Trajectories of antidepressant use and characteristics associated with trajectory groups among young refugees and their Swedish-born peers with diagnosed common mental disorders-findings from the REMAIN study.

PURPOSE: This study aimed to (1) identify the trajectories of prescribed antidepressants in refugee youth and matched Swedish-born peers diagnosed with common mental disorder (CMD) and (2) characterize the trajectories according to sociodemographic and medical factors. METHODS: The study population comprised 2,198 refugees and 12,199 Swedish-born individuals with both Swedish-born parents, aged 16-25 years in 2011, residing in Sweden and treated in specialised healthcare for CMD 2009-11. Group-based trajectory modelling was used to identify different trajectory groups of antidepressant use-based on annual defined daily dosages (DDDs). Multinomial logistic regression was applied to investigate the association of sociodemographic and medical characteristics with the identified trajectories. Nagelkerke pseudo-R2 values were estimated to evaluate the strength of these associations. RESULTS: Four trajectory groups of antidepressant use among young refugees were identified with following proportions and DDD levels in 2011: 'low constant' (88%, < 100), 'low increasing' (2%, ≈710), 'medium decreasing' (8%, ≈170) and 'high increasing' (2%, ≈860). Similar trajectories, however, with different proportions were identified in Swedish-born: 67%, 7%, 21% and 5%, respectively. The most influential factors discriminating the trajectory groups among refugees were 'duration of stay in Sweden' (R2 = 0.013), comorbid 'other mental disorders' (R2 = 0.009) and 'disability pension' (R2 = 0.007), while 'disability pension' (R2 = 0.017), comorbid 'other mental disorders' (R2 = 0.008) and 'educational level' (R2 = 0.008) were the most important determinants discriminating trajectory groups among Swedish-born youth. CONCLUSION: The lower use of antidepressants in refugees with CMDs compared to their Swedish-born counterparts warrants health literacy programs for refugees and training in transcultural psychiatry for healthcare professionals.

Trajectories of labour market marginalisation among young adults with newly diagnosed attention-deficit/hyperactivity disorder (ADHD).

AIMS: Labour market marginalisation (LMM), i.e. severe problems in finding and keeping a job, is common among young adults with attention-deficit/hyperactivity disorder (ADHD). This study aimed to disentangle the extent of LMM as well as the heterogeneity in patterns of LMM among young adults with ADHD and what characterises those belonging to these distinct trajectories of LMM. METHODS: This population-based register study investigated all 6287 young adults, aged 22-29 years, who had their first primary or secondary diagnosis of ADHD in Sweden between 2006 and 2011. Group-based trajectory (GBT) models were used to estimate trajectories of LMM, conceptualised as both unemployment and work disability, 3 years before and 5 years after the year of an incident diagnosis of ADHD. Odds ratios (ORs) with 95% confidence intervals (CIs) for the association between individual characteristics and the trajectory groups of LMM were estimated by multinomial logistic regression. RESULTS: Six distinct trajectories of LMM were found: 'increasing high' (21% belonged to this trajectory group) with high levels of LMM throughout the study period, 'rapidly increasing' (19%), 'moderately increasing' (21%), 'constant low' (12%) with low levels of LMM throughout the study period, 'moderately decreasing' (14%) and finally 'fluctuating' (13%), following a reversed u-shaped curve. Individuals with the following characteristics had an increased probability of belonging to trajectory groups of increasing LMM: low educational level (moderately increasing: OR: 1.4; CI: 1.2-1.8, rapidly increasing: OR: 1.7; CI: 1.3-2.1, increasing high: OR: 2.9; CI: 2.3-3.6), single parents (moderately increasing: OR: 1.6; CI: 1.1-2.4, rapidly increasing: OR: 2.0; CI: 1.3-3.0), those born outside the European Union/the Nordic countries (rapidly increasing: OR: 1.7; CI: 1.1-2.5, increasing high: OR: 2.1; CI: 1.4-3.1), persons living in small cities/villages (moderately increasing: OR: 2.4; CI: 1.9-3.0, rapidly increasing: OR: 2.1; CI: 1.6-2.7, increasing high: OR: 2.6; CI: 2.0-3.3) and those with comorbid mental disorders, most pronounced regarding schizophrenia/psychoses (rapidly increasing: OR: 6.7; CI: 2.9-19.5, increasing high: OR: 12.8; CI: 5.5-37.0), autism spectrum disorders (rapidly increasing: OR: 4.6; CI: 3.1-7.1, increasing high: OR: 9.6; CI: 6.5-14.6), anxiety/stress-related disorders (moderately increasing: OR: 1.3; CI: 1.1-1.7, rapidly increasing: OR: 2.0; CI: 1.6-2.5, increasing high: OR: 1.8; CI: 1.5-2.3) and depression/bipolar disorder (moderately increasing: OR: 1.3; CI: 1.0-1.6, rapidly increasing: OR: 1.7; CI: 1.4-2.2, increasing high: OR: 1.5; CI: 1.2-1.9). CONCLUSIONS: About 61% of young adults were characterised by increasing LMM after a diagnosis of ADHD. To avoid marginalisation, attention should especially be given to young adults diagnosed with ADHD with a low educational level, that are single parents and who are living outside big cities. Also, young adults with comorbid mental disorders should be monitored for LMM early in working life.

Cumulative exposure to childhood adversity, and treated attention deficit/hyperactivity disorder: a cohort study of 543 650 adolescents and young adults in Sweden.

BACKGROUND: Though childhood adversity (CA) has been associated with the risk of attention deficit/hyperactivity disorder (ADHD), little is known about the effect of cumulative CAs and whether there are clusters of CAs that are more closely related with ADHD. METHODS: We used a Swedish cohort of 543 650 individuals born 1987-1991. Register-based CAs included familial death, substantial parental substance abuse and psychiatric disorder, substantial parental criminality, parental separation, household public assistance recipiency, and residential instability. Individuals were followed from year 2006 when they were 15-19 years of age, for treated ADHD, defined as a registered ICD diagnosis and/or prescription of medications to treat ADHD. Logistic regression analysis was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Latent Class Analyses (LCA) were used to identify clusters based on the different CAs. RESULTS: All CAs increased the odds of ADHD in late adolescence and early adulthood; ORs ranged from 1.6 (95% CI 1.5-1.8) for familial death to 2.7 (95% CI 2.6-2.9) for household public assistance. We found a dose-response relationship between cumulative CA and ADHD; individuals with 4+ CAs had a markedly increased risk for ADHD (OR 5.5, 95% CI 5.0-6.0). LCA analyses revealed six distinct classes of CA associated with ADHD, of which 'exposure to most adversities' entailed highest risk. CONCLUSION: CA is a strong risk factor for ADHD, particularly when accumulated. Early and efficient detection of CA is of importance for interventions targeted to improve long-term mental health outcomes among disadvantaged children.

Suicide in first episode psychosis: a nationwide cohort study.

BACKGROUND: Relatively little is known about suicide in diagnostic subtypes of first episode psychosis (FEP). Our aim was to assess suicide rates and potential risk factors for suicide in FEP. METHODS: This is a national register-based cohort study of patients born in 1973-1978 in Sweden and who were hospitalized with a FEP between ages 15 and 30years (n=2819). The patients were followed from date of discharge until death, emigration, or 31st of December 2008. The suicide rates for six diagnostic subtypes of FEP were calculated. Suicide incidence rate ratios (IRRs) were calculated to evaluate the association between suicide and psychiatric, familial, social, and demographic factors. RESULTS: In total 121 patients died by suicide. The overall suicide rate was 4.3 (95% confidence interval [CI] 3.5-5.0) per 1000person-years. The highest suicide rates were found in depressive disorder with psychotic symptoms and in delusional disorder. In an adjusted model, the strongest risk factors for suicide were self-harm (IRR 2.7, CI 1.7-4.4) or a conviction for violent crime (IRR 2.0, CI 1.3-3.2). Also having a first-degree relative with a schizophrenia/bipolar diagnosis (IRR 2.1, CI 1.2-3.6) or substance use disorder (IRR 2.0, CI 1.2-3.2) were significant risk factors for suicide. CONCLUSIONS: Impulsive behavior such as self-harm as well as having a family history of severe mental disorder or substance use are important risk factors for suicide in FEP.

A five year diagnostic follow-up of 1,840 patients after a first episode non-schizophrenia and non-affective psychosis.

OBJECTIVE: It is not clear which patients with a first psychotic episode will develop schizophrenia. We performed a diagnostic follow-up of patients treated for a first time non-affective, non-schizophrenia psychosis and explored potential predictors of a subsequent schizophrenia or schizoaffective diagnosis. METHODS: This register-based cohort study comprises individuals born between 1973 and 1978 in Sweden, with a first hospital-treated psychosis excluding schizophrenia, schizoaffective disorder, bipolar disorder and depressive disorder with psychotic symptoms (n=1840). The patients were followed for five years regarding subsequent diagnoses. Psychiatric, social, family history of psychiatric illness, premorbid intellectual level, head injuries and obstetrical complications were investigated by logistic regression as predictors of schizophrenia or schizoaffective diagnosis. RESULTS: During the follow-up, 18% were diagnosed with schizophrenia or schizoaffective disorder, 5% were diagnosed with bipolar disorder, whereas 29% were not re-admitted to a psychiatric clinic. Patients with a first-degree relative hospitalized for schizophrenia and/or bipolar disorder had an increased risk of subsequent diagnosis for schizophrenia or schizoaffective disorder (odds ratio 1.9 and 95% confidence interval 1.1 to 3.0)), whereas previous severe criminality was associated with a decreased risk (odds ratio 0.5, 95% confidence interval 0.3-0.8). CONCLUSION: Diagnostic outcome was diverse after a first non-schizophrenia and non-affective psychosis. Family history of severe mental illness and no previous conviction for severe criminality were the strongest risk factors for a future schizophrenia or schizoaffective diagnosis.

Suicidal behavior among delinquent former child welfare clients.

Child welfare clients represent a high-risk group for delinquency and adult criminality, but also for future suicidal behavior. We examine associations between delinquency and suicidal behavior in a national child welfare population. This register-based cohort study is based on data for all Swedish former child welfare clients born between 1972 and 1981 that experienced interventions before their adolescent years. We followed 27,228 individuals from age 20 years until 31 December 2006. Juvenile delinquency was defined as being convicted of at least one crime between age 15 and 19. The risk of suicidal behavior was calculated as incidence rate ratios (IRRs). Fifteen percent of the women and 40% of the men had at least one conviction between the age 15 and 19. The adjusted risk of suicidal behavior among women with five or more convictions was 3.5 (95% CI 2.0-6.2); corresponding IRR for men was 3.9 (95% CI 3.1-4.9). Child welfare experience-specifically of out-of-home care-in combination with delinquency is a potent risk factor for suicidal behavior among young adults. However, we cannot exclude that some of this association is an epiphenomenon of uncontrolled confounders, such as impulsivity or severity of psychiatric disease. Despite this caveat, results should be disseminated to practitioners in the health and correction services.