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Background: The influence of maternal temperament on child behavior, and whether maternal temperament impact boys and girls differently is not thoroughly studied. The aim was to investigate the impact of maternal temperament and character on child externalizing and internalizing problems at age 3.

Methods: A birth-cohort of 1723 mothers and their children were followed from birth to age 3. At the child's age of 3 months, the mothers filled out standardized instruments on their temperament and character using the Temperament and Character Inventory (TCI) and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS). At the child's age of 3 years, the mothers reported on child behavior using the Child Behaviour Checklist (CBCL).

Results: Maternal temperamental trait novelty seeking was positively associated with externalizing problems in the total population and in girls. Harm avoidance was positively associated with externalizing problems in the total population and in boys, and with internalizing problems in the total population and boys and girls respectively. Maternal character traits of self-directedness and cooperativeness were negatively associated with both externalizing and internalizing problems in the total population and in boys and girls respectively.

Conclusions: Maternal character traits were more influential on child behavior than were temperamental traits, and thus the opportunities for intervention targeted at parental support are good. Maternal mental health and socioeconomic aspects also increased the risk for child behavior problems, indicating the need for recognition and support in clinical settings.

Non-adherence to antidepressant drug treatment is common. In a recent study in depressed primary care patients, we reported a strong relationship between adherence and response after 6 months. With the use of a naturalistic design, the patients in that study were prospectively followed for 2 years. The purpose of the present study was to investigate the patients' long-term outcome and, in particular, to examine the impact of patients' treatment adherence on response, remission and relapse. Of the 1031 patients in the intent-to-treat (ITT) sample, 835 completed the study. After 2 years, the overall remission rate defined as a Montgomery-Asberg Depression Rating Scale score of nine or less was 68% in the ITT sample analysed with the last observation carried forward (LOCF) technique, and 75% in observed cases. In total, 34% of the responders experienced at least one relapse. Response rates (LOCF) were significantly higher in adherent compared to non-adherent patients at week 24 [95% confidence interval (CI) = 21.4-32.1], year 1 (95% CI = 12.3-22.2) and year 2 (95% CI = 9.2-19.0). Remission rates (LOCF) were also significantly higher in the group of adherent patients at week 24 (95% CI = 9.6-21.5), year 1 (95% CI = 10.0-21.5) and year 2 (95% CI = 11.0-22.0). No relationship between adherence and relapse rate was observed, although the mean time from response to first sign of relapse was significantly longer in the adherent patients (95% C I= 9-97 days). In conclusion, this 2-year follow-up study showed superior long-term recovery in patients who were adherent to antidepressant medication compared to non-adherent patients.

PURPOSE: Depression at all ages is recognized as a global public health concern, but less is known about the welfare burden following early-life depression. This study aimed to (1) estimate the magnitude of associations between depression in adolescence and social transfer payments in adulthood; and (2) address the impact of major comorbid psychopathology on these associations.

METHODS: This is a longitudinal cohort study of 539 participants assessed at age 16-17 using structured diagnostic interviews. An ongoing 25-year follow-up linked the cohort (n = 321 depressed; n = 218 nondepressed) to nationwide population-based registries. Outcomes included consecutive annual data on social transfer payments due to unemployment, work disability, and public assistance, spanning from age 18 to 40. Parameter estimations used the generalized estimating equations approach.

RESULTS: Adolescent depression was associated with all forms of social transfer payments. The estimated overall payment per person and year was 938 USD (95% CI 551-1326) over and above the amount received by nondepressed controls. Persistent depressive disorder was associated with higher recipiency across all outcomes, whereas the pattern of findings was less clear for subthreshold and episodic major depression. Moreover, depressed adolescents presenting with comorbid anxiety and disruptive behavior disorders evidenced particularly high recipiency, exceeding the nondepressed controls with an estimated 1753 USD (95% CI 887-2620).

CONCLUSION: Adolescent depression is associated with considerable public expenditures across early-to-middle adulthood, especially for those exposed to chronic/persistent depression and psychiatric comorbidities. This finding suggests that the clinical heterogeneity of early-life depression needs to be considered from a longer-term societal perspective.

While Roux-en-Y gastric bypass (RYGB) surgery in obese individuals typically improves glycemic control and prevents diabetes, it also frequently causes asymptomatic hypoglycemia. Previous work showed attenuated counterregulatory responses following RYGB. The underlying mechanisms as well as the clinical consequences are unclear. In this study, 11 subjects without diabetes with severe obesity were investigated pre- and post-RYGB during hyperinsulinemic normo-hypoglycemic clamps. Assessments were made of hormones, cognitive function, cerebral blood flow by arterial spin labeling, brain glucose metabolism by F-18-fluorodeoxyglucose (FDG) positron emission tomography, and activation of brain networks by functional MRI. Post- versus presurgery, we found a general increase of cerebral blood flow but a decrease of total brain FDG uptake during normoglycemia. During hypoglycemia, there was a marked increase in total brain FDG uptake, and this was similar for post- and presurgery, whereas hypothalamic FDG uptake was reduced during hypoglycemia. During hypoglycemia, attenuated responses of counterregulatory hormones and improvements in cognitive function were seen postsurgery. In early hypoglycemia, there was increased activation post- versus presurgery of neural networks in brain regions implicated in glucose regulation, such as the thalamus and hypothalamus. The results suggest adaptive responses of the brain that contribute to lowering of glycemia following RYGB, and the underlying mechanisms should be further elucidated.

Negative symptoms comprise anhedonia, avolition, and blunted affect. Although first described in schizophrenia, these symptoms share phenomenology with the depressive state. Pharmacological treatment has not been successful in reducing negative symptoms. Repetitive transcranial magnetic stimulation (rTMS) is a non-pharmacological treatment option for moderate to severe depression. There have also been attempts to treat negative symptoms in both schizophrenia and depression with rTMS.

Cardiovascular disease is common in schizophrenia and depression. Heart rate variability (HRV) is an established proxy for cardiac autonomic functioning and numerous studies have found lower HRV in patients with schizophrenia and depression. The impact of psychopharmacological treatment on HRV has been extensively studied and anticholinergic compounds have been found to decrease HRV.

Lastly, since the most commonly used rTMS depression targets are also the brain regions involved in central autonomic regulation, there is reason to consider a potential effect of rTMS on HRV.

The overall aim of this thesis was to investigate negative symptoms, rTMS, and HRV in schizophrenia and depression.

Study I was a validation study of a Swedish translation of the Clinical Assessment Interview for Negative Symptoms (CAINS). Thirty-four patients with schizophrenia were interviewed and it was concluded that the Swedish version of the CAINS exhibited acceptable psychometric properties.

Study II was a double-blind randomized controlled trial of rTMS for negative symptoms in schizophrenia and depression. There was a significant decrease of negative symptoms in the depression group, but not in the schizophrenia group. There were no effects on overall depressive symptoms in either group.

Study III assessed determinants of HRV in schizophrenia, depression, and healthy controls. The results indicated lower HRV in both patient groups, even after controlling for several factors, and also that anticholinergic burden impacted HRV.

In Study IV, the relationship between HRV and the functional and structural connectivity of the anterior cingulate cortex was investigated in patients with schizophrenia and compared with that in healthy controls. It was found that connectivity with the cerebellum might play a role in the autonomic modulation network in patients with schizophrenia.

Lastly, in Study V, the effect of a treatment course with rTMS on HRV was investigated in patients with depression, as well as HRV’s relationship to symptom change. No effects on HRV were detected, nor any correlations between HRV and symptom change. Further, baseline HRV could not predict treatment response.

PURPOSE: The Clinical Assessment Interview for Negative Symptoms (CAINS) was developed in order to advance the assessment of negative symptoms. The aim of this study was to validate the Swedish version of the CAINS. MATERIALS AND METHODS: Thirty-four out-patients with a schizophrenia spectrum disorder were recruited. All patients were videotaped while interviewed with the CAINS and the Brief Psychiatric Rating Scale (BPRS). Another rater watched the video recordings in the reverse order, enabling a blinded design. The patients also filled in self-reported measures of depression, quality of life, and social and vocational functioning. We calculated inter-rater agreement and internal consistency for the CAINS. We also calculated validity measures by correlating the subscales Motivation and Pleasure (CAINS-MAP) and Expression (CAINS-EXP) to subscales of the BPRS. RESULTS: The blinded inter-rater agreement for the CAINS total score was high (ICC = 0.92) but slightly lower for the expression subscale (ICC = 0.76). Cronbach's alpha was 0.84 for the total score. Convergent validity with the negative symptoms subscale of BPRS was different for the blinded and the unblinded data, with a CAINS-MAP correlation of 0.10 (p = 0.580) and a CAINS-EXP correlation of 0.48 (p = 0.004) in the blinded data. The unblinded data had a CAINS-MAP correlation of 0.38 (p = 0.026) and a CAINS-EXP correlation of 0.87 (p < 0.001). Self-rated measures of anhedonia correlated to CAINS-MAP with a coefficient of 0.68 (p < 0.001), while the CAINS-EXP only had a correlation of 0.16 (p = 0.366) to these measures. CONCLUSION: The Swedish version of the CAINS displays adequate psychometric properties in line with earlier validation studies.

Introduction: Perinatal complications, such as perinatal depression and preterm birth, are major causes of morbidity and mortality for the mother and the child. Prediction of high risk can allow for early delivery of existing interventions for prevention. This ongoing study aims to use digital phenotyping data from the Mom2B smartphone application to develop models to predict women at high risk for mental and somatic complications.

Methods and analysis: All Swedish-speaking women over 18 years, who are either pregnant or within 3 months postpartum are eligible to participate by downloading the Mom2B smartphone app. We aim to recruit at least 5000 participants with completed outcome measures. Throughout the pregnancy and within the first year postpartum, both active and passive data are collected via the app in an effort to establish a participant's digital phenotype. Active data collection consists of surveys related to participant background information, mental and physical health, lifestyle, and social circumstances, as well as voice recordings. Participants' general smartphone activity, geographical movement patterns, social media activity and cognitive patterns can be estimated through passive data collection from smartphone sensors and activity logs. The outcomes will be measured using surveys, such as the Edinburgh Postnatal Depression Scale, and through linkage to national registers, from where information on registered clinical diagnoses and received care, including prescribed medication, can be obtained. Advanced machine learning and deep learning techniques will be applied to these multimodal data in order to develop accurate algorithms for the prediction of perinatal depression and preterm birth. In this way, earlier intervention may be possible.

Ethics and dissemination: Ethical approval has been obtained from the Swedish Ethical Review Authority (dnr: 2019/01170, with amendments), and the project fully fulfils the General Data Protection Regulation (GDPR) requirements. All participants provide consent to participate and can withdraw their participation at any time. Results from this project will be disseminated in international peer-reviewed journals and presented in relevant conferences.

Background: Childhood adversities are associated with an elevated risk for common mental disorders (CMDs). Whether the strength of the association also holds for young employees is unclear. Given the increase in CMD rates in young adults over the past decade, identification of risk factors has important implications for future public health interventions. The current study aimed to investigate the effects of childhood adversities on CMDs. Additionally, the role of occupational class (non-manual/manual workers) in the relationship was examined.

Methods: This population-based longitudinal cohort study included 544,003 employees, 19-29 years, residing in Sweden in 2009. Adversities included parental death, parental mental and somatic disorders, parental separation or single-parent household, household public assistance and residential instability. Estimates of risk of CMDs, measured as prescription of antidepressants and/or psychiatric care with a clinical diagnosis of CMDs, between 2010 and 2016 were calculated as relative risks (RR) with 95% confidence intervals (CI), using a modified Poisson regression analysis. Occupational class (non-manual/manual workers) was explored as a potential moderator.

Results: In both manual and non-manual workers, childhood adversities were associated with an elevated risk of subsequent CMDs. The risk was moderated by occupational class, i.e., especially pronounced risk was found in manual workers who had experienced cumulative adversity (adjusted RR 1.76, 95% CI 1.70-1.83) when compared to non-manual workers with no adversity. Among the adversities examined, having had a parent treated for a mental disorder, having grown up in a household living on public assistance or having experienced residential instability were the strongest predictors of CMDs.

Conclusion: Our findings suggest that, among young employees, manual workers with a history of multiple childhood adversities are especially vulnerable to subsequent CMDs.

Background

The study aimed to examine differences in, and characteristics of psychiatric care utilization in young refugees who came to Sweden as unaccompanied or accompanied minors, compared with that of their non-refugee immigrant and Swedish-born peers.

Methods

This register-linkage cohort study included 746 688 individuals between 19 and 25 years of age in 2009, whereof 32 481 were refugees (2896 unaccompanied and 29 585 accompanied) and 32 151 non-refugee immigrants. Crude and multivariate Cox regression models yielding hazard ratios (HR) and 95% confidence intervals (CI) were conducted to investigate subsequent psychiatric care utilization for specific disorders, duration of residence and age at migration.

Results

The adjusted HRs for psychiatric care utilization due to any mental disorder was significantly lower in both non-refugee and refugee immigrants when compared to Swedish-born [aHR: 0.78 (95% CI 0.76–0.81) and 0.75 (95% CI 0.72–0.77, respectively)]. Within the refugee group, unaccompanied had slightly lower adjusted risk estimates than accompanied. This pattern was similar for all specific mental disorders except for higher rates in schizophrenia, reaction to severe stress/adjustment disorders and post-traumatic stress disorder. Psychiatric health care utilization was also higher in immigrants with more than 10 years of residency in Sweden entering the country being younger than 6 years of age.

Conclusions

For most mental disorders, psychiatric health care utilization in young refugees and non-refugee immigrants was lower than in their Swedish-born peers; exceptions are schizophrenia and stress-related disorders. Arrival in Sweden before the age of 6 years was associated with higher rates of overall psychiatric care utilization.

Pavlovian fear conditioning is widely used to study mechanisms of fear learning, but high-throughput studies are hampered by the labor-intensive nature of examining participants in the lab. To circumvent this bottle-neck, fear conditioning tasks have been developed for remote delivery. Previous studies have examined remotely delivered fear conditioning protocols using expectancy and affective ratings. Here we replicate and extend these findings using an internet-delivered version of the Screaming Lady paradigm, evaluating the effects on negative affective ratings and response time to an auditory probe during stimulus presentation. In a sample of 80 adults, we observed clear evidence of both fear acquisition and extinction using affective ratings. Response times were faster when probed early, but not later, during presentation of stimuli paired with an aversive scream. The response time findings are at odds with previous lab-based studies showing slower as opposed to faster responses to threat-predicting cues. The findings underscore the feasibility of employing remotely delivered fear conditioning paradigms with affective ratings as outcome. Findings further highlight the need for research examining optimal parameters for concurrent response time measures or alternate non-verbal indicators of conditioned responses in Pavlovian conditioning protocols.

The present study examines a self-report version of the Global Assessment of Functioning Scale according to Axis V (GAF self-report). The sample (n = 73) was a psychiatric outpatient population from a catchment area clinic. Patients with psychotic and organic mental disorders were not included. The diagnostic distribution on Axis I was similar to the findings from previous studies. Axis II disorders were identified among 47%, of whom a majority also had a concomitant Axis I disorder. The mean GAF expert score was 66.5 (range: 48-86). High complexity and severity of disorders and a high number of fulfilled Axis II criteria were significantly associated with low GAF scores. Independent expert ratings on GAF were correlated with the GAF self-report overall at r = 0.62, varying from 0.45 to 0.91 between different diagnostic groups. In general, the patients scored themselves lower (mean: -4.4 units) than expert ratings. Patients with depressive symptoms from an adjustment disorder or mood disorder were most prone to underestimation. Women also tended to score themselves lower than experts did. Conclusively, the GAF self-report turned out to be a valid and reliable unidimensional instrument measuring psychological, social and occupational functioning. The GAF is easy to handle, and with a self-report version as a complement, Axis V could be more frequently used in future clinical practice and research.

Background

Intermittent theta burst stimulation (iTBS) over the dorsomedial prefrontal cortex (DMPFC) has shown promise in open-label trials of depression.

Methods

In this randomized, double-blind, sham controlled trial we evaluate iTBS over the DMPFC for anhedonia, avolition, and blunted affect in patients with schizophrenia or depression. Active iTBS was delivered over the DMPFC with 1200 pulses per session, twice daily over ten weekdays at target intensity with an angled figure-of eight coil. Sham condition comprised the magnetically shielded side of the coil and simultaneous transcutaneous electrical nerve stimulation. Primary outcome was change on the Clinical Assessment Interview for Negative Symptoms (CAINS).

Results

Twenty-eight patients were randomized to active iTBS and 28 to sham. Mean (standard deviation) change in CAINS score from baseline to the day after last treatment was -5.3 (8.1) in active iTBS and -2.1 (7.1) in sham. A linear model showed no significant effect of treatment, accounting for baseline scores p=.088. Sub analyses per diagnostic group showed a significant effect in patients with depression, p=.038, but not in the schizophrenia group, p=.850. However, overall depressive symptoms did not change significantly in patients with depression. There were three serious adverse events, all in the sham group.

Limitations

Possibly too short treatment course and few patients with schizophrenia.

Conclusion

In this first transdiagnostic randomized controlled trial of iTBS over DMPFC for anhedonia, avolition, and blunted affect it can be concluded that it was generally tolerable and safe but only more effective than sham in the subgroup of patients with depression.

The main purpose of the current trial was to test if a brief trauma-focused cognitive-behaviour therapy protocol (prolonged exposure; PE) provided within 72 h after a traumatic event could be effective in decreasing the incidence of post-traumatic stress disorder (PTSD), thus replicating and extending the findings from an earlier trial. After a pilot study (N = 10), which indicated feasible and deliverable study procedures and interventions, we launched an RCT with a target sample size of 352 participants randomised to either three sessions of PE or non-directive support. Due to an unforeseen major reorganisation at the hospital, the RCT was discontinued after 32 included participants. In this paper, we highlight obstacles and lessons learned from our feasibility work that are relevant for preventive psychological interventions for PTSD in emergency settings. One important finding was the high degree of attrition, and only 75% and 34%, respectively, came back for the 2-month and 6-month assessments. There were also difficulties in reaching eligible patients immediately after the event. Based on our experiences, we envisage that alternative models of implementation might overcome these obstacles, for example, with remote delivery of both assessments and interventions via the internet or smartphones combined with multiple recruitment procedures. Lessons learned from this terminated RCT are discussed in depth.

Background: The use of remotely delivered early intervention after trauma may prevent and/or reduce symptoms of post-traumatic stress. Our research group evaluated a novel three-week therapist-guided internet-delivered intervention based on prolonged exposure (Condensed Internet-Delivered Prolonged Exposure; CIPE) in a pilot trial. The results indicated that the intervention was feasible, acceptable and reduced symptoms of post-traumatic stress at post-intervention compared to a waiting-list condition. Exposure to traumatic memories can be emotionally demanding and there is a need for detailed investigation of participants? experiences in receiving this type of intervention remotely.

Objective: Investigate participants? experiences of receiving CIPE early after trauma.Method: In this study, qualitative thematic analysis was used and semi-structured interviews with 11 participants six months after intervention completion were conducted. All interviews were audio-recorded and transcribed verbatim.

Results: One overarching theme labelled as ?demanding and effective? was identified. Participants expressed that treatment effects could only be achieved by putting in a lot of effort and by being emotionally close to the trauma memory during exposure exercises. Participants reported CIPE to be a highly credible- and educative intervention that motivated them to fully engage in exposure exercises. The most distressing parts of the intervention was perceived as tolerable and important to do to heal psychologically after trauma. For many participants, the possibility to engage in the intervention whenever and where it suited them was helpful, although some participants described it as challenging to find a balance between their own responsibility and when to expect therapist support. The internet-based format was perceived as a safe forum for self-disclosure that helped some participants overcome avoidance due to shame during imaginal exposure.

Conclusion: CIPE was considered demanding, yet effective by the interviewed participants. The most distressing parts of the intervention was perceived to be the most important and were tolerable and feasible to provide online.