Preference for novel biomedical HIV pre-exposure prophylaxis methods among adolescent girls and young women in Kampala, Uganda: a mixed methods study.

Background: Novel HIV pre-exposure prophylaxis (PrEP) methods including a potential future HIV vaccine, will increase prevention options for adolescent girls and young women (AGYW) at high risk of HIV infection in Eastern and Southern Africa, yet data on AGYW's preferences for various PrEP methods is limited. We investigated preferences for five biomedical PrEP methods (oral, injectable, vaginal ring, implant, HIV vaccine) among 14-24-years-old AGYW in Kampala, Uganda. Methods: From January to December 2019, we conducted a mixed methods study including 265 high-risk AGYW. After receiving two education sessions on the five PrEP methods, participants were asked about their "most preferred PrEP method." Multinomial logistic regression (oral PrEP as reference category) was used to determine participant characteristics associated with method preference. Results are presented as adjusted relative risk ratios (aRRR) with 95% confidence intervals (CI). In-depth interviews were conducted with 20 selected participants to examine reasons influencing PrEP preferences and suggestions for method improvements. Transcripts were analyzed thematically. Results: Participants preferred methods were: HIV vaccine (34.7%), oral PrEP (25.7%), injectable PrEP (24.9%), PrEP implant (13.6%), and vaginal ring (1.1%). Preference for injectable PrEP increased with every year of age (aRRR 1.22; 95% CI 1.04-1.44) and among participants with chlamydia or gonorrhoea (aRRR 2.53; 95% CI 1.08-5.90), while it was lower among participants having sexual partner(s) living with HIV or of unknown HIV status (aRRR 0.30; 95% CI 0.10-0.91). Preference for PrEP implants also increased with age (aRRR 1.42; 95% CI 1.14-1.77) and was strong among participants having ≥10 sexual partners in the past 3 months (aRRR 3.14; 95% CI 1.16-8.55), while it was lower among those with sexual partner(s) living with HIV or of unknown HIV status (aRRR 0.25; 95% CI 0.07-0.92). PrEP method preference was influenced by product attributes and prior experiences with similar product forms commonly used in health care. Conclusion: AGYW have varied preferences for biomedical PrEP method and those with higher sexual behavioral risk prefer long-acting methods. As we anticipate more available PrEP options, oral PrEP use should be supported among AGYW, especially for those with sexual partners living with HIV or of unknown HIV status.

Maternal Steroid Hormone Levels in Early Pregnancy and Autism in the Offspring: A Population-Based, Nested Case-Control Study.

BACKGROUND: A role for prenatal steroid hormones in the etiology of autism has been proposed, but evidence is conflicting. METHODS: Here, we examined serum levels of maternal estradiol, testosterone, 17-hydroxyprogesterone (OHP), and cortisol from the first trimester of gestation (mean = 10.1 weeks) in relation to the odds of diagnosed autism with and without co-occurring intellectual disability (ID) in the offspring (n = 118 autism with ID, n = 249 autism without ID, n = 477 control). Levels of maternal hormones were measured using highly sensitive liquid chromatography tandem mass spectrometry, standardized according to gestational timing of sample collection, and analyzed with restricted cubic spline logistic regression models adjusting for child's sex and maternal health, demographic, and socioeconomic factors. RESULTS: We observed significant nonlinear associations between maternal estradiol, 17-OHP, and cortisol with autism, which varied with the presence of co-occurring ID. Compared to mean levels, lower levels of estradiol were associated with higher odds of autism with ID (odds ratio for concentrations 1 SD below the mean = 1.66; 95% CI, 1.24-2.11), while higher cortisol levels were associated with lower odds (odds ratio for 1 SD above the mean = 0.55; 95% CI, 0.36-0.88). In contrast, higher 17-OHP was associated with increased odds of autism without ID (odds ratio for 1 SD above the mean = 1.49; 95% CI, 1.11-1.99). We observed no evidence for interaction with sex of the child. CONCLUSIONS: These findings support the notion that the maternal steroid hormonal environment in early pregnancy may contribute to autism, but also emphasize the complex relationship between early-life steroid exposure and autism.

Prevalence of sexual harassment and its association with aspects self-reported health: A cross-sectional study in Sweden.

AIMS: Sexual harassment is common and may have serious consequences for well-being and health. We investigated the prevalence of sexual harassment in the general population of Stockholm County across socio-demographic groups and sexual identity, and its association with self-reported health. METHODS: Experiences of sexual harassment in the previous 12 months and its associations with self-reported health (depression, anxiety, suicidal ideation) were assessed in 2021/2022 among a random sample of 22,890 residents in Stockholm County aged 16 and older. Analyses were done using descriptive statistics and multivariate logistic regression (odds ratios and 95% confidence intervals (CI)). Calibration weights were used to estimate population-representative rates with 95% CI. RESULTS: The highest weighted prevalence was observed among 16- to 24-year-olds (18.9%, 95% CI 16.9%-20.9%). Women (9.5%; 95% CI 8.8%-10.1%) reported a higher prevalence than men (2.9%; 95% CI 2.5%-3.3%). Compared to heterosexual people, bisexual and homosexual people reported a higher prevalence of sexual harassment. No significant difference was observed related to country of birth. People who were students, unemployed or on sick leave were more exposed than employed people, although this was not significant when adjusted for age and registered sex. Experiences of sexual harassment was associated with higher odds of all aspects of self-reported health. CONCLUSIONS: Experiences of sexual harassment in the general population are common and associated with adverse self-reported health. There is a need for enhanced efforts to prevent sexual harassment in the general population and to empower specific risk groups such as women and sexual minorities.

Sexual health among the oldest old: a population-based study among people aged 85 years and older in Stockholm, Sweden.

Background: Sexual health is an important contributor to the well-being and life satisfaction of people aged ≥85 years, known as the oldest old. However, little is known about sexual health in this population. Aim: To examine aspects of sexual health among the oldest old and explore its associations with sociodemographic, health-related, and lifestyle factors. Methods: We conducted a population-based cross-sectional study including 183 individuals aged ≥85 years who were residents in Stockholm County, Sweden. Responders (response rate, 63%) were interviewed on a range of health, sociodemographic, and lifestyle parameters, including aspects of sexual health. Participants' responses to the sexual health items were reported as proportions with 95% CIs. Associations were examined with multivariable logistic regression. Outcomes: We examined sexual activity, sexual satisfaction, problems related to sexual health, and inquiries on sexual health by a health care provider. Results: Twelve percent of participants (95% CI, 8%-17.6%) were sexually active, and 63.9% (95% CI, 56.5%-70.9%) were satisfied with their sexual lives during the past year. A third (35%; 95% CI, 28.4%-42.2%) reported at least a problem related to sexual health. Only 2.2% (95% CI, 0.6%-5.5%) were asked about sexual health by a health care provider, while 8.2% (95% CI, 4.7%-13.2%) identified a need for such an assessment. Yet, 85.2% (95% CI, 79.3%-90.0%) indicated no need for their sexual health to be evaluated by a health care provider. Being partnered was positively associated with sexual activity (adjusted odds ratio, 9.13; 95% CI, 2.53-32.90), whereas having strong social support was positively associated with being satisfied with one's sexual life (adjusted odds ratio, 2.96; 95% CI, 1.53-5.74). Clinical Implications: Health care providers should be proactive in assessing the sexual health of the oldest individuals. Strengths and Limitations: A representative sample of an underresearched population was used in this study. However, the generalizability of our findings may be restricted due to the small sample. To maintain statistical power from a relatively small sample, we might have lost explanatory power. Given the observational cross-sectional nature of the data, we cannot draw causal inferences based on the observed associations. Conclusions: A 10th of participants were sexually active, and the majority were satisfied with their sexual lives. Although many participants reported problems related to sexual health, few expressed the need to discuss sexual health with health care providers. Future studies should explore potential barriers to addressing sexual health and unmet health care needs among the oldest old.

Implementing digital sexual and reproductive health care services in youth clinics: a qualitative study on perceived barriers and facilitators among midwives in Stockholm, Sweden.

BACKGROUND: Digital health care services have the potential to improve access to sexual and reproductive health care for youth but require substantial implementation efforts to translate into individual and public health gains. Health care providers are influential both regarding implementation and utilization of the services, and hence, their perceptions of digital health care services and the implementation process are essential to identify and address. The aim of this study was to explore midwives' perception of digital sexual and reproductive health care services for youth, and to identify perceived barriers and facilitators of the implementation of digital health care provision in youth clinics. METHODS: We performed semi-structured interviews with midwives (n = 16) working at youth clinics providing both on-site and digital sexual and reproductive health care services to youth in Stockholm, Sweden. Interview data were analyzed using a content analysis approach guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Midwives acknowledged that the implementation of digital health care improved the overall access and timeliness of the services at youth clinics. The ability to accommodate the needs of youth regarding their preferred meeting environment (digital or on-site) and easy access to follow-up consultations were identified as benefits of digital health care. Challenges to provide digital health care included communication barriers, privacy and confidentiality concerns, time constraints, inability to offer digital appointments for social counselling, and midwives' preference for in person consultations. Experiencing organizational support during the implementation was appreciated but varied between the respondents. CONCLUSION: Digital sexual and reproductive health care services could increase access and are valuable complements to on-site services in youth clinics. Sufficient training for midwives and organizational support are crucial to ensure high quality health care. Privacy and safety concerns for the youth might aggravate implementation of digital health care. Future research could focus on equitable access and youth' perceptions of digital health care services for sexual and reproductive health.

Parental Mental Illness and the Likelihood of Child Out-of-Home Care: A Cohort Study.

OBJECTIVES: To detail the relationship between parental mental illness and the likelihood of out-of-home care (OHC) among their children, and to identify factors which modify this relationship. METHODS: Using Swedish national registers, children born in 2000 to 2011 (n = 1 249 463) were linked to their parents. Time-dependent parental mental illness (nonaffective and affective psychosis, substance misuse, depression, anxiety and stress, eating disorders, personality disorders, attention deficit hyperactivity disorder, autism, and intellectual disability), was identified through International Classification of Diseases codes. RESULTS: After adjustment for socioeconomic factors, children living with mentally ill parents were 4 times as likely to be placed in OHC than children without (95% confidence interval [CI] 4.24-4.61). The highest hazard ratio (HR) was in the youngest children aged 0 to 1 year (5.77, 95% CI 5.42-6.14), exposed to maternal illness (HR 4.56, 95% CI 4.37-4.76), and parental intellectual disability (HR 4.73, 95% CI 4.09-5.46). Children with parental mental illness with multiple risk factors were at particularly high risk. Compared with children without parental mental illness, and those with university-educated parents, children whose parents had mental illness and only had education to age 16 had a 15 times higher risk of OHC (95% CI 13.75-16.54). CONCLUSIONS: Children with parental mental illness are considerably more likely to be removed from home into care during childhood, particularly during the first year of life and if they are from socially disadvantaged families. Greater knowledge of these risks should lead to increased support for vulnerable new families.

Mode of delivery and subsequent self-perceived sexual life satisfaction: a population-based cohort study.

BACKGROUND: The potential association between mode of obstetrical delivery and subsequent sexual outcomes of the birthing parent remains uncertain and has not been well investigated from the perspective of positive sexual life satisfaction. OBJECTIVE: This study aimed to investigate if there was any association between mode of delivery and subsequent sexual life satisfaction of the birthing parent. A secondary aim was to assess the extent to which this association changed when stratified by time elapsed since delivery. STUDY DESIGN: The study matched participants in the Stockholm Public Health Cohort with deliveries recorded in the Swedish Medical Birth Register. Any deliveries recorded in the registry before the participation in the Stockholm Public Health Cohort were included (n=46,078). The length of time from delivery to outcome assessment varied from 1 month to 41 years (mean, 18 years [±10.8]). Mode of delivery was retrieved from the same registry, whereas self-perceived sexual life satisfaction was retrieved from the Stockholm Public Health Cohort Questionnaires where participants had assessed their sexual life satisfaction as 1 out of 5 mutually exclusive options. Multinomial logistic regression was used to test for any association between mode of delivery (cesarean, instrumental, and spontaneous vaginal delivery) and sexual life satisfaction, both overall and stratified by time elapsed since delivery. RESULTS: After adjusting for covariates, no statistically significant (P < .05) difference in subsequent sexual life satisfaction of the birthing parent between modes of delivery was identified. Adjusted odds ratios for assessing sexual life satisfaction as the lowest level ("very unsatisfactory") were 1.11 (95% confidence interval, 0.98-1.25) for cesarean delivery and 1.16 (95% confidence interval, 0.99-1.35) for instrumental delivery, compared with spontaneous vaginal delivery. The difference in covariate-adjusted prevalence of the lowest level of sexual life satisfaction among the different groups categorized by time since delivery was small: 4.0% (95% confidence interval, 2.4%-5.6%) for cesarean delivery as opposed to 2.8% (95% confidence interval, 2.1%-3.6%) for spontaneous vaginal delivery within 2 years since delivery. CONCLUSION: These findings do not support any impact of mode of delivery on the subsequent self-perceived sexual life satisfaction among birthing people, either overall or across different time periods since delivery.

Effects of COVID-19 measures on access to HIV/STI testing and condoms among adults in Sweden: a cross-sectional online survey.

AIMS: To investigate the self-reported impact of COVID-19 measures on access to testing for HIV and other sexually transmitted infections (STIs) and condoms and factors associated with reduced access among adults in Sweden. METHODS: Cross-sectional data were collected in late 2020 through a web panel with adults (18-49 years) in Sweden as part of the International Sexual Health And REproductive health survey (I-SHARE) (N=1307). The primary outcome was self-reported access to HIV/STI testing and condoms during COVID-19 measures. Logistic regression was used to assess adjusted odds ratios of experiencing reduced access to HIV/STI testing and condoms in relation to sociodemographic characteristics, changes in sexual behaviours and COVID-19-related factors. RESULTS: Of the 1138 sexually active respondents, 17% wanted an HIV/STI test, and of those over half (57%) reported reduced access during the COVID-19 measures in 2020. Compared with cis-women, transgender or non-binary respondents were more likely to experience lower access to testing. Among those who usually used condoms (n=568), 23% reported hampered condom access due to COVID-19 restrictions. Reduced condom access was associated with identifying as non-cis gender and a cis-man compared with cis-woman, non-heterosexual orientation, being foreign-born and financially worried. CONCLUSIONS: Findings indicate that access to HIV/STI testing and condoms among sexually active adults of reproductive age in Sweden was disrupted during the COVID-19 pandemic in 2020 with varied impact depending on sexual orientation, gender identity or socioeconomic situation. This signals the importance of ensuring equitable access to sexual and reproductive health services and commodities in future crises response.

Prevention of Childhood Adversities and Children's Common Mental Disorders and School Grades.

Importance: Adversity during childhood can limit children's chances of achieving their optimal developmental and psychological outcomes. Well-designed observational studies might help identify adversities that are most implicated in this, thereby helping to identify potential targets for developing interventions. Objective: To compare the association between preventing childhood poverty, parental mental illness and parental separation, and the population rate of offspring common mental disorders (ages 16-21 years) or average school grades (age 16 years). Design, Setting, and Participants: A population-based, longitudinal cohort study using Swedish registries was conducted. A total of 163 529 children born in Sweden between January 1, 1996, and December 31, 1997, were followed up until their 21st birthday. They were linked to registries using Sweden's national personal identification number. Children were linked to birth parents, hospital records, and school data. Parents were linked to registries containing health, income, sociodemographic, and obstetric data. Analyses were conducted between January 10, 2021, and August 26, 2022. Exposures: Childhood adversities of relative poverty (household disposable income <50% of the median), parental inpatient admission for a mental illness, or parental separation. Adversities were categorized into developmental periods: ages 0 to 3, 4 to 7, 8 to 11, and 12 to 16 years. Main Outcomes and Measures: The main outcomes were children's hospital records with a diagnosis of anxiety or depression between ages 16 and 21 years and school grades at the end of compulsory education (age 16 years). The parametric g-formula modeled population changes in outcomes associated with the counterfactual, hypothetical preventing adversity exposures, accounting for fixed and time-varying confounders. Adjustments were made for parental demographic characteristics, obstetric variables, and socioeconomic data at birth. Results: A total of 163 529 children were included in the cohort (51.2% boys, 51.4% born in 1996). Preventing all adversities was associated with an estimated change in the prevalence of offspring common mental disorders from 10.2% to 7.6% and an improvement in school grades with an SD of 0.149 (95% CI, 0.147-0.149). Preventing parental separation provided for the greatest improvement, with an estimated 2.34% (95% CI, 2.23%-2.42%) fewer children with a common mental disorder and an improvement in school grades by 0.127 SDs (0.125-0.129). Greater improvements were shown by hypothetically targeting adolescents (age 12-16 years) and those whose parents had a mental illness when the child was born. Conclusions and Relevance: The results of this cohort modeling study suggest that preventing childhood adversity could provide notable improvements in the rates of common mental disorders and school grades. Many children might achieve better life outcomes if resources are properly allocated to the right adversities (parental separation), the right groups (children with parental mental illness), and at the right time (adolescence).

A population-based cohort study of sex and risk of severe outcomes in covid-19.

There is a male sex disadvantage in morbidity and mortality due to COVID-19. Proposed explanations to this disparity include gender-related health behaviors, differential distribution of comorbidities and biological sex differences. In this study, we investigated the association between sex and risk of severe COVID-19 while adjusting for comorbidities, socioeconomic factors, as well as unmeasured factors shared by cohabitants which are often left unadjusted. We conducted a total-population-based cohort study (n = 1,854,661) based on individual-level register data. Cox models was used to estimate the associations between sex and risk for severe COVID-19. We additionally used a within-household design and conditional Cox models aiming to account for unmeasured factors shared by cohabitants. A secondary aim was to compare the risk of COVID-19 related secondary outcomes between men and women hospitalized due to COVID-19 using logistic regression. Men were at higher risk for hospitalization (HR = 1.63;95%CI = 1.57-1.68), ICU admission (HR = 2.63;95%CI = 2.38-2.91) and death (HR = 1.81;95%CI = 1.68-1.95) due to COVID-19, based on fully adjusted models. However, the effect of sex varied significantly across age groups: Among people in their 50s, men had > four times higher risk of COVID-19 death. The within-household design did not provide any further explanation to the sex disparity. Among patients hospitalized due to COVID-19, men had an increased risk for viral pneumonia, acute respiratory distress syndrome, acute respiratory insufficiency, acute kidney injury, and sepsis which persisted in fully adjusted models. Recognition of the combined effect of sex and age on COVID-19 outcomes has implications for policy strategies to reduce the adverse effects of the disease.

Parenthood and lower risk of suicide in women and men: the total Swedish population followed across adulthood.

BACKGROUND: Previous studies suggest a protective effect of parenthood on suicide, but little is known about how the association may change across the lifespan, or in relation to sex, marital status or occurrence of psychiatric disorders. METHODS: We followed a cohort of over 5 million Swedish women and men, from 1991 to 2011, up to max. age 75, for death by suicide using national registers. Information on childbirths/adoptions, potential confounders and modifying factors were obtained from national registers. We assessed the associations between parenthood and suicide across adulthood using within time-stratified Cox regression models, with parenthood as a time-dependent exposure. RESULTS: Parents had a lower risk of suicide than non-parents across the lifespan, after adjusting for sociodemographic factors. The association was most pronounced in young adults, especially young women, but attenuated with increasing age and converged between sexes in older age groups. The lower risk of suicide over the life course was similar whether parents were married, unmarried or divorced, apart from married men; among them, parents only had a lower risk above age 55. The lower risk in parents was also evident in people with a history of psychiatric hospitalizations, but disappeared from age 55 in this population. CONCLUSION: The lower risk of suicide was present in both parents, was most pronounced in young adulthood and weakened with increasing age. Our results are consistent with a plausible mechanism where feelings of responsibility and connectedness are protective against suicide in parents.

Association between parental mental illness and autoimmune diseases in the offspring - A nationwide register-based cohort study in Sweden.

Mental illness has been previously linked with autoimmune diseases, yet the associations between parental mental illness and offspring's risk of autoimmune diseases is largely unknown. We conducted a population-based cohort study of 2,192,490 Swedish children born between 1991 and 2011 and their parents to determine the associations between parental mental illness and risk of autoimmune diseases among the offspring. Time-dependent diagnoses of parental mental illness (psychosis, alcohol/drug misuse, depression, anxiety, eating disorders, personality disorders, attention deficit hyperactivity disorder, autism spectrum disorder) and offspring autoimmune diseases (type 1 diabetes (T1D), juvenile idiopathic arthritis (JIA), systemic lupus erythematosus, psoriasis, multiple sclerosis, inflammatory bowel disease (IBD), coeliac disease) were identified from inpatient/outpatient healthcare visits. Associations were measured by hazard ratios (HRs) adjusted for potential confounders. Overall, parental mental illness was associated with a small increase in risk of offspring's autoimmune diseases (HR 1.05, 95% CI 1.02-1.08). However, parental common mental disorder (anxiety/depression) was associated with higher risk of JIA, psoriasis, and T1D (HR T1D 1.11, 95% CI 1.01-1.22), while maternal psychosis with reduced risk of coeliac disease (HR 0.68, 95% CI 0.49-0.95) and paternal alcohol/drug misuse with reduced risk of IBD (HR 0.80, 95% CI 0.64-0.99). Maternal eating disorders were associated with a markedly increased risk for T1D (HR 1.41, 95% CI 1.05-1.89). Further studies are needed to confirm these findings and to understand underlying mechanisms. There is a need for greater clinical awareness about potential risk of JIA, psoriasis, and T1D among children of parents with common psychiatric morbidity.

Gender differences in the treatment of patients with borderline personality disorder.

It is debated whether men with borderline personality disorder (BPD) are less often treated for their disorder, compared to women, even when they have sought care. Here, the aim was to examine gender differences in the treatment of patients with BPD. Through linkage to Swedish health and administrative registers, we identified all patients diagnosed with BPD (n = 5530) in Stockholm County from 2012 to 2016. We ascertained information on sociodemographic characteristics, comorbid psychiatric diagnoses, and all mental health care utilization within inpatient and outpatient mental health care, including receipt of psychiatric medication and various psychological therapies. We identified 802 men and 4,728 women with BPD during the study period. Men with BPD were less likely than their female counterparts to be treated with psychotherapy as well as psychiatric medication. Most of the differences in treatment with psychological therapies were nonsignificant in the multivariate model, indicating they are likely the result of differences in sociodemographic variables and comorbidity between men and women with BPD. Men with BPD were in average 4 years older than women at the time of the first BPD diagnosis, had lower education, and were also more likely to receive social welfare support. In conclusion, few men are diagnosed with BPD and those who are diagnosed are likely to receive somewhat less psychiatric medication and psychological therapies compared to women. Researchers and clinicians need to focus more on men with BPD to improve help-seeking and recognition of this disabling condition in men and enable equal treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychological Distress, Suicidal Ideation, and Suicide Attempt Among Lesbian, Gay, and Bisexual Immigrants: Population-Based Findings from the Stockholm Public Health Cohort.

In a large, population-based sample in Sweden, we sought to examine mental health disparities between lesbian, gay and bisexual (LGB) and heterosexual individuals with different immigration statuses. We conducted a population-based study including 1799 LGB and 69,324 heterosexual individuals, recruited in 2010 and 2014 as part of the Stockholm Public Health Cohort. Data were obtained from self-administered surveys that were linked to nationwide registers. We examined associations between mental health outcomes (i.e., psychological distress, suicidal ideation, and suicide attempt) and sexual orientation (LGB versus heterosexual), immigration status (immigrant versus Nordic-born), and their interaction. Sex-stratified weighted multivariable logistic regression analyses were used to calculate adjusted odds ratios with 95% confidence intervals. LGB individuals demonstrated substantially elevated odds of all mental health outcomes compared to heterosexuals; immigrants reported moderately elevated odds of psychological distress and suicide attempt, but not suicidal ideation, compared to Nordic-born individuals. Interaction terms between sexual orientation and immigration status were significant at p < 0.05 for psychological distress for both sexes and for suicidal ideation and attempt among women. Unexpectedly, models probing interactions generally demonstrated that Nordic-born LGB individuals demonstrated greater risk of psychological distress, suicidal ideation, and suicide attempt than did immigrant LGB individuals, especially among women. Supplemental analyses showed that Nordic-born bisexual women demonstrated the highest risk of all studied outcomes. Being LGB in Sweden is generally a stronger risk factor for poor mental health among Nordic-born than immigrant populations. These findings call for future intersectionality-focused research to delineate the unique cultural, social, and psychological factors associated with mental health and resilience among LGB immigrants.

Parenthood is associated with lower suicide risk: a register-based cohort study of 1.5 million Swedes.

OBJECTIVE: To determine whether parenthood among 25- to 44-year-olds is associated with a lower suicide rate in men and women in Sweden, and whether this is explained by selection into parenthood. METHODS: In total, 1,582,360 Swedish women and men, born between 1967 and 1985, and childless at their 25th birthday, were followed from 1992 to 2011. All data originated from linkage to national Swedish registers. Cox regression models were used with time-varying parenthood status to estimate adjusted hazard ratios and 95% confidence intervals (aHR;CI) for suicide. RESULTS: Having one, two, three or more children was associated with 64%, 79% and 78% lower suicide rate, respectively, compared with having no children, in models with basic adjustments. When a wide range of indicators of selection into parenthood were taken into account, the suicide rate was 58% lower in parents with one child and 70% lower in parents with two or more children compared with childless individuals (aHR 0.42 [95% CI 0.36-0.48]; 0.30 [95% CI 0.25-0.35]; 0.30 [95% CI 0.21-0.42]). In fathers with one, two, three or more children suicide rate was 54%, 64% and 59% lower, respectively, compared with non-fathers whereas in mothers was 70%, 83% and 93% lower, respectively, compared with non-mothers. CONCLUSION: Parenthood among 25-to 44-year-olds is associated with a lower suicide risk in both men and women but to a larger extent among women, and particularly in parents with two or more children. Although selection into parenthood is possible, a protective effect of parenthood on suicide is likely in both men and women.

Prevalence of parental mental illness and association with socioeconomic adversity among children in Sweden between 2006 and 2016: a population-based cohort study.

BACKGROUND: Children of parents with mental illness are a vulnerable group, but their numbers and their exposure to adversity have rarely been examined. We examined the prevalence of children with parents with mental illness in Sweden, trends in prevalence from 2006 to 2016, and these children's exposure to socioeconomic adversity. METHODS: We did a population-based cohort study among all children (aged <18 years) born in Sweden between Jan 1, 1991, and Dec 31, 2011, and their parents, followed up between Jan 1, 2006, and Dec 31, 2016. We included children who were identified in the Total Population Register and linked to their birth parents, excluding adopted children and those with missing information on both birth parents. We used a comprehensive register linkage, Psychiatry Sweden, to follow up for indicators of parental mental illness and socioeconomic adversity. Marginal predictions from a standard logistic regression model were used to estimate age-specific, 3-year period prevalence of parental mental illness and trends in prevalence for 2006-16. Using cross-sectional data on each child, indicators of socioeconomic adversity were compared between children with and without concurrent parental mental illness using logistic regression. FINDINGS: Of 2 198 289 children born in Sweden between Jan 1, 1991, and Dec 31, 2011, we analysed 2 110 988 children (96·03% of the total population). The overall prevalence of children with diagnosed parental mental illness between 2006 and 2016 was 9·53% (95% CI 9·50-9·57). This prevalence increased with age of the child, from 6·72% (6·65-6·78) of the youngest children (0 to <3 years) to 10·80% (10·73-10·89) in the oldest (15 to <18 years). The prevalence of diagnosed parental mental illness increased from 8·62% (8·54-8·69) in 2006-09 up to 10·95% (10·86-11·03) in 2013-16. Children with any type of parental mental illness had markedly higher risk of socioeconomic adversity, such as living in poorer households or living separately from their parents. INTERPRETATION: Currently, 11% of all Swedish children have a parent with a mental illness treated within secondary care. These children have markedly higher risk of broad socioeconomic adversity than do other children. There is a need to understand how socioeconomic adversity and parental mental illness influence vulnerability to poor life outcomes in these children. FUNDING: European Research Council, National Institute for Health Research, Region Stockholm, and the Swedish Research Council.

Childhood appendectomy and adult mental disorders: A population-based cohort study.

BACKGROUND: Recent studies suggest that disruption of the colonic microbiota homeostasis is associated with low-grade systemic inflammation and mental disorders. The cecal appendix may influence the homeostasis of the colonic microbiota. In this large population-based study, we investigated whether early removal of the appendix is associated with an increased risk of mental disorders later in life. MATERIALS AND METHODS: All Swedish individuals born between 1973 and 1992 (N = 1,937,488) were included and followed prospectively until December 31, 2016 for any psychiatric International Classification of Disease diagnosis from age 14 or later in life. The main exposure was defined as having a history of appendectomy before age 14 (N = 44,259); the second exposure, appendicitis before age 14 but without appendectomy (N = 1,542), and the third exposure studied was a history of hernia surgery before age 14 (N = 35,523). Control groups for each respective exposure were all unexposed individuals in the study population. RESULTS: Individuals exposed to appendectomy before age 14 had a 19% increased risk of depressive disorder (adjusted hazard ratio [aHR] = 1.19; 95% confidence interval [95% CI]: 1.15-1.23), 27% increased risk of bipolar affective disorder (aHR = 1.27; 95% CI: 1.17-1.37), and a 20% increased risk of an anxiety disorder (aHR = 1.20; 95% CI: 1.16-1.23) compared to individuals unexposed to childhood appendectomy. We found no association between appendectomy and increased risk of obsessive-compulsive disorder and schizophrenia and there was no association between appendicitis without appendectomy and mental disorders. The association between childhood hernia surgery and mental disorders later in life was small but significant. CONCLUSION: Childhood appendectomy, but not appendicitis without appendectomy, was associated with a significantly increased risk of mood and anxiety disorders in adulthood.

Association between maternal and paternal mental illness and risk of injuries in children and adolescents: nationwide register based cohort study in Sweden.

OBJECTIVE: To determine the association between parental mental illness and the risk of injuries among offspring. DESIGN: Retrospective cohort study. SETTING: Swedish population based registers. PARTICIPANTS: 1 542 000 children born in 1996-2011 linked to 893 334 mothers and 873 935 fathers. EXPOSURES: Maternal or paternal mental illness (non-affective psychosis, affective psychosis, alcohol or drug misuse, mood disorders, anxiety and stress related disorders, eating disorders, personality disorders) identified through linkage to inpatient or outpatient healthcare registers. MAIN OUTCOME MEASURES: Risk of injuries (transport injury, fall, burn, drowning and suffocation, poisoning, violence) at ages 0-1, 2-5, 6-9, 10-12, and 13-17 years, comparing children of parents with mental illness and children of parents without mental illness, calculated as the rate difference and rate ratio adjusted for confounders. RESULTS: Children with parental mental illness contributed to 201 670.5 person years of follow-up, while children without parental mental illness contributed to 2 434 161.5 person years. Children of parents with mental illness had higher rates of injuries than children of parents without mental illness (for any injury at age 0-1, these children had an additional 2088 injuries per 100 000 person years; number of injuries for children with and without parental mental illness was 10 235 and 72 723, respectively). At age 0-1, the rate differences ranged from 18 additional transport injuries to 1716 additional fall injuries per 100 000 person years among children with parental mental illness compared with children without parental mental illness. A higher adjusted rate ratio for injuries was observed from birth through adolescence and the risk was highest during the first year of life (adjusted rate ratio at age 0-1 for the overall association between any parental mental illness that has been recorded in the registers and injuries 1.30, 95% confidence interval 1.26 to 1.33). Adjusted rate ratios at age 0-1 ranged from 1.28 (1.24 to 1.32) for fall injuries to 3.54 (2.28 to 5.48) for violence related injuries. Common and serious maternal and paternal mental illness was associated with increased risk of injuries in children, and estimates were slightly higher for common mental disorders. CONCLUSIONS: Parental mental illness is associated with increased risk of injuries among offspring, particularly during the first years of the child's life. Efforts to increase access to parental support for parents with mental illness, and to recognise and treat perinatal mental morbidity in parents in secondary care might prevent child injury.

Fertility trends of women with serious mental illness in the United Kingdom 1992-2017: A primary care cohort study using the clinical practice research datalink.

BACKGROUND: Changes in care may mean women with serious mental illness (SMI) are more fertile. We investigated 1) the live-birth and pregnancy rate of women with and without SMI over time, 2) the likelihood of pregnancy when using second or first-generation antipsychotics. METHOD: Retrospective cohort study of women (15-45 years) registered in Clinical Practice Research Datalink (CPRD) general practices between 1992 and 2017. Each analysis year, women with SMI (affective and non-affective psychotic disorder) were matched with up to four women with no record of SMI on age, calendar year and general practice. Pregnancy and live-birth rates and the rate ratio (RR) comparing women with and without SMI were estimated. The stability of the RR between years was tested. For women with SMI, the pregnancy rates when on or off first or second-generation antipsychotics were calculated and compared using Poisson regression models. RESULTS: In total, 12,524 women with SMI were matched to 50,074 women without SMI, median age 34 [IQR 28-39] years. Between 1992 and 2017 women with SMI had 50% fewer live-births than women without SMI (RR 0..50, 95%CI 0.45-0.55). The pregnancy rate ratio increased from 0.64 (95%CI 0.48-0.86) (1992-1994) to 1.00 (95%CI 0.81-1.22) (2016-2017), (p < 0.0001), but this change was only seen in women with affective disorders. Women are most likely to become pregnant after discontinuing either a second-generation or first-generation antipsychotic (RR 1.74, 95%CI 1.42-2.13). CONCLUSIONS: Women with SMI are increasingly experiencing pregnancy but not live-birth, which suggests the reproductive health needs of these women are unmet.