In-patient psychiatric care and non-substance-related psychiatric diagnoses among individuals seeking treatment for alcohol and substance use disorders: associations with all-cause mortality and suicide.

BACKGROUND: The largest excess mortality risk has been reported for combinations of psychiatric disorders that included substance use disorders. AIMS: To study the associations of different non-substance-related in-patient psychiatric diagnoses with all-cause mortality and suicide up to 28 years of age after entering substance use treatment. METHOD: National register data on psychiatric hospital admissions and death were combined with the treatment records of over 10 000 individuals in substance use treatment between 1990 and 2009. Cox regression was used to calculate hazard ratios (HRs) with 95% CIs for all-cause and suicide-specific mortality from the time of entering substance use treatment. RESULTS: Nearly one-third (31.4%; n = 3330) of the study population had died during follow-up or by their 65th birthday, with more than one in ten (n = 385) from suicide. Over half of the study population (53.2%) had undergone psychiatric in-patient care and 14.1% involuntary psychiatric care during the study period. Bipolar disorder and unipolar depression were associated with a 57% (HR 1.57, 95% CI 1.18-2.10) and 132% (HR 2.32, 95% CI 1.21-4.46) increase in risk of suicide, respectively. Involuntary psychiatric care was associated with a 40% increase in risk of suicide (HR 1.42, 95% CI 1.05-1.94). CONCLUSION: Severe psychiatric morbidity is common among individuals seeking treatment for alcohol and/or substance use and specifically mood disorders appear to increase the risk of suicide. Treatment service planning needs to focus on integrated care for concomitant substance use and psychiatric disorders to address this risk.

Association between the discontinuation of substance use inpatient treatment and the risk of committing a crime leading to imprisonment: A Finnish registry-based 5-year follow-up.

BACKGROUND: Discontinuation of substance use inpatient treatment is common, generally due to dropout and rule breaking. In turn, this is associated with worse long-term substance use outcomes. AIM: To investigate whether people who discontinued voluntary inpatient substance use treatment have a higher risk of imprisonment for a crime within 5 years of discontinuance than those who completed treatment. METHODS: This registry-based follow-up study focused on all inpatient treatment episodes between 2002 and 2009 (N = 2893) in a Finnish hospital for treating addictions. Data from national registers on criminality, hospitalisations and education were linked. Cox regression analysis was used. RESULTS: Discontinued treatment episodes were 1.4 times more likely to be followed by criminality leading to imprisonment during the 5-year follow-up period compared with completed treatment periods, after adjusting for age, gender, education, substance use diagnoses, earlier mental health disorders and prior imprisonments. CONCLUSIONS: Our findings strengthen the argument for ensuring completion of substance use treatment episodes; better completion rates could decrease the harm caused by serious criminality. Indeed, we recommend that crime reduction should be included to the long-term goals of substance use treatment.

Persistent offenders and adolescence-limited offenders: Differences in life-courses.

BACKGROUND AND AIMS: As our previous study indicated, almost half of juvenile delinquents continued offending in adulthood, while the rest ceased to do so. We compared these groups with each other and with non-offenders in the life-course use of alcohol, identity development and life situation. METHODS: Based on the Jyväskylä Longitudinal Study of Personality and Social Development, four groups were formed at age 42 for men and women: persistent, adolescence-limited and adult-onset offenders and non-offenders. Longitudinal data (N = 369; 53% males) have been collected at ages 8, 14, 20, 27, 36, 42 and 50. RESULTS: Persistent offending, but not adolescence-limited offending, was associated with the accumulation of problems in adulthood and an elevated risk of death before age 54. For males, persistent offending was associated with heavy drinking from adolescence to middle age, diffuse identity, high divorce rates and poverty. For females, persistent offending was associated with heavy drinking in adulthood and a higher rate of being outside the workforce in middle age. In males, adolescence-limited offending was associated with more controlled drinking in adulthood, and in females, with early divorce from the partner and advanced identity. CONCLUSIONS: Detecting the risks of the accumulation of problems and potential for positive transitions of juvenile delinquents until middle age will be important for prevention and treatment.

The association of alcohol use and quality of life in depressed and non-depressed individuals: a cross-sectional general population study.

PURPOSE: To compare the associations of alcohol-related variables with Quality of Life (QoL) in depressed and non-depressed individuals of the general population. METHODS: This cross-sectional study utilized data from the FINRISK 2007 general population survey. A subsample (n = 4020) was invited to participate in an interview concerning alcohol use. Of them, 2215 (1028 men, 1187 women; response rate 55.1%) were included in the analyses. Bivariate associations between mean weekly alcohol consumption, frequency of binge drinking, Alcohol Use Disorders Identification Test (AUDIT)-score and QoL were analysed according to categorization into depressed and non-depressed using the Beck Depression Inventory, Short Form. Linear regression models were calculated in order to determine the associations of the alcohol variables and QoL after adjusting for socio-demographic variables as well as somatic and mental illness. RESULTS: Depressed individuals had lower mean QoL and higher AUDIT-scores than non-depressed respondents. Bivariate correlations showed that mean weekly alcohol consumption, frequency of binge drinking and AUDIT-scores were statistically significantly associated with impaired QoL in depressed individuals. Abstinence was not associated with QoL. After adjustment for covariates, frequency of binge drinking and AUDIT-score were statistically significantly associated with QoL in depressed individuals and AUDIT-score in the non-depressed group. When analysing all respondents regardless of depression, both AUDIT-score and binge drinking were associated with QoL. CONCLUSIONS: Of the alcohol-related variables, binge drinking and alcohol problems indicated by AUDIT-score contributed to impaired QoL in depressed individuals and both should be assessed as part of the clinical management of depression.

Health-related quality of life in alcohol dependence: a systematic literature review with a specific focus on the role of depression and other psychopathology.

BACKGROUND: Health-related quality of life (HRQOL) is considered a valid measure of treatment effectiveness in addictions. However, alcohol research has lagged behind other biomedical fields in using HRQOL outcomes as primary or secondary endpoints. Previous work has suggested that psychiatric co-morbidity may mediate the relationship between alcohol dependence and HRQOL. AIM: The goal was to summarize the literature on HRQOL and its domains in the context of alcohol dependence. A specific focus was on the impact of depression and other psychopathology on these areas of life. MATERIALS AND METHODS: A database search of MEDLINE and PsychINFO was performed within the scope of PARADISE (Psychosocial fActors Relevant to brAin DISorders in Europe); a European Commission funded coordination action. Using pre-defined eligibility criteria, 42 studies were identified. A systematic approach to data collection was employed. RESULTS AND CONCLUSIONS: Alcohol dependence was shown to affect overall HRQOL and its domains, including general health, physical and mental health, general and social functioning, activities of daily living, pain and sleep. The evidence demonstrating that alcohol dependence is a primary cause of impairments in overall HRQOL, general health, mental and physical health and social functioning was fairly strong. Treatment interventions helped improve HRQOL and its aforementioned domains. The reduction or cessation of alcohol use facilitated these improvements; however, it was not reported to be predictive of improvement in all instances where improvement was reported. Depression was associated with further decreases in HRQOL. Personality disorders contributed to the severity of social functioning impairment.

Stability in health behavior patterns in middle adulthood: a 19-year follow-up study.

Objective: This study investigated subgroups of adults with particular health behavior patterns, their stability over 19 years, and the role of sociodemographic and personality characteristics in these.Methods and Measures: Data on smoking, alcohol consumption, and physical activity were collected at ages 42, 50, and 61 in the Jyväskylä Longitudinal Study of Personality and Social Development (n = 205-302). Latent class, latent transition, and logistic regression analyses were used.Results: Four similar classes of health behaviors were identified at each age. A class named low alcohol consumption (AC)-high physical activity (PA) included individuals with the lowest levels of alcohol consumption and the highest levels of physical activity, and a class named high AC-low PA vice versa. Classes between these extremes of alcohol consumption and physical activity levels were nonsmokers with the lowest proportion of smokers, and smokers vice versa. Although transitions emerged, class memberships were relatively stable. Women, those who were married, held a degree, had higher occupational status, and certain personality traits at age 42 were more likely to belong continuously to healthier classes compared to a stable membership in high AC-low PA.Conclusion: Health behaviors exist in patterns, are relatively stable across adulthood, and associated with sociodemographic and personality characteristics.

Imprisonment, community sanctions and mortality by cause of death among patients with substance use disorder - a 28-year follow-up using Finnish register data.

BACKGROUND: The first few weeks' post-imprisonment are associated with high mortality, particularly among individuals with a history of substance use. Excess risk may vary by societal context due to a range of penal systems and substance use patterns. Using data on Finnish individuals who had sought treatment for substance use, we studied the association between criminal sanctions with cause-specific mortality. METHODS: The database contained 10887 individuals who had sought treatment between 1990 and 2009. Their treatment data were combined with register data on imprisonments and community sanctions and weekly mortality between 1992 and 2015. Mortality was analysed using discrete-time survival models. We controlled for age and sociodemographic factors, and analysed whether education, type of substance used and the type of latest sentence modified the associations. FINDINGS: Mortality was high in the first two weeks after sanctions (all-cause odds ratio [OR] 2.61, 95% confidence interval [CI] 1.67-4.07; drug-related deaths OR 8.52, 95% CI 4.64-15.7). Excess risk declined over time (OR after 12 weeks: 1.19, 95% CI 1.07-1.31). Most of the excess risk was attributable to external causes. Mortality was low during imprisonment, but not during community sanctions. The patterns were similar by level of education, substance use and the type of latest sentence. CONCLUSIONS: Community sanctions were not associated with mortality among people with substance use disorders. Mortality was low during imprisonment, but high post-release. Criminal sanctions should be better utilised as intervention touchpoints and follow-up resources should target prisoners with substance use treatment history to reduce post-release mortality.

Integrated care model and point of care diagnostics facilitate Hepatitis C treatment among patients receiving opioid agonist therapy: a retrospective review of medical records.

BACKGROUND: Hepatitis C virus (HCV) is common among individuals in opioid agonist therapy (OAT). HCV treatment has previously been unavailable for most HCV positive OAT patients in Finland. The removal of treatment restrictions and attempts to reach HCV elimination goals have increased the number of OAT patients needing HCV treatment. The objectives of this study were 1) to characterize Finnish HCV positive OAT patients and evaluate their eligibility for HCV treatment at addiction service units, and 2) to retrospectively review the outcomes of treated patients. METHODS: The study focused on HCV positive OAT patients (n = 235). Demographics and clinical parameters were retrospectively reviewed using the patients' medical records. The eligibility of providing HCV treatment to patients at addiction service units were evaluated based on patients' clinical characteristics, such as liver function and patterns of substance use. The outcomes of patients receiving HCV treatment were reviewed. RESULTS: Of HCV antibody positive OAT patients, 75% had chronic HCV. Of 103 HCV patients screened for liver fibrosis either with Fibroscan or APRI (aspartate aminotransferase to platelet ratio index), 83 patients (81%) had no indication of severe liver damage. Point of care (POC) HCV tests were used for 46 patients to lower the threshold of attending laboratory testing. All patients preferred POC testing to conventional blood testing. Twenty patients had received HCV treatment, 19 completed the treatment and achieved sustained virologic response (SVR) at the end of the treatment. Of the 18 patients available for evaluation of SVR at 12 weeks after the treatment (SVR12), 17 achieved SVR12. CONCLUSIONS: The integrated model consisting of HCV diagnostics and treatment at the addiction service unit was successfully implemented within normal OAT practice.

Psychosocial difficulties and treatment retention in inpatient detoxification programmes.

Aims: Treatment retention is associated with addiction treatment outcomes. Research regarding predictors of retention at inpatient detoxification treatment is limited. The aim of this study was to investigate whether psychosocial difficulties (PSDs) are associated with treatment retention among Finnish inpatients undergoing detoxification treatment. Design: This register-based study included real-life data on detoxification treatment episodes (n = 2,752) between February of 2016 and May of 2019 from several inpatient treatment units in Finland. The PARADISE24fin instrument was used to assess PSDs. Socio-demographic and substance use related variables, as well as PSDs, were analysed with regard to treatment retention. Multiple logistic regression models were used to identify predictors of treatment incompletion. Results: Of the 2,752 detoxification treatment episodes, 80.3% (n = 2,209) were completed. Men and women differed with regard to the variables associated with treatment retention. After adjusting for confounders, younger age (≤ 35 years), being less educated (≤ 9 years), being unemployed, using opioids, polysubstance use and more severe dependence were associated with treatment incompletion. Overall severity of PSDs (PARADISE24fin mean score) became non-significant after adjusting for confounders. However, having more severe cognitive difficulties was significantly associated with treatment incompletion, while more severe difficulties in daily activities was associated with treatment completion. Conclusions: Special attention should be paid to younger individuals with opioid and/or polysubstance use, as well as those with cognitive difficulties, in order to retain people in treatment.

Mortality of treatment-seeking men and women with alcohol, opioid or other substance use disorders - A register-based follow-up study.

BACKGROUND: Alcohol (AUD), opioid (OUD) and other substance use disorders (SUD) are associated with an increased risk of premature death. The aim of this register-based follow-up study was to compare the risk of death between individuals who had sought treatment for AUDs, OUDs and other SUDs in Finland. DESIGN, SETTING, PARTICIPANTS: Data included 10,888 individuals who had sought help from three clinics at some point between 1990 and 2009. Treatment data were linked to national register data concerning education, hospitalizations and death by the year 2018. MEASUREMENTS: Individuals were categorized into four groups: only alcohol (AUD-only), all OUDs (OUD-all), other or multiple SUDs (SUD-other) and outpatients without substance-related diagnoses or hospitalizations (SU-NAS); in mortality analyses, those who had started in opioid substitution treatment (OST) were analyzed separately. COX regression analyses were used to calculate the risk of death by the year 2018 or up to 15 years after seeking treatment. RESULTS: Among the 10,888 treatment-seeking individuals the cumulative mortality rates during 1-, 5- and 15-year follow-up were 2.5% (n = 271), 10.9% (n = 1191) and 28.4% (n = 3096), respectively. The mean age at death varied according to substance of use (55.0 years for AUD-only, 35.8 OUD-all, 45.8 SUD-other and 55.6 SU-NAS). The patients who had started in OST had a lower risk of death compared to the other groups, as did the SU-NAS group that likely included individuals with a less severe course of AUDs/SUDs. There were no differences between the AUD-only, OUD-other and SUD-other groups for the risk of death during the 15-year follow-up period when gender and year of birth were included as covariates. CONCLUSIONS: The mortality rates were very high; however, most of the deaths occurred several years after seeking treatment. The lower mortality amongst the patients who had initiated OST solidifies previous knowledge on the benefits of OST and efforts should be made to improve access to treatment. These results show that treatment plays a role in lowering the risk of death among individuals with AUDs/SUDs.

Identifying psychosocial difficulties of inpatients with substance use disorders: evaluation of the usefulness of the PARADISE24 for clinical practise.

Purpose: Improvements in overall functioning and well-being are important goals in the treatment of substance use disorders. The aim of the current study was to evaluate the usefulness of the PARADISE24 instrument for studying the scope and severity of psychosocial difficulties by comparing the results with other measures in the context of substance use disorders.Materials and methods: This cross-sectional study included two independent inpatient samples. The first sample consisted of 80 interviews including the PARADISE24 and 10 other measures. The second sample consisted of the responses of 1082 inpatients to a self-administered PARADISE24 questionnaire.Results: Inpatients with substance use disorders had experienced a wide range of psychosocial difficulties and the two samples produced similar results. Highest scores were observed for emotional difficulties. The PARADISE24 showed convergent validity with measures of disability and depressive symptoms and discriminant validity with personality traits and environmental factors (i.e., social support and caretaker's empathy). Psychosocial difficulties were inversely associated with quality of life and self-assessed health.Conclusion: The PARADISE24 provides a wide range of useful information on psychosocial difficulties for clinical work and it can be used as a self-administered questionnaire in the evaluation and treatment of substance use disorders.Implications for rehabilitationIndividuals undergoing inpatient treatment for substance use disorders experience various and severe psychosocial difficulties.The PARADISE24 is an evidence-based instrument for assessing the scope and severity of 24 common psychosocial difficulties among neurological and psychiatric disorders.The PARADISE24 also offers a time-efficient method which can be used as a self-administered questionnaire in the context of substance use disorders.Comparison between the PARADISE24 and 10 commonly used measures showed that the PARADISE24 covered a wide variety of clinically relevant issues in one questionnaire.

Longitudinal properties of the PARADISE24fin questionnaire in treatment of substance use disorders.

AIM: Improvement of overall functioning is an important goal in the treatment of substance use disorders, and thus tools for monitoring change are needed. The current study aimed to evaluate the longitudinal metric invariance and sensitivity to change for the PARADISE24fin questionnaire. METHODS: A total of 1153 patients with substance use disorders completed the PARADISE24fin in two measurement occasions along their treatment. Patients were categorized into three groups according to their treatment status at the second occasion (end of the treatment, on-treatment follow-up, and re-start treatment). The latent structure of the PARADISE24fin questionnaire was analyzed in the two measurement occasions with confirmatory factor analyses. Evidence of the PARADISE24fin sensitivity to change was studied comparing mean change scores for the three treatment status groups. RESULTS: The PARADISE24fin showed a strong longitudinal metric invariance across the two occasions in the three treatment status groups. The PARADISE24fin scores decreased during treatment, especially among the group of patients that had completed their treatment. CONCLUSIONS: The PARADISE24fin is a reliable questionnaire to measure changes in psychosocial difficulties in substance use disorders overtime.

A developmental approach to alcohol drinking behaviour in adulthood: a follow-up study from age 8 to age 42.

AIMS: To study the links of family background, child and adolescent social behaviour, and (mal)adaptation with heavy drinking by age 20 and with the frequency of drinking, binge drinking, Cut-down, Annoyed, Guilt, Eye-opener (CAGE) questionnaire scores and problems due to drinking at ages 27 and 42 years. DESIGN: In the Finnish Jyväskylä Longitudinal Study of Personality and Social Development, data have been collected by interviews, inventories and questionnaires. Behavioural data were gathered at ages 8 and 14; data on alcohol consumption were gathered at ages 14, 20, 27, 36 and 42. PARTICIPANTS: A total of 184 males and 163 females; 94% of the original sample of the 8-year-olds. FINDINGS: Family adversities, externalizing problem behaviours, low school success, truancy and substance use in adolescence were associated in early middle age with problems due to drinking in both genders, and to binge drinking and CAGE scores in females. The antecedents varied, however, across the indicators of drinking and gender. The frequency of drinking was least predictable by the studied antecedents. Childhood and adolescent antecedents and drinking up to age 20 explained 43% of males' and 31% of females' problem drinking at age 42; 31% and 19%, respectively, at age 27. CONCLUSIONS: The early warning signs of drinking problems should be taken seriously in the preventive work for alcohol abuse. Problem drinking in early middle age is preceded by maladjustment to school, early age of onset of drinking and heavy drinking in adolescence even more significantly than problem drinking in early adulthood.

Validity of the PARADISE24 questionnaire in people with substance use disorders: A measure to assess psychosocial difficulties.

OBJECTIVES: Psychosocial difficulties (PSDs) are common in people with substance use disorders (SUDs). The PARADISE24 has been shown to be an adequate tool for measuring PSDs in inpatients with SUDs. The aim of this study is to evaluate the psychometric properties of the PARADISE24 in a sample of patients with SUDs. METHODS: 2637 participants with SUDs completed the PARADISE24 questionnaire during their treatment. The latent structure of the PARADISE24 questionnaire was analyzed in the outpatient sample by means of exploratory and confirmatory factor analysis (EFA and CFA). Metric invariance was then assessed in relation to the inpatient sample using multiple group CFA. Finally, evidences of known-groups validity were checked to test the ability of the questionnaire to differentiate between socio-demographic and clinical groups. RESULTS: The one-factor model presented an adequate fit in both the EFA (CFI = 0.98; TLI = 0.98; RMSEA = 0.07) and the CFA (CFI = 0.98; TLI = 0.98; RMSEA = 0.07) solutions. The reliability of the scale was found to be high (α = 0.93). Strict metric invariance between inpatients and outpatients was achieved (RMSEA = 0.063; TLI = 0.983; CFI = 0.981). The PARADISE24 was able to discriminate between the inpatients and outpatients at both latent (d = 0.98) and observed levels (d = 0.86). CONCLUSIONS: The PARADISE24 is a unidimensional tool that is reliable for assessing and comparing PSDs in both outpatients and inpatients with SUDs. Further research is required for evaluating the ability of the PARADISE24 to quantify longitudinal changes in PSDs.

Factors Related to Social Support in Neurological and Mental Disorders.

Despite the huge body of research on social support, literature has been primarily focused on its beneficial role for both physical and mental health. It is still unclear why people with mental and neurological disorders experience low levels of social support. The main objective of this study was to explore what are the strongest factors related to social support and how do they interact with each other in neuropsychiatric disorders. The study used cross-sectional data from 722 persons suffering from dementia, depression, epilepsy, migraine, multiple sclerosis, Parkinson's disease, schizophrenia, stroke, and substance use disorders. Multiple linear regressions showed that disability was the strongest factor for social support. Extraversion and agreeableness were significant personality variables, but when the interaction terms between personality traits and disability were included, disability remained the only significant variable. Moreover, level of disability mediated the relationship between personality (extraversion and agreeableness) and level of social support. Moderation analysis revealed that people that had mental disorders experienced lower levels of support when being highly disabled compared to people with neurological disorders. Unlike previous literature, focused on increasing social support as the origin of improving disability, this study suggested that interventions improving day-to-day functioning or maladaptive personality styles might also have an effect on the way people perceive social support. Future longitudinal research, however, is warranted to explore causality.

Age of onset of drinking and the use of alcohol in adulthood: a follow-up study from age 8-42 for females and males.

AIM: To investigate longitudinally for both genders the relation between the age of onset of drinking and several indicators of alcohol use. DESIGN AND SETTING: In the Finnish Jyväskylä Longitudinal Study of Personality and Social Development, data have been collected by interviews, inventories, and questionnaires. Data on alcohol consumption was gathered at ages 14, 20, 27, 36 and 42 years; behavioural data at age 8. PARTICIPANTS: A total of 155 women and 176 men; 90.4% of the original sample consisting of 12 complete school classes in 1968. MEASUREMENTS: The age of onset of drinking was determined based on participants' responses that were closest to the actual age of onset of drinking. Four indicators of the adult use of alcohol were used: frequency of drinking, binge drinking, Cut-down, Annoyed, Guilt, Eye-opener (CAGE) and Malmö modified Michigan Alcoholism Screening Test (Mm-MAST). Socio-emotional behaviour at age 8 was assessed using teacher ratings and peer nominations. FINDINGS: Early onset of drinking was related to the four indicators of the use of alcohol in adulthood both in men and women. The level of adult alcohol use and alcohol problems was significantly higher in men. The risk for heavy drinking was highest in men and women if drinking was started at less than age 16 years. Socio-emotional behaviour and school success at age 8 did not predict the age of onset of drinking. CONCLUSIONS: Delaying the initiation of drinking from early adolescence to late adolescence is an important goal for prevention efforts. No clear risk group for early initiators of drinking could be identified on the basis of preceding behaviour among 8-year-olds.

Understanding the Impact of Brain Disorders: Towards a 'Horizontal Epidemiology' of Psychosocial Difficulties and Their Determinants.

OBJECTIVE: To test the hypothesis of 'horizontal epidemiology', i.e. that psychosocial difficulties (PSDs), such as sleep disturbances, emotional instability and difficulties in personal interactions, and their environmental determinants are experienced in common across neurological and psychiatric disorders, together called brain disorders. STUDY DESIGN: A multi-method study involving systematic literature reviews, content analysis of patient-reported outcomes and outcome instruments, clinical input and a qualitative study was carried out to generate a pool of PSD and environmental determinants relevant for nine different brain disorders, namely epilepsy, migraine, multiple sclerosis, Parkinson's disease, stroke, dementia, depression, schizophrenia and substance dependency. Information from these sources was harmonized and compiled, and after feedback from external experts, a data collection protocol including PSD and determinants common across these nine disorders was developed. This protocol was implemented as an interview in a cross-sectional study including a convenience sample of persons with one of the nine brain disorders. PSDs endorsed by at least 25% of patients with a brain disorder were considered associated with the disorder. PSD were considered common across disorders if associated to 5 out of the 9 brain disorders and if among the 5 both neurological and psychiatric conditions were represented. SETTING: The data collection protocol with 64 PSDs and 20 determinants was used to collect data from a convenience sample of 722 persons in four specialized health care facilities in Europe. RESULTS: 57 of the PSDs and 16 of the determinants included in the protocol were found to be experienced across brain disorders. CONCLUSION: This is the first evidence that supports the hypothesis of horizontal epidemiology in brain disorders. This result challenges the brain disorder-specific or vertical approach in which clinical and epidemiological research about psychosocial difficulties experienced in daily life is commonly carried in neurology and psychiatry and the way in which the corresponding health care delivery is practiced in many countries of the world.

Determinants of Psychosocial Difficulties Experienced by Persons with Brain Disorders: Towards a 'Horizontal Epidemiology' Approach.

BACKGROUND: Persons with brain disorders experience significant psychosocial difficulties (PSD) in daily life, e.g. problems with managing daily routine or emotional lability, and the level of the PSD depends on social, physical and political environments, and psychologic-personal determinants. Our objective is to determine a brief set of environmental and psychologic-personal factors that are shared determinants of PSD among persons with different brain disorders. METHODS: Cross-sectional study, convenience sample of persons with either dementia, stroke, multiple sclerosis, epilepsy, migraine, depression, schizophrenia, substance dependence or Parkinson's disease. Random forest regression and classical linear regression were used in the analyses. RESULTS: 722 subjects were interviewed in four European countries. The brief set of determinants encompasses presence of comorbidities, health status appraisal, stressful life events, personality changes, adaptation, self-esteem, self-worth, built environment, weather, and health problems in the family. CONCLUSIONS: The identified brief set of common determinants of PSD can be used to support the implementation of cross-cutting interventions, social actions and policy tools to lower PSD experienced by persons with brain disorders. This set complements a recently proposed reliable and valid direct metric of PSD for brain disorders called PARADISE24.

PARADISE 24: A Measure to Assess the Impact of Brain Disorders on People's Lives.

OBJECTIVE: To construct a metric of the impact of brain disorders on people's lives, based on the psychosocial difficulties (PSDs) that are experienced in common across brain disorders. STUDY DESIGN: Psychometric study using data from a cross-sectional study with a convenience sample of 722 persons with 9 different brain disorders interviewed in four European countries: Italy, Poland, Spain and Finland. Questions addressing 64 PSDs were first reduced based on statistical considerations, patient's perspective and clinical expertise. Rasch analyses for polytomous data were also applied. SETTING: In and outpatient settings. RESULTS: A valid and reliable metric with 24 items was created. The infit of all questions ranged between 0.7 and 1.3. There were no disordered thresholds. The targeting between item thresholds and persons' abilities was good and the person-separation index was 0.92. Persons' abilities were linearly transformed into a more intuitive scale ranging from zero (no PSDs) to 100 (extreme PSDs). CONCLUSION: The metric, called PARADISE 24, is based on the hypothesis of horizontal epidemiology, which affirms that people with brain disorders commonly experience PSDs. This metric is a useful tool to carry out cardinal comparisons over time of the magnitude of the psychosocial impact of brain disorders and between persons and groups in clinical practice and research.

Contribution of early and adult factors to socioeconomic variation in blood pressure: thirty-four-year follow-up study of school children.

OBJECTIVE: To prospectively examine the role of childhood and adulthood factors in the association between socioeconomic status (SES) and adult systolic and diastolic blood pressure (SBP, DBP). METHODS: One hundred and five boys and 101 girls who were 8 years of age at entry into the study were observed for 34 years in the Jyväskylä Longitudinal Study of Personality and Social Development, Finland. Data were gathered on educational attainment and occupational status, as indicators of SES, and potential explanatory factors related to 0, (14), 27, 36, and 42 years of age. SBP and DBP were assessed at 15 and 42 years of age. RESULTS: In a structural equation model adjusted for sex and childhood SBP, educational attainment was inversely associated with adult SBP (structural coefficient -0.17, p<.05). Incorporating the effects of parental SES and adult body mass index into the model attenuated this association so that it was no longer significant. Variation in birth weight, unemployment, smoking, alcohol consumption, and use of antihypertensive medication had marginal or no impact on the education-SBP association. No socioeconomic variation was found for DBP or occupational status. CONCLUSIONS: Prospective evidence suggests a weak association between low educational attainment and development of high SBP. Parental SES and adult BMI were the key explanatory factors for this association.