was completed by 73 054 people, with 42 761 starting interventions, and 16 499 people participating in at least one of the follow-ups. Persons who did not choose to start the interventions served as controls. RESULTS: At baseline, the intervention group had a higher level of stress and lower gratitude and confidence in the future than the control group. Both groups showed improvement in the level of stress, but improvement was more marked in the intervention group (P < .001 for both time points). In confidence in the future and gratitude, people who chose interpersonal interventions showed significant improvements at both time points (P < .001), whereas those choosing lifestyle interventions showed improvement only at the 2-month follow-up. Participants who had done the exercises according to instructions had the most sustained improvements in measures of psychological health at the 2-year follow-up. As for lifestyle, people who had started lifestyle interventions increased their exercise (P < .001 at both time points). CONCLUSIONS: Internet-based interventions are feasible for mental health promotion and should be available for people interested in improving their psychological well-being and lifestyle.

[Online therapies - what is known about their functionality]. / Nettiterapiat - mitä tiedetään toimivuudesta.

Online therapies are partly automated therapies, in which psychotherapeutic contents have been complemented with computer-aided presentational and educational contents, with a therapist giving support to the progress of the patient. As methods, these therapeutic programs incorporate therapeutic methods that have proven effective, such as remodeling of thoughts, activation of behavior and exposure, empathy, strengthening of cooperative relationship and motivation, and general support for self-reflection. For instance, online therapies already constitute part of the Finnish treatment guidelines on depression. Online therapies are available throughout Finland for the essential psychiatric illnesses.

Clozapine use and sedentary lifestyle as determinants of metabolic syndrome in outpatients with schizophrenia.

BACKGROUND: Schizophrenia patients are in danger of developing metabolic syndrome (MetS) and its outcomes type 2 diabetes and cardiovascular disease. Antipsychotic treatment and adverse lifestyle increase the burden of metabolic problems in schizophrenia, but little is known about the role of patients' current psychiatric problems and living arrangements in MetS. AIMS: This study aims to evaluate correlations between MetS, severity of psychiatric symptoms, living arrangements, health behaviour and antipsychotic medication in outpatients with schizophrenia spectrum disorders. METHODS: A general practitioner and psychiatric nurses performed a comprehensive health examination for all consenting patients with schizophrenia spectrum disorders treated in a psychosis outpatient clinic. Examination comprised of an interview, a questionnaire, measurements, laboratory tests and a general clinical examination. Diagnosis of MetS was made according to International Diabetes Federation (IDF) definition. Correlations were calculated and logistic regression analysis performed with SAS. RESULTS: 276 patients (men n = 152, mean age ± standard deviation = 44.9 ± 12.6 years) participated in the study; 58.7% (n = 162) of them had MetS according to the IDF definition. Clozapine use doubled the risk of MetS (OR = 2.04, 95% CI 1.09-3.82, P = 0.03), whereas self-reported regular physical activity decreased the risk significantly (OR = 0.32, 95% CI 0.18-0.57, P < 0.001). We found no correlations between MetS and living arrangements or current severity of psychiatric symptoms. CONCLUSIONS: MetS was alarmingly common in our sample. Even moderate physical activity was associated with decreased risk of MetS. Promotion of a physically active lifestyle should be one of the targets in treatment of schizophrenia, especially in patients using clozapine.

Antidepressant sales and the risk for alcohol-related and non-alcohol-related suicide in Finland--an individual-level population study.

OBJECTIVES: A marked decline in suicide rates has co-occurred with increased antidepressant sales in several countries but the causal connection between the trends remains debated. Most previous studies have focused on overall suicide rates and neglected differential effects in population subgroups. Our objective was to investigate whether increasing sales of non-tricyclic antidepressants have reduced alcohol- and non-alcohol-related suicide risk in different population subgroups. METHODS: We followed a nationally representative sample of 950,158 Finnish adults in 1995-2007 for alcohol-related (n = 2,859) and non-alcohol-related (n = 8,632) suicides. We assessed suicide risk by gender and social group according to regional sales of non-tricyclic antidepressants, measured by sold doses per capita, prevalence of antidepressant users, and proportion of antidepressant users with doses reflecting minimally adequate treatment. Fixed-effects Poisson regression models controlled for regional differences and time trends that may influence suicide risk irrespective of antidepressant sales. RESULTS: The number of sold antidepressant doses per capita and the prevalence of antidepressant users were unrelated to male suicide risk. However, one percentage point increase in the proportion of antidepressant users receiving minimally adequate treatment reduced non-alcohol-related male suicide risk by one percent (relative risk 0.987, 95% confidence interval 0.976-0.998). This beneficial effect only emerged among men with high education, high income, and employment, among men without a partner, and men not owning their home. Alcohol-related suicides and female suicides were unrelated to all measures of antidepressant sales. CONCLUSION: We found little evidence that increase in overall sales or in the prevalence of non-tricyclic antidepressant users would have caused the fall in suicide rates in Finland in 1995-2007. However, the rise in the proportion of antidepressant users receiving minimally adequate treatment, possibly due to enhanced treatment compliance, may have prevented non-alcohol-related suicides among men.

Does hospital admission risk for depression vary across social groups? A population-based register study of 231,629 middle-aged Finns.

PURPOSE: Evidence on social differentials in depression outcomes remains inconsistent. We assess social predictors of psychiatric admission for depression in a community setting. METHODS: A register-based 14% sample of community-dwelling Finns aged 40-64 at the end of 1997 was assessed for depression and psychiatric comorbidity, using register data on psychiatric hospital care and medication purchases in 1996-1997. Those with inpatient treatment for unipolar depression (n = 846), those with antidepressant treatment (n = 8,754), and those with neither (n = 222,029) were followed for psychiatric admission with a diagnosis of unipolar depression in 1998-2003. Differentials in admission rates by socioeconomic position, employment status, and living arrangements were studied using Cox proportional hazards modelling. RESULTS: Among those with prior inpatient or antidepressant treatment, the material aspects of socioeconomic position increased admission risk for depression by 20-40%, even after controlling for baseline depression severity and psychiatric comorbidities, whereas education and occupational social class were unrelated to admission risk. Among inpatients, also having no partner, and among antidepressant users, being previously married and living without co-resident children increased admission risk. However, among inpatients few excess risks reached statistical significance. Among those with no inpatient or antidepressant treatment, all measures of low social position and not living with a partner predicted admission, and the factors had more predictive power in admission than among those with prior treatment. CONCLUSIONS: Further studies should disentangle the mechanisms behind the higher admission risk among those with fewer economic resources and no co-resident partner.

Association of stigma resistance with emotion regulation - functional magnetic resonance imaging and neuropsychological findings.

BACKGROUND: [corrected] Personal characteristics contribute to whether negative attitudes in society are internalized as deteriorating self-stigma. Studies in healthy subjects suggest that resilience is associated with the regulation of amygdala activation by the medial prefrontal cortex (mPFC), but little is known about the factors that contribute to individual stigma resistance in psychiatric patients. METHODS: We assessed stigma (by measuring association strengths between social inferiority and schizophrenia by an implicit association test) in 20 patients with schizophrenia and in 16 age- and sex-matched healthy control subjects. The brain activation strengths were measured by functional magnetic resonance imaging during evaluation of schizophrenia-related statements and of control statements. RESULTS: Association strengths between social inferiority and schizophrenia were inversely related to the strength of the activation of the rostro-ventral mPFC. This inverse correlation survived adjustment for global functioning, depression symptom scores, and insight. Activation of the rostro-ventral mPFC was negatively correlated with activation of the amygdala. The association strengths between social inferiority and schizophrenia correlated with the compromised performance in a Stroop task, which is a measure of cognitive regulation. DISCUSSION: Our findings suggest that individual stigma resistance is associated with emotion regulation. These findings may help to understand better stigma resistance and thereby aid the development of patient interventions that add to the public anti-stigma work in reducing devastating effects of stigma.

Confidence in the future, health-related behaviour and psychological distress: results from a web-based cross-sectional study of 101 257 Finns.

OBJECTIVES: To investigate the role of socioeconomic status and psychological stress to potential associations between confidence in the future and a wide range of health-related behaviours. DESIGN: Web-based cross-sectional study including an 'Electronic Health Check' at the Finnish Happiness-Flourishing Study website linked to a TV programme on happiness and depression. SETTING: The Finnish population with access to the internet. PARTICIPANTS: 101 257 Finns aged 18 and above (21 365 men; 79 892 women). Participants who were under the age of 18 and who did not provide information about their gender were excluded. PRIMARY OUTCOME MEASURES: As planned, we assessed smoking, weekly alcohol consumption and binge drinking, daily intake of fruits and vegetables and regular exercise. RESULTS: Compared with participants with low confidence in the future, those with high confidence were less likely to be daily smokers (men OR 0.58, 95% CI 0.52 to 0.65; women 0.57, 95% CI 0.53 to 0.61) and binge drinkers (men 0.57; 0.52 to 0.63; women 0.54; 0.50 to 0.57). Participants with high confidence in the future were more likely to exercise regularly (men OR 2.82, 95% CI 2.55 to 3.13; women 2.57, 95% CI 2.44 to 2.71) and consume vegetables (men OR 2.48, 95% CI 2.25 to 2.74; women 2.13, 95% CI 2.03 to 2.24) and fruits (men OR 2.09, 95% CI 1.86 to 2.35; women 1.83, 95% CI 1.74 to 1.93) daily. Adjustment for current psychological distress and satisfaction for income attenuated the results. CONCLUSIONS: Having confidence in the future is strongly associated with a healthy lifestyle, as assessed by a healthy diet, physical exercise and substance abuse. Health-related interventions may benefit from tailoring interventions according to the target population's level of confidence in the future as well as their level of psychological distress.

Parental use of antidepressant medication and family type in the risk for incident psychiatric morbidity in offspring.

BACKGROUND: Maternal depression increases the risk for psychiatric morbidity in offspring but the effects of paternal depression and family type are less studied. METHODS: We assessed the effects of parental antidepressant use on offspring psychiatric morbidity in various family settings. RESULTS: Our register-based study followed 132637 children for incident psychiatric morbidity in 1998-2003. The highest risk for psychiatric morbidity was in children living with both parents on antidepressants or with a lone parent on antidepressants. We found little variation in the effects according to parental or offspring gender. CONCLUSIONS: Parental depression as measured by antidepressant use, and single parenthood pose a risk for psychiatric morbidity in offspring.

Alcohol-related deaths and social factors in depression mortality: a register-based follow-up of depressed in-patients and antidepressant users in Finland.

BACKGROUND: Excess mortality of depression is established for various causes of death, but evidence is scarce on alcohol-related causes. It also remains unclear whether the magnitude of the excess varies by social factors. This study aimed to quantify the contribution of alcohol-related causes of death and to assess modifying effects of socioeconomic position, employment status, and living arrangements in the excess mortality of depression. METHODS: A 14% sample of community-dwelling Finns aged 40-64 at the end of 1997 was assessed for depression, using register data on psychiatric hospital care and antidepressant use in 1996-1997. Depressed in-patients (n=897), out-patients using antidepressants (n=13,658), and non-depressed individuals (n=217,140) were followed up for cause-specific mortality in 1998-2007, distinguishing between alcohol- and non-alcohol-related deaths, and testing for variation in the excess mortality according to baseline social factors. RESULTS: Depressed in- and out-patients had significant excess mortality for suicide (age-adjusted rate ratios RR=3.77 for men and RR=6.35 for women), all accidental and violent causes (RR=3.47 and RR=4.43), and diseases (RR=1.67 and RR=1.41). Of the excess, alcohol-related causes accounted for 50% among depressed men and 30% among women. Excess mortality varied little by social factors, particularly in non-alcohol-related causes. Where variation was significant, the relative excess was larger among those with higher socioeconomic position and the employed. Absolute excess was, however, larger among those with lower socioeconomic position, the unemployed, and the unpartnered. LIMITATIONS: Depression was measured indirectly by hospital and antidepressant use. CONCLUSIONS: The results highlight the major role of alcohol in depression mortality.

Depressive symptoms, major depressive episodes and cognitive test performance-what is the role of physical activity?

BACKGROUND: Positive associations between physical activity and cognitive test performance in depressed subjects have been proposed in clinical studies. The contribution of severity and recency of depressive symptoms at the population level is not known. AIMS: This study aims to examine whether regular physical activity associates with better verbal fluency and psychomotor speed in depressed subjects using a large population-based sample. METHODS: Data was obtained from the population-based Finnish Health 2000 Study, gathered in 2000-2001. Depressive symptoms and depressive disorders were assessed by the Beck Depression Inventory (BDI) and the Composite International Diagnostic Interview (CIDI), correspondingly. Cognitive test performance was assessed by the animal naming test and psychomotor speed with a simple and multi-choice reaction time test. Physical activity (Gothenburg scale) was self-reported. Complete data were obtained from 3658 subjects aged 30-64 years. Socio-demographic factors, health behaviours and use of antidepressants and anxiolytics were used as covariates in the linear regression models. Adjusted means were calculated using the predictive margins method. RESULTS: Regular physical activity associated with better performance in reaction time tests and better verbal fluency among men with depressive symptoms or with a major depressive episode. Physical activity also associated with cognitive test performance among non-depressed men and women, but among them the differences between the physical activity groups were smaller. CONCLUSION: Regular physical activity may be a useful tool in supporting neurocognitive functioning among depressed subjects.

Living alone and antidepressant medication use: a prospective study in a working-age population.

BACKGROUND: An increasing proportion of the population lives in one-person households. The authors examined whether living alone predicts the use of antidepressant medication and whether socioeconomic, psychosocial, or behavioral factors explain this association. METHODS: The participants were a nationally representative sample of working-age Finns from the Health 2000 Study, totaling 1695 men and 1776 women with a mean age of 44.6 years. In the baseline survey in 2000, living arrangements (living alone vs. not) and potential explanatory factors, including psychosocial factors (social support, work climate, hostility), sociodemographic factors (occupational grade, education, income, unemployment, urbanicity, rental living, housing conditions), and health behaviors (smoking, alcohol use, physical activity, obesity), were measured. Antidepressant medication use was followed up from 2000 to 2008 through linkage to national prescription registers. RESULTS: Participants living alone had a 1.81-fold (CI = 1.46-2.23) higher purchase rate of antidepressants during the follow-up period than those who did not live alone. Adjustment for sociodemographic factors attenuated this association by 21% (adjusted OR = 1.64, CI = 1.32-2.05). The corresponding attenuation was 12% after adjustment for psychosocial factors (adjusted OR = 1.71, CI = 1.38-2.11) and 9% after adjustment for health behaviors (adjusted OR = 1.74, CI = 1.41-2.14). Gender-stratified analyses showed that in women the greatest attenuation was related to sociodemographic factors and in men to psychosocial factors. CONCLUSIONS: These data suggest that people living alone may be at increased risk of developing mental health problems. The public health value is in recognizing that people who live alone are more likely to have material and psychosocial problems that may contribute to excess mental health problems in this population group.

Psychiatric comorbidity in couples: a longitudinal study of 202,959 married and cohabiting individuals.

PURPOSE: To examine whether partner's psychiatric and somatic disorders are risk factors for incidence of psychiatric disorders among non-psychiatric individuals at baseline. METHODS: Register-based 6-year follow-up on Finns (106,935 men and 96,024 women aged 40 and over), living with a married or cohabiting partner at the end of 1997. The outcome measures included non-psychotic major depressive disorder (MDD), substance use disorder (SUD), and severe psychiatric disorder, evaluated using information on reimbursement for drug costs, purchases of prescription medication, and principal causes of hospitalization. RESULTS: Among persons whose partner had any psychiatric disorder, the incidence rate ratio (IRR) for own MDD, controlling for own age at baseline, was 1.58 (95% confidence interval 1.48-1.69) in men, and 1.58 (1.48-1.69) in women. Among persons whose partner had somatic hospitalization, the IRR for own MDD was 1.14 (1.08-1.20) in men and 1.20 (1.15-1.25) in women. Among both men and women, the highest risk for incidence of own MDD was among persons whose partner had both MDD and SUD (IRR 2.65, 1.67-4.21 and IRR 2.13, 1.62-2.80, respectively). Further adjustment for sociodemographic and union characteristics had little effect on the associations. CONCLUSIONS: In married and cohabiting couples, partner's somatic and particularly psychiatric morbidity associate with psychiatric disorders in non-psychiatric subjects, independent of sociodemographic and union characteristics. The healthy spouse's care burden is a potential point of intervention in order to prevent new psychiatric morbidity, but also to provide the mentally ill first partner a chance to recover in a supportive family environment.

Childhood and current determinants of heavy drinking in early adulthood.

AIMS: To explore the association of parental education, childhood living conditions and several adversities with heavy drinking in early adulthood, and to analyze the effect of the respondent's current circumstances on these associations. METHOD: The analyses were conducted in a sample of 1234 adults aged 18-29 years participating in the Finnish Health 2000 Survey (65% of the original representative two-stage cluster sample, N = 1894). The outcome measure was heavy drinking measured by g/week for pure alcohol (for men >or=280 g/week and for women >or=140 g/week). RESULTS: 8% of young adult men and 5% of women were heavy drinkers. In both genders, parental alcohol problems and other childhood adversities, poor own education, and unemployment status increased the risk of heavy drinking. The impact of childhood on heavy drinking was partly independent and partly mediated by adult characteristics, in particular, for both genders, low level of education. CONCLUSIONS: Childhood adversities are associated with heavy drinking in early adulthood among both genders. Childhood social circumstances as well as low educational level and unemployment should be taken into account in planning preventive policies to tackle the harms caused by excessive alcohol use at the individual and population level.

Alcohol consumption, abstaining, health utility, and quality of life--a general population survey in Finland.

AIMS: To examine the associations between alcohol consumption and utility-based health-related quality of life (HRQoL), subjective quality of life (QoL), self-rated health (SRH), and mental distress. METHODS: Representative general population survey in Finland, with 5871 persons aged 30-64 years. HRQoL was measured with two health utility instruments (15D and EQ-5D), QoL and SRH were measured with RATING scales, and mental distress with a General Health Questionnaire (GHQ-12). Past alcohol problems were diagnosed with a structured psychiatric interview known as the composite international diagnostic interview (CIDI). Alcohol consumption was examined with a self-report questionnaire. RESULTS: Negative associations between alcohol and well-being were observed on several measures for women consuming more than 173 g and men more than 229 g per week. Former drinkers scored worst on most measures, even in comparison to the highest drinking decile. For men, all statistically significant associations between moderate drinking and well-being disappeared when sociodemographic factors and former drinkers were controlled for. For women, moderate alcohol use associated with better SRH and EQ-5D as compared to abstainers. However, the possible health utility benefits associated with moderate alcohol consumption were of clinically insignificant magnitude. CONCLUSIONS: Failure to separate former drinkers and other abstainers produces a significant bias favoring moderate drinkers. As the possible health utility benefits of moderate alcohol use were clinically insignificant, it suffices to investigate mortality, when estimating the public health impact of moderate alcohol consumption using quality-adjusted life years.

Mortality differences according to living arrangements.

BACKGROUND: Research has revealed mortality differences between marital status groups in different societies and different periods of time. Due to the increase in consensual unions, living alone and other changes in living arrangements, it is necessary to apply a more detailed classification of living arrangements that incorporates partnership situation and household composition. METHODS: We analyse mortality by cause-of-death in the total Finnish population aged 30 or over in 1996-2000. The linked register dataset includes 15.7 million person-years and 210,139 deaths. RESULTS: In the working aged population, cohabiters had nearly 70% excess mortality when compared with married people. Among working aged men living with someone other than a partner and among men living alone, mortality was three times higher than among married men. Among women, mortality in these groups was close to that of cohabiters. In the older population, mortality in the other groups was 15-40% higher than among married persons. Adjusting for education, social class and employment status attenuated the mortality differences by 7-31%. Having no children was associated with excess mortality in working aged women and men in each living arrangement group. The relative differences were greatest in deaths from alcohol-related causes, followed by deaths from accidents among men and working aged women and lung cancer in women. CONCLUSIONS: We observed wide mortality differences according to living arrangements, particularly among the working aged. These differences were partly explained by socioeconomic factors. Excessive alcohol use seems to be one major cause of mortality differences.

Living arrangements, heavy drinking and alcohol dependence.

AIMS: To assess the variation in heavy drinking and alcohol dependence by living arrangements, and the contribution of social and behavioural factors to this variation. DESIGN: The Health 2000 survey is a nationally representative cross-sectional survey conducted in Finland in 2000-2001 (N = 4589 in the age-range of 30-54 years, response rate 81%). MEASUREMENTS: Living arrangements; married, cohabiting, living with other(s) than a partner, and living alone. Consumption of beer, wine and spirits in the past month was converted into grams of alcohol/week, and heavy drinking was classified as > or =280 (men) and > or =140 (women) grams/week. Twelve-month prevalence of alcohol dependence was diagnosed by a mental health interview (CIDI). FINDINGS: As compared to the married, cohabiting and living alone associated with heavy drinking (age-adjusted OR; 95% CI: 1.71;1.17-2.49 and OR 2.15;1.55-3.00 in men; OR 1.54;0.96-2.46 and OR 1.67;1.07-2.63 in women) and alcohol dependence (OR 2.29;1.44-3.64 and OR 3.66;2.39-5.59 in men; OR 2.56;1.10-5.94 and OR 4.43;2.03-9.64 in women). Living with other(s) than a partner associated with heavy drinking. Those who cohabited without children or lived alone had the highest odds for alcohol dependence. Among both genders, adjusting for main activity and financial difficulties attenuated the odds for heavy drinking and alcohol dependence by approximately 5-30% each, and additionally among women adjusting for urbanisation attenuated the odds for heavy drinking by approximately 15-45%. CONCLUSIONS: Cohabiting and living alone are associated with heavy drinking and alcohol dependence. Unemployment, financial difficulties and low social support, and among women also living in an urban area, seem to contribute to the excess risk.

Living arrangements and mental health in Finland.

BACKGROUND: Non-married persons are known to have poor mental health compared with married persons. Health differences between marital status groups may largely arise from corresponding differences in interpersonal social bonds. However, official marital status mirrors the social reality of persons to a decreasing extent, and living arrangements may be a better measure of social bonds. Little is known about mental health in different living arrangement groups. This study aims to establish the extent and determinants of mental health differences by living arrangement in terms of psychological distress (GHQ) and DSM-IV psychiatric disorders (CIDI). METHODS: Data were used from the nationally representative cross sectional health 2000 survey, conducted in 2000-1 in Finland. Altogether 4685 participants (80%) aged 30-64 years were included in these analyses; comprehensive information was available on measures of mental health and living arrangements. Living arrangements were measured as follows: married, cohabiting, living with other(s) than a partner, and living alone. RESULTS: Compared with the married, persons living alone and those living with other(s) than a partner were approximately twice as likely to have anxiety or depressive disorders. Cohabiters did not differ from the married. In men, psychological distress was similarly associated with living arrangements. Unemployment, lack of social support, and alcohol consumption attenuated the excess psychological distress and psychiatric morbidity of persons living alone and of those living with other(s) than a partner by about 10%-50% each. CONCLUSIONS: Living arrangements are strongly associated with mental health, particularly among men. Information on living arrangements, social support, unemployment, and alcohol use may facilitate early stage recognition of poor mental health in primary health care.