To Örebro University

OBJECTIVE: We aimed to examine the variability of chronic obstructive pulmonary disease (COPD) exacerbations and mortality, between primary healthcare centres, and their associations with comorbid diseases and body mass index, during an 8-year follow-up.

DESIGN: This was a cohort study using multilevel modelling with follow-up from 2014 to 2022. Data came from questionnaires in 2014 and 2022 and medical record reviews between 2004 and 2014. The main outcomes were exacerbations in 2022 and mortality by 2022. Exacerbations were defined as any emergency visit, and/or use of oral steroids or antibiotics due to worsening of COPD symptoms during the previous 6 months.

SETTING: The PRAXIS study included patients at 76 primary healthcare centres in central Sweden.

PARTICIPANTS: Primary care patients aged ≤75 years and with a diagnosis of COPD in their medical records between 2007 and 2010 were included in 2014 (n=1163) and followed up in 2022 (n=906). There were no other exclusion criteria.

RESULTS: The 809 patients with complete data attended 70 primary care centres. Multilevel multinomial regression estimated risks of exacerbations and mortality, calculating relative risk ratios (RRRs) with 95% CIs. The intraclass correlation coefficient (ICC) quantified the proportion of variance attributed to variability between centres. The ICC was 0.024, indicating 2.4% of the variation was explained by differences between centres. Patients with a history of depression in 2014 had an increased risk of subsequent exacerbations (RRR 1.95, 95% CI 1.13 to 3.39). For mortality, there were associations with history of anxiety, RRR 3.71 (95% CI 2.06 to 6.87), or cardiovascular disease, especially chronic heart failure, RRR 2.69 (95% CI 1.36 to 5.33). Body mass index had a U-shaped association with mortality.

CONCLUSIONS: The variability between centres was small and patient factors appear to be of more importance for COPD exacerbations and mortality than differences between these primary care settings. As expected, pre-existing cardiovascular disease is associated with future excess mortality risk, but, notably, anxiety may also be an important risk factor. Individualised care and management of comorbidity is thus essential among patients in primary care with COPD.

OBJECTIVES: Depression is common in the oldest-old population (aged ≥85 years), a population in which research is lacking and the effects of psychopharmacological treatment may be adverse. Electroconvulsive therapy (ECT) appears to be well tolerated by older patients with depression; however, it is used rarely in clinical practice and research concerning the oldest-old is lacking. The objective of this study was to assess response and remission rates, as well as adverse effects, in oldest-old depressed patients treated with ECT.

METHODS: This was a nationwide Swedish register study including 522 oldest-old patients treated with ECT for depression. Two propensity score matched control groups were also included: young patients treated with ECT, and oldest-old depressed patients not treated with ECT. Response and remission rates, clinician-reported adverse events, prognostic factors (including comorbid diseases and treatment parameters), adverse events requiring hospitalization, as well as deaths within 1 week from discharge, were assessed.

RESULTS: The oldest-old receiving ECT reported higher response (81.2%) and remission (53.3%) rates than younger counterparts (67.4% versus 27.4%, respectively). Severe psychotic depression was the only prognostic factor for response and remission. The oldest-old experienced fewer adverse events, most commonly confusion and cardiovascular complications, compared to controls. Compared with oldest-old patients not receiving ECT, the ECT group had fewer hospitalizations following discharge.

CONCLUSION: ECT is a viable treatment option for oldest-old patients with depression, who show higher response and remission rates than younger patients, as well as fewer hospitalizations than oldest-old patients not treated with ECT.

Eating disorders (ED) have a high comorbidity with major depressive disorder (MDD). Antidepressants often lack effect in these patients. While electroconvulsive therapy (ECT) is the most effective treatment for severe MDD, there are no large studies in the ED patient group yet. We aimed to compare the outcome of ECT for MDD in patients with and without eating disorders. We conducted a register-based study for patients with MDD and comorbid ED treated with ECT in Sweden between 2012-2023. The outcomes were compared to a matched control group without comorbid ED. The primary outcome was a response to treatment according to the Clinical Global Impression Improvement Scale (CGI-I). Secondary outcomes were remission according to CGI-I and subjective memory complaint. There were 861 patients in the ED group and 1,722 in the control group; of these 93.2% were female. The response rate was 58.4% in the ED group and 62.4% in the control group (OR 0.8, 95% CI 0.7-0.9, p <0.05). The frequency of subjective memory complaints in the ED versus the control group was 25.9% and 24.8%, respectively (OR 1.1, 95% 0.8-1.3 CI, p = 0.6). High response rates after ECT for MDD were found in the ED group but were significantly lower than in the matched control group. Subjective memory complaints did not differ significantly. Further studies are required comparing the outcome of ECT versus alternative treatments among patients with ED complicated by severe MDD.

Prior research has established that insomnia is predctive of pain in adolescents and that psychological mechanisms have a crucial role in this relationship. Adolescent girls report more insomnia and pain than boys, yet little is known of gender differences in how insomnia influences pain. This study assessed gender differences in levels and trajectories of insomnia and pain during adolescence, and whether rumination and negative mood mediated the effect of insomnia on pain. Longitudinal survey data measured on 5 annual occasions (Nbaseline = 2,767) were analyzed in a multigroup longitudinal serial mediation model. A final model was generated with insomnia as the predictor, rumination and depressed mood as mediators, pain as the outcome, and gender the grouping variable. The results showed that insomnia predicted pain in adolescents, with an effect 3.5 times larger in girls than boys. Depressed mood was the main mediator in boys. In girls, rumination was the only significant mediator. There were significant gender differences in the effects of insomnia on rumination and pain, and in the effects of rumination on depressed mood and pain, with stronger effects in girls. These results highlight that girls and boys should be considered separately when studying the relationship between insomnia and pain. PERSPECTIVE: Levels of insomnia and pain are progressively higher in adolescent girls than boys, across adolescence. The predictive strength of insomnia symptoms for future pain is 3.5 times greater in girls, with distinct gender-specific underlying pathways: rumination partially mediates this effect in girls, while depressed mood does so in boys.

OBJECTIVE: The majority of patients hospitalized for treatment of a manic episode are readmitted within 2 years despite maintenance treatment. Electroconvulsive therapy (ECT) has been associated with lower rehospitalization rates in some psychiatric conditions, but its association with readmission after a manic episode has not been investigated. Therefore, the aim of this study was to determine whether the time to readmission in patients with mania treated with ECT was longer than in patients not treated with ECT and whether there were subgroups of patients that benefited more.

METHODS: This was a nationwide register-based, observational study. All patients diagnosed with bipolar disorder, manic episode, admitted to any hospital in Sweden between 2012 and 2021 were included. Patients contributed data to the study for every admission. All admissions were followed up until psychiatric readmission, death, or the end of the study (December 31, 2021). Association between ECT and time to readmission was analyzed. A paired samples model was performed for 377 patients with at least two admissions for mania, treated with ECT at one admission and without ECT at the other admission. Times to readmission were analyzed.

RESULTS: A total of 12,337 admissions were included; mean (SD) age 47.7 (17.2), 5443 (44.1%) men. Readmission rate within 1 year was 54.6%. ECT was administered in 902 (7.3%) admissions. Within 30 days after admission, 182 out of 894 (20.4%) patients treated with ECT versus 2105 out of 11,305 (18.6%) patients treated without ECT were readmitted. There was no association between ECT and time to readmission (aHR 1.00, 95% CI 0.86-1.16, p = 0.992) in the model with all admissions. The paired samples model included 754 admissions (377 patients), mean (SD) age during admission without ECT was 45.6 (16.5), and with ECT 46.6 (16.4), 147 (39.0%) were men. In that model, readmission rate within 30 days for treatment with ECT was 19.0%, and for treatments without ECT, 24.1% (aHR 0.75, 95% CI 0.55-1.02, p = 0.067).

CONCLUSION: Readmission rates after inpatient treatment of mania were high. ECT was not significantly associated with longer time to readmission, but there was a trend toward a protective effect of ECT when admissions with and without ECT were compared within the same patients.

Introduction: Psychiatric disorders are common during pregnancy, affecting up to 16% of pregnant women. Severe depression and anxiety have significant negative effects on the health of both the mother and the developing fetus. Electroconvulsive therapy (ECT) is considered a treatment option for pregnant women with severe psychiatric disorders when other treatments have been ineffective or pose risks to the fetus. Knowledge of the safety and efficacy of ECT during pregnancy, however, remains limited.

Methods: Data were obtained from nationwide registries of pregnant women in Sweden who received ECT for a severe psychiatric disorder from January 2008 to December 2021. ECT-related outcomes in pregnant women were compared by propensity score matching with a group of non-pregnant women who also received ECT. Pregnancy-related outcomes were compared with two additional control groups: one consisting of the same group of women who did not receive ECT during another pregnancy and the other composed of pregnant women admitted to inpatient psychiatric care but who did not receive ECT, matched based on propensity score.

Results: Ninety-five pregnant women received ECT during the study period, accounting for 97 pregnancies. The response rate to ECT in pregnant women (n = 54) was similar to the matched control group of non-pregnant women (74% vs. 65%; OR 1.61; 95% CI 0.79-3.27). Rates of adverse events related to ECT were similar to those in the control group. There were no pre-term births or severe adverse outcomes related to the pregnancy, that were close in time to ECT. Therefore, no adverse outcomes related to pregnancy and childbirth could be directly attributed to ECT. The likelihood of premature birth and a 5-min Apgar score <7 in the newborn were both significantly higher in the ECT group, compared with the matched non-ECT group (OR 2.33, 95% CI 1.15-4.73, p = 0.008, and OR 3.68, 95% CI 1.58-8.55, p < 0.001, respectively). By contrast, no significant differences were observed when women in the pregnant ECT group were compared with the same group lacking ECT during another pregnancy.

Conclusions: ECT was associated with a positive treatment response in pregnant women with severe psychiatric disorders. The response rate to ECT was similar in pregnant and non-pregnant women. Nevertheless, the risks of premature birth and of a slightly poorer condition in newborns were higher in women who did than did not receive ECT, emphasizing the need for increased attention to severe psychiatric disorders during pregnancy.

Introduction

Sleep problems are increasingly recognized as a significant health concern among youth, with insufficient sleep affecting the majority of adolescents worldwide. Emerging research challenges the traditional view that sleep disturbances are merely symptoms of underlying mental disorders, suggesting instead a bidirectional relationship where sleep issues may also contribute to the development of psychopathology. Despite this growing evidence in adults, the role of sleep disturbances as predictors of mental illness in children and adolescents remains inconclusive. 

Aim

This study aims to systematically review and synthesize existing research to better understand how sleep problems in children and adolescents may predict future mental health issues.

Methods

* Conducted per PRISMA and SYMBALS guidelines, combining active learning machine learning and backwards snowballing.

* Titles and abstracts were screened by multiple authors using ASReview software.

* The databases Embase, MEDLINE, Web of Science and PsychINFO were searched. * Inclusion criteria: Primary studies in English language, Participants 0-18 years at baseline, Sleep disturbance as exposure, Mental illness (diagnosis or symptoms) as outcome, Longitudinal studies with at least 1 month between timepoints.

Results

A total of 136* studies were eligible for inclusion in the systematic review, published between 2000 and 2024.

Of these, 63 concerned adolescents at baseline, 45 school-aged children, and 28 concerned infants, toddlers and pre-school children. 

Some 46 of the studies concerned the broader construct Internalising symptoms, encompassing both depression and anxiety. A total of 59 studies concerned depression as outcome, 26 studies anxiety, 18 studies ADHD, 5 studies GAD, 5 studies social anxiety, 5 studies separation anxiety, and 4 studies psychosis. Rarer outcomes included panic disorder, PTSD, borderline personality disorder, oppositional defiant disorder, mania, OCD, and bipolar disorder. 

A significant association was found in 153 of the analyses (81.8 %), while 34 (18.2 %) did not. The most studied outcome was depression, where 50 studies found an association and 9 did not, followed by internalising symptoms (45 yes, 1 no) and anxiety (24 yes, 2 no). Several additional outcomes were studied, demonstrating more ambiguous results. The information is depicted in Figure 1. 

Conclusions

The preliminary results of this study provide convincing evidence that sleep problems predict later mental illness in children and adolescents: primarily regarding internalising symptoms, anxiety and depression, with more equivocal evidence regarding ADHD, psychosis, GAD, social anxiety and separation anxiety. The majority of studies concern adolescents. More studies on specific mental disorders beyond depression and anxiety are needed.