Background: Nonheterosexual individuals have higher risk of psychiatric morbidity. Together with growing evidence for sexual orientation‐related brain differences, this raises the concern that sexual orientation may be an important factor to control for in neuroimaging studies of neuropsychiatric disorders.

Methods: We studied sexual orientation in adult psychiatric patients with bipolar disorder (BD) or ADHD in a large clinical cohort (N = 154). We compared cortical brain structure in exclusively heterosexual women (HEW, n = 29) with that of nonexclusively heterosexual women (nHEW, n = 37) using surface‐based reconstruction techniques provided by FreeSurfer.

Results: The prevalence of nonheterosexual sexual orientation was tentatively higher than reported in general population samples. Consistent with previously reported cross‐sex shifted brain patterns among homosexual individuals, nHEW patients showed significantly larger cortical volumes than HEW in medial occipital brain regions.

Conclusion: We found evidence for a sex‐reversed difference in cortical volume among nonheterosexual female patients, which provides insights into the neurobiology of sexual orientation, and may provide the first clues toward a better neurobiological understanding of the association between sexual orientation and mental health. We also suggest that sexual orientation is an important factor to consider in future neuroimaging studies of populations with certain mental health disorders.

ABSTRACTBackground and objectives Despite devastating psychopathology after childhood trauma, no evidence-based prevention has been identified. After the Islamic State (IS) war in Iraq and Syria, a group intervention program is provided to the internally displaced and refugee children, in attempt to prevent posttraumatic psychopathology, and to identify children whoneed special care.Methods A Crisis Intervention Program for Children and Adolescents is developed by the author. Three instruments (Crisis Expression Guidelines, Crisis Screening Instrument, and Modified Family Map) are delivered through Training of Trainers (ToT) to help the displaced and refugee children (6-11 and 12-18 years) within a one-hour group session (10-30 children) express thoughts and emotions related to the war crises, and to screen for further care.Results In a pilot project, 37 professionals working with children applied to the ToT course and 300 IDP teachers completed training to provide CIPCA to the Internally Displaced People (IDP) and refugee children in the temporary camps in the region. In a pilot project, 315 children received the CIPCA, and a further 67500 school children are waiting for the intervention when the schools start in the IDP camps. Screening revealed 15.2% of theparticipating children need individual assessment.Conclusion CIPCA is applicable as a cost and time effective crisis intervention to IDP and refugee children of IS war. Further expansion of the program is planned. Follow-up will evaluate the preventive effect of CIPCA.

Background Child mental health and child and adolescent psychiatry is increasinglybecoming an indicator for any modern society to bring up child perspectives preparing forprosperous future. This field was lacking as an own medical speciality in the Middle Eastuntil the establishment of the Department of Child Mental Health at the College of Medicine,University of Duhok in 20 September 2001.

Objectives To build up local competence in Child Mental Health, and to introduce Child andAdolescent Psychiatry as a modern subject in the curriculums at the College of Medicine,University of Duhok, in the Kurdistan region of Iraq.

Methods The Department of Child Mental Health (CMH) was established at the College ofMedicine, University of Duhok, in collaboration with the Department of Neuroscience, Childand Adolescent Psychiatry at the Uppsala University in Sweden. Education programs aredelivered from the Uppsala University in Sweden to the College of Medicine, University ofDuhok in Iraqi Kurdistan, at three levels; community-based education, undergraduate medicaleducation, and postgraduate education to achieve High Diploma (Master) degree, adjusted tothe local system in Kurdistan.

Results The CMH is a unit belonged to the pediatrics at the College of Medicine, and havinglinks to the Directorates of Health, Education and Social Care in Duhok. Lectures in Childand Adolescent Psychiatry are delivered to the fifth year medicine students one week inautumn to be followed by another week of teaching in clinical case discussions in springevery year. The final examination consisting of the means of scores collected during the firsttheory and the second clinical courses compose 20% of the final pediatric examination. Thepostgraduate program consists of two-year education, after one-year pediatric residency, toobtain specialist competence in the subject.

Conclusions Transferring up-to-date knowledge on modern subjects from advancedinternational universities to the universities in Iraq is necessary and possible if modernteaching methods are effectively utilized. The CMH is proved to be a good example ofsuccessful collaboration, making the College of Medicine at the University of Duhok as thefirst school of medicine in the Middle East having Child and Adolescent Psychiatry as anobligatory teaching subject.

Aim: To identify a posttraumatic stress disorder profile for the Child Behaviour Checklist. Method: Checklist item scores for 806 school-aged children in Iraqi Kurdistan (201 randomly selected from the general population, 241 orphans, 199 primary medical care visitors and 165 hospital in-patients) were analysed against the Posttraumatic Stress Symptom Scale for Children (PTSS-C) scores, estimating not only stress diagnoses, but also nonstress-related, child-specific posttraumatic symptoms. Results: Twenty checklist items, which revealed significant correlations with the stress diagnoses, formed the checklist-stress profile with acceptable reliability and validity, and significant correlation to the PTSS-C estimates. Conclusion: A child-specific stress profile for the checklist is recommended for use as a screening instrument.

To identify child mental health problems in a mid-sized to large city in Iraqi Kurdistan, the Reporting Questionnaire for Children (RQC), followed by the Child Behaviour Checklist (CBCL) and the Post-traumatic Stress Symptom Checklist for Children (PTSS-C), were administered in interview form to the caregivers of 806 school-aged children. To cover different categories of children, four samples were randomly selected from among the general population (n = 201), orphans (n = 241), primary medical care patients (n = 199), and hospital patients (n = 165). The RQC revealed satisfactory validity against a deviant CBCL cut-off. The screening capacity of the RQC was further supported by its similarity to the CBCL in distribution of problem scores among the four samples and its positive correlation with the CBCL, but not with the trauma-related PTSS-C. Although the general population showed lower problem scores than the orphans and the two clinical samples, problem scores in all instruments were considerably higher than those reported from other societies. The RQC seems to be useful as a first-stage screening instrument for child mental health problems in Kurdistan.

The objective of the study was to examine the efficacy of EMDR treatment for children with post-traumatic stress disorder ( PTSD) compared with untreated children in a waiting list control group (WLC) participating in a randomized controlled superiority trial (RCT). Thirty-three 6-16-year-old children with a DSM-IV diagnosis of PTSD were randomly assigned to eight weekly EMDR sessions or the WLC group. The Posttraumatic Stress Symptom Scale for Children (PTSS-C scale) was used in interviews with children to evaluate their symptoms and outcome. Post-treatment scores of the EMDR group were significantly lower than the WLC indicating improvement in total PTSS-C scores, PTSD-related symptom scale, and the subscales re-experiencing and avoidance among subjects in the EMDR group, while untreated children improved in PTSD-non-related symptom scale. The improvement in re-experiencing symptoms proved to be the most significant between-group difference over time. The results of the present exploratory study including a limited number of children with PTSD are encouraging and warrant further controlled studies of larger samples of children suffering from PTSD.

BACKGROUND: This paper aims to compare orphans' development in two different care systems.

METHODS: Based on age, sex, psychological trauma scores, competence and psychological problem scores, two comparable samples were found representing orphans in the traditional foster care (n = 94) and the orphanages (n = 48) in a middle-large city in Iraqi Kurdistan. At an index interview, Child Behaviour Checklist (CBCL), Harvard-Uppsala Trauma Questionnaire for Children and Post-traumatic Stress Symptoms for Children (PTSS-C) were administered to the caregivers. After 1 year the CBCL, and after 2 years both the CBCL and the PTSS-C, were-re-administered, consecutively.

RESULTS: Although both samples revealed significant decrease in the means of total competence and problem scores over time, the improvement in activity scale, externalizing problem scores and post-traumatic stress disorder-related symptoms proved to be more significant in the foster care than in the orphanages. While the activity scale improved in the foster care, the school competence deteriorated in both samples, particularly among the girls in the orphanages. The improvement of boys' activity scores in the foster care, and deterioration of girls' school competence in the orphanages were the most significant gender differences between samples over time.

CONCLUSIONS: Even if the two orphan care systems showed more similarities than differences, the foster care revealed better outcomes over time. The results are discussed in relation to gender, age, socio-economic situation, cultural values and the characteristics of each care system.

 Five years after the military operation “Anfal” in Iraqi Kurdistan, 45 families were randomly selected among the survivors in two displacement camps. The Posttraumatic Stress Symptoms for Children (PTSS-C) and the Harvard Trauma Questionnaire (HTQ) were administered to the oldest child and the caregiver in each family, respectively. Posttraumatic stress disorder (PTSD) was reported in 87% of children and 60% of their caregivers. While childhood PTSD was only significantly predicted by child trauma score and the duration of captivity, it was neither predicted by maternal PTSD nor did it disappear after the reunion with the PTSD-free father. However, the small sample size makes the results hypotheses rather than conclusive.

Objective To find out child-adjusted protocol for eye movement desensitization and reprocessing (EMDR). Method Child-adjusted modification were made in the original adult-based protocol, and within- session measurements, when EMDR was used in a randomized controlled trial (RCT) on thirty-three 6-16-year-old children with post-traumatic stress disorder ( PTSD). Results EMDR was applicable after certain modifications adjusted to the age and developmental level of the child. The average treatment effect size was largest on re-experiencing, and smallest on hyperarousal scale. The age of the child yielded no significant effects on the dependent variables in the study. Conclusions A child-adjusted protocol for EMDR is suggested after being applied in a RCT for PTSD among traumatized and psychosocially exposed children.

How are we to understand a child's development--both the potentiating and inhibiting factors? The past two decades have witnessed intensive research both on mental trauma and its possible effects on the child's developing brain, and on the importance of risk factors and protective factors in children's development and health. Research in these two fields has been conducted concurrently and has yielded new, important, and in many cases complementary, information. To promote the general availability and clinical applicability of these advances in our knowledge, it is necessary to modify our conceptual approach, basing it on the child's perspective instead.

The Posttraumatic Stress Symptoms in Children (PTSS-C) was developed as a cross-cultural semi-structured interview to diagnose posttraumatic stress disorder (PTSD) and to identify PTSD-non-related posttraumatic stress symptoms in children after various traumatic experiences. The psychometric properties were studied in two different child populations in Iraqi Kurdistan (the survivors of the military operation “Anfal”, and the orphans), in a sample of Kurdistanian refugee children in Sweden, and in a comparison sample of Swedish children. The instrument yielded satisfactory internal consistency, high interrater agreement, and excellent validity on cross-validation with the Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI) and the Diagnostic Interview for Children and Adolescents (DICA) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

The prevalence and correlates of post-traumatic stress disorder (PTSD) were assessed in random samples of school-aged Kurdistanian children and their parents in homeland and exile. Of the 376 eligible children at the two sites, 312 children and their parents (293 mothers and 248 fathers) completed the Harvard-Uppsala Trauma Questionnaire and Posttraumatic Stress Symptom interviews for children, and Harvard Trauma Questionnaire for parents. Unlike their children, fathers showed significantly higher PTSD frequencies in exile than in the homeland. The fathers' PTSD negatively correlated with the living standard and fathers' education, while child PTSD mostly correlated with maternal education and living in exile. Living in exile seems to have a negative impact on fathers' post-traumatic reactions, despite its positive influence on children. High drop-outs in exile limit the conclusions.

Background: Traumatic experiences and post-traumatic stress symptoms were assessed in Kurdish children in their native country and in exile. Method: 312 randomly selected school-age children at two sites completed assessments of traumatic experiences and post-traumatic symptoms. Results: Although traumatic experiences showed more similarities than differences between the two samples, the PTSD frequencies and post-traumatic stress symptom scores were higher in Kurdistan than in exile. Living in exile showed negative correlation with PTSD frequencies and post-traumatic stress symptom scores. Conclusions: Living in exile seems to have trauma healing effect on children of Kurdistan.

Experiencing conflictual relations with one's parents while growing up has been linked to onset, recurrence, and worse treatment outcome of adolescent depression. While this suggests that significant problems in the parent-youth relationship make depressive disorders more relentless, it is not clear whether this effect lasts into adulthood. Our aim was to examine if major and minor conflict with parents while growing up predicts depression in adulthood in youth with and without a history of depression. We utilized data from the Uppsala Longitudinal Adolescent Depression Study. This community-based cohort was assessed with structured diagnostic interviews both at age 16-17 and at follow-up 15 years later. The analyses included 382 individuals (227 with a history of child or adolescent depression; 155 peers without such a history). Binary logistic regression was used, adjusting for sex, disruptive behavior disorders, and additional family-related adversities. Among individuals with adolescent depression, major conflict with parents was strongly associated with adult depression (adjusted OR 2.28, 95% CI 1.07-4.87). While major conflict with parents was rare among non-depressed controls, a non-significant association of similar magnitude was still observed. Minor conflict, on the other hand, was not significantly associated with adult depression. Overall, conflict with parents did not predict adult anxiety disorders, substance use, suicidal behavior, somatoform disorders, or psychotic disorders. In conclusion, major parent-youth conflict during upbringing seems to be linked with an increased risk of depression in adulthood. These findings underscore the need to consider contextual/familial factors in the prevention and clinical management of early-life depression.

Purpose: To present the Uppsala Longitudinal Adolescent Depression Study, initiated in Uppsala, Sweden, in the early 1990s. The initial aim of this epidemiological investigation was to study the prevalence, characteristics and correlates of adolescent depression, and has subsequently expanded to include a broad range of social, economic and health-related long-term outcomes and cost-of-illness analyses.

Participants: The source population was first-year students (aged 16-17) in upper-secondary schools in Uppsala during 1991-1992, of which 2300 (93%) were screened for depression. Adolescents with positive screening and sex/age-matched peers were invited to a comprehensive assessment. A total of 631 adolescents (78% females) completed this assessment, and 409 subsequently completed a 15year follow-up assessment. At both occasions, extensive information was collected on mental disorders, personality and psychosocial situation. Detailed social, economic and health-related data from 1993 onwards have recently been obtained from the Swedish national registries for 576 of the original participants and an age-matched reference population (N=200 000).

Findings to date: The adolescent lifetime prevalence of a major depressive episode was estimated to be 11.4%. Recurrence in young adulthood was reported by the majority, with a particularly poor prognosis for those with a persistent depressive disorder or multiple somatic symptoms. Adolescent depression was also associated with an increased risk of other adversities in adulthood, including additional mental health conditions, low educational attainment and problems related to intimate relationships.

Future plans: Longitudinal studies of adolescent depression are rare and must be responsibly managed and utilised. We therefore intend to follow the cohort continuously by means of registries. Currently, the participants are approaching mid-adulthood. At this stage, we are focusing on the overall long-term burden of adolescent depression. For this purpose, the research group has incorporated expertise in health economics. We would also welcome extended collaboration with researchers managing similar datasets.

Background: The estimated prevalence rate of Pervasive Developmental Disorders (PDD) in children is 6 per 1.000. Parenting children who are intellectually impaired and have PDDs is known to be linked to the impaired well-being of the parents themselves. However, there is still little available data on health-related quality of life (HRQL) in parents of children with Asperger Syndrome ( AS) and High-Functioning Autism (HFA), or other PDD diagnoses in children of normal intelligence. The present study aimed to evaluate aspects of HRQL in parents of school-age children with AS/HFA and the correlates with child behaviour characteristics.

Methods: The sample consisted of 31 mothers and 30 fathers of 32 children with AS/HFA and 30 mothers and 29 fathers of 32 age and gender matched children with typical development. Parental HRQL was surveyed by the use of the 12 Item Short Form Health Survey (SF-12) which measures physical and mental well-being. The child behaviour characteristics were assessed using the structured questionnaires: The High-Functioning Autism Spectrum Screening Questionnaire (ASSQ) and The Strengths and Difficulties Questionnaire (SDQ).

Results: The mothers of children with AS/HFA had lower SF-12 scores than the controls, indicating poorer physical health. The mothers of children with AS/HFA also had lower physical SF-12 scores compared to the fathers. In the AS/HFA group, maternal health was related to behaviour problems such as hyperactivity and conduct problems in the child.

Conclusion: Mothers but not fathers of children with AS/HFA reported impaired HRQL, and there was a relationship between maternal well-being and child behaviour characteristics.

Sleep patterns of 32 school-age children with Asperger syndrome (AS) and high-functioning autism (HFA) were compared to those of 32 typically developing age- and gender-matched children, using parent survey and one week of diary and actigraphic monitoring. Parents of children with AS/HFA more commonly reported that their children had difficulty falling asleep. One week of sleep recording with diary and actigraphy confirmed that children in the AS/HFA group spent a longer time awake in bed before falling asleep than children in the control group, possibly because the children in the AS/HFA group had earlier bedtimes. Other essential aspects of sleep patterns coincided between the groups. The sleep patterns of children with AS and HFA did not differ.

Poor family relationships during childhood have been shown to have long-term negative effects on an offspring's health. However, few studies have followed the offspring to retirement age, and relatedly, knowledge about the link between poor family relationships and premature death is scarce. The aim of this study was to examine the association between poor family relationships in adolescence and the risk of premature death, even when considering other adverse childhood conditions. Prospective data from the Stockholm Birth Cohort study were used, with 2636 individuals born in 1953 who were followed up until age 65. Information on family relations was based on interviews with the participants' mothers in 1968. Information on mortality was retrieved from administrative register data from 1969-2018. Cox proportional hazards regressions showed that poor family relationships in adolescence were associated with an increased risk of premature death, even when adjusting for childhood conditions in terms of household social class, household economic poverty, contact with the child services, parental alcohol abuse, and parental mental illness (Hazard Ratio (HR), 2.08, 95% Confidence Interval (CI), 1.40-3.09). The findings show that poor family relationships in adolescence can have severe and long-lasting health consequences, highlighting the importance of early interventions.

In this study, the authors compared guided Internet-delivered self-help with one-session exposure treatment (OST) in a sample of snake phobic patients. A total of 30 patients were included following a screening on the Internet and a structured clinical interview. The Internet treatment consisted of four weekly text modules which were presented on a web page, a video in which exposure was modelled, and support provided via Internet. The OST was delivered in a three-hour session following a brief orientation session. The main outcome was the behavioural approach test (BAT), and as secondary measures questionnaires measuring anxiety symptoms and depression were used. Results showed that the groups did not differ at post-treatment or follow-up, with the exception of a significant interaction for the BAT in favour of the OST. At post-treatment, 61.5% of the Internet group and 84.6% of the OST group achieved a clinically significant improvement on the BAT. At follow-up, the corresponding figures were 90% for the Internet group and 100% for the OST group (completer sample). Within-group effect sizes for the Snake Phobia Questionnaire were large (d=1.63 and d=2.31 for the Internet and OST groups, respectively, at post-treatment). It is concluded that guided Internet-delivered exposure treatment is a potential treatment option in the treatment of snake phobia, but that OST probably is better.

Attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are neurodevelopmental conditions of overlapping etiologies and phenotypes. For ASD, we recently reported altered elemental metabolic patterns in the form of short and irregular zinc and copper cycles. Here, we extend the application of these biomarkers of prenatal and early postnatal elemental metabolism to distinguish between individuals diagnosed with ADHD and/or ASD and neurotypical controls. We recruited twins discordant for ADHD, ASD and other neurodevelopmental diagnoses from national twin studies in Sweden (N = 74) diagnosed according to DSM-5 clinical consensus and standardized psychiatric instruments. Detailed temporal profiles of exposure to 10 metals over the prenatal and early childhood periods were measured using tooth biomarkers. We used recurrence quantification analysis (RQA) to characterize properties of cyclical metabolic patterns of these metals. Regularity (determinism) and complexity (entropy) of elemental cycles was consistently reduced in ADHD for cobalt, lead, and vanadium (determinism: cobalt, β = -0.03, P = 0.017; lead, β = -0.03, P = 0.016; and vanadium, β = -0.03, P = 0.01. Entropy: cobalt, β = -0.13, P = 0.017; lead, β = -0.18, P = 0.016; and vanadium, β = -0.15, P = 0.008). Further, we found elemental pathways and dynamical features specific to ADHD vs ASD, and unique characteristics associated with ADHD/ASD combined presentation. Dysregulation of cyclical processes in elemental metabolism during prenatal and early postnatal development not only encompasses pathways shared by ADHD and ASD, but also comprise features specific to either condition.

Background. Prior studies suggest parental and perinatal risk factors are associated with later offending. It remains uncertain, however, if such risk factors are similarly related to sexual offending. Method. We linked socio-demographic, family relations, and perinatal (obtained at birth) data from the nationwide Swedish registers from 1973 to 2009 with information on criminal convictions of cases and control subjects. Male sex offenders (n = 13 773) were matched 1: 5 on birth year and county of birth in Sweden to male controls without sexual or non-sexual violent convictions. To examine risk-factor specificity for sexual offending, we also compared male violent, non-sexual offenders (n = 135 953) to controls without sexual or non-sexual violent convictions. Predictors included parental (young maternal or paternal age at son's birth, educational attainment, violent crime, psychiatric disorder, substance misuse, suicide attempt) and perinatal (number of older brothers, low Apgar score, low birth weight, being small for gestational age, congenital malformations, small head size) variables. Results. Conditional logistic regression models found consistent patterns of statistically significant, small to moderate independent associations of parental risk factors with sons' sexual offending and non-sexual violent offending. For perinatal risk factors, patterns varied more; small for gestational age and small head size exhibited similar risk effects for both offence types whereas a higher number of older biological brothers and any congenital malformation were small, independent risk factors only for non-sexual violence. Conclusions. This nationwide study suggests substantial commonalities in parental and perinatal risk factors for the onset of sexual and non-sexual violent offending.

Although prior research suggests associations between parental characteristics and later sexual offending in offspring, possible links between early pregnancy-related factors and sexual offending remain unclear. Early risk markers unique to sexual offending, however, may be more prominent among sexual offenders with atypical sexual interests, such as individuals involved with child sexual exploitation material (CSEM; also referred to as child pornography). We examined the prospective association between parental and pregnancy-related risk markers and a behavioral indicator of pedophilic interest, CSEM offending. All 655 men born in Sweden and convicted of CSEM offending between 1988 to 2009 were matched 1:5 on sex, birth year, and county of birth in Sweden to 3,928 controls without sexual or nonsexual violent convictions. Paternal age (adjusted odds ratio [AOR] = 1.3, 95% confidence interval [CI] [1.1, 1.7]), parental education (AOR = 0.8, 95% CI [0.6, 0.9]), parental violent criminality (AOR = 2.9, 95% CI [2.2, 3.8]), number of older brothers (AOR = 0.8, 95% CI [0.6, 0.9] per brother), and congenital malformations (AOR = 1.7, 95% CI [1.2, 2.4]) all independently predicted CSEM convictions. This large-scale, nationwide study suggests parental risk markers for CSEM offending. We did not, however, find convincing evidence for pregnancy-related risk markers, with the exception of congenital malformations and having fewer older brothers.

The aim of this study was to describe the pediatric population with ADHD and their pharmacological treatment. Using the Swedish National Patient Register and the Prescribed Drug Register we identified individuals below 19 years of age who were diagnosed or medically treated for ADHD for the first time 2006-2007. The unique patient identifiers were used to link information from the two registers to describe demographic characteristics, hospital care and drug treatments. Logistic regression model estimated the association between age, sex, frequency of hospitalization, diagnosis or treatment for other mental disorders and risk of gap in the treatment. Totally the study included 7931 patients of whom 74% were males. The mean age at first diagnosis was 12 years. Some 84% were medically treated for ADHD and approximately 90% received methylphenidate as the first substance. Combination therapy was rare and the most common combination was methylphenidate and atomoxetine. More than 55% of the patients, which could be followed up for two years after start of treatment, had at least one treatment gap of six months. Older age at diagnosis, lower number of hospitalizations and comorbidity with other mental disorders increased risks of gaps in medication. Approximately one fifth of the patients recorded in the National Patient Register as diagnosed with ADHD did not receive pharmacological treatment. Medication adherence seems to be low, when measured as gaps in treatment.

PURPOSE: To assess the generalizability of findings from randomized controlled trials (RCTs) evaluating emotion recognition (ER) training for children and adolescents with autism spectrum disorder (ASD).

METHODS: We present a systematic review and narrative synthesis of the determinants of external validity in RCTs on ER training. Generalizability of the findings across situations, populations, settings, treatment delivery, and intervention formats was considered.

RESULTS: We identified 13 eligible studies. Participants were predominantly boys with ASD in the normative IQ range (IQ > 70), with an age span from 4 to 18 years across studies. Interventions and outcome measures were highly variable. Several studies indicated that training may improve ER, but it is still largely unknown to what extent training effects are translated to daily social life.

CONCLUSION: The generalizability of findings from currently available RCTs remains unclear. This underscores the importance of involving children with ASD and their caregivers in informed treatment decisions.

A dualist approach that distinguishes between mind and body is still the norm in Western medicine. Although we now know that physical and mental health are related in adults, little is known about if, or with what mechanisms, mental illnesses or depression early in life, will affect future physical and psychological health. In-between mental and somatic disorders there are somatic symptoms without medical explanation. These are symptoms that cause much suffering and impairment which are costly for society. Still little is known what they are, how they should be treated and what consequences they have for adolescents when they grow up. This study aims to investigate the long-term relationship between mental and somatic disease and the outcome of adolescents with functional somatic symptoms.

The thesis is based on a 15-year follow-up study of a population-based investigation of adolescent depression. In 1991–1993 first year students in upper secondary school (age 16–17) in Uppsala, Sweden, were screened for depression (n=2300). Adolescents with positive screening and selected peers with negative screening (n=631) were assessed regarding mental health and somatic symptoms. At around age 31, the participants were followed-up in personal interviews (n=369) and national registers (n=609). Outcomes regarding mental DSM-IV diagnosis, in-patient ICD-10 disease diagnosis from the patient register, and blood vessel wall thickness were assessed.

The most important finding is the unexpected poor short and long-term outcome in adolescents with somatic symptoms. The result proves the need for better treatment. The strong prediction of functional somatic symptoms for mental disorder, independent of adolescent depression, suggests that somatic symptoms and depression symptoms are different expressions of a common disorder. Female adolescents with depression need more psychiatric and somatic in-patient care but the males do not. Instead, they have considerably more in-patient stays due to alcohol and drug abuse. The males might be taken care of outside the health care system and seem to need special attention. In women with adolescent and recurrent adult depression there is an association with premature aging of the carotid wall. These women are at risk of developing early cardio-vascular disease and need early interventions.

OBJECTIVE: Early-onset psychosis (EOP) and bipolar disorder (EOBP) (at <18 years of age), are associated with an increased future risk of cardiovascular disease (CVD) and premature death. Yet it is unknown whether the arteries show visible signs of atherosclerosis in EOP and EOBP. This study investigated whether having EOP or EOBP was associated with detectable signs of preclinical atherosclerosis.

METHOD: By using 22 MHz high-frequency ultrasound, different layers of the arterial wall of the left common carotid artery (LCCA) were assessed in 77 individuals with EOP (n = 25), EOBP (n = 22), and in age-matched healthy controls (n = 30). Conventional CVD confounders were included in the analyses.

RESULTS: Adolescents with EOP and EOBP, compared to controls, had a significantly thicker LCCA intima thickness (0.132 vs. 0.095 mm, p < .001) and intima/media ratio (0.24 vs. 0.17 p < .001). There was a nonsignificant intima difference between EOP and EOBP. Conventional CVD risk factors did not explain the association between EOP/EOBP and intima thickness. In the group of EOP/EOBP, there was a significant correlation between the dose of current antipsychotic medication and intima thickness; however, the correlation was attenuated to a nonsignificant level when adjusted for global function.

CONCLUSIONS: Adolescents with EOP or EOBP had an increased LCCA intima thickness, interpreted as a sign of preclinical atherosclerosis. Global function of the disorders was the strongest determinant of intima thickness. The findings, if replicated, might have implications for long-term treatment of EOP and EOBP in order to reduce a future risk of CVD.

Adolescent depression is common. Earlier studies indicate that relapses and recurrences are common. But many questions are still unanswered. The aim of the present study has been to follow subjects with adolescent depressions, identified in a population-based study, over a 15-year period. Subjects with adolescent depression (n = 362) and a comparison group (n = 250) were followed in the National Swedish registers.

The formerly depressed females had significantly more out-patient visits, and a significantly higher proportion (78.4% versus 69.6%) had at least one out-patient visit. Among the males, no significant differences were found as concerns out-patient visits. The formerly depressed females had significantly more in-patient stays (3.6 versus 2.4) and a significantly higher total number of in-patient days (27.4 versus 10.1). A significantly higher proportion had in-patient days due to mental disorders (9.5% versus 4.6%), in particular anxiety disorders (4.9% versus 1.0%). As concerns the males, a significantly higher proportion had in-patient days due to mental disorders (16.5% versus 1.8%), in particular alcohol and drug abuse (7.6% versus 0%).

Among the formerly depressed females there were no significant differences against the comparison group as concerns the proportion of being a mother, number of children per woman, or age at first child. However, a significantly higher proportion of the formerly depressed females had had different, usually mild, disorders related to pregnancy (8.6% versus 0.6%). The children of the women with adolescent depressions were not affected.

Background

There is a lack of population-based long-term longitudinal research on mental health status and functional physical/somatic symptoms. Little is known about the long-term mental health outcomes associated with somatic symptoms or the temporal relationship between depression and such symptoms. This 15-year study followed up adolescents with depression and matched controls, screened from a population-based sample, who reported different numbers of somatic symptoms.

Methods

The total population of 16–17-year-olds in Uppsala, Sweden, was screened for depression in 1991–1993. Adolescents who screened positive and an equal number of healthy controls took part in a semi-structured diagnostic interview. In addition, 21 different self-rated somatic symptoms were assessed. Sixty-four percent of those adolescents participated in a follow-up structured interview 15 years later.

Results

Somatic symptoms in adolescence predicted depression and other adult mental disorders regardless of the presence of adolescent depression. In adolescents with depression, the number of functional somatic symptoms predicted, in a dose response relationship, suicidal behavior, bipolar episodes, and psychotic episodes as well as chronic and recurrent depression. Contrary to expectations, the somatic symptoms of abdominal pain and perspiration without exertion better predicted depression than all DSM-IV depressive symptoms. Abdominal pain persisted as an independent strong predictor of depression and anxiety, even after controlling for other important confounders.

Conclusions

Somatic symptoms in adolescence can predict severe adult mental health disorders. The number of somatic symptoms concurrent with adolescent depression is, in a stepwise manner, linked to suicidal attempts, bipolar disorders, psychotic disorders, and recurrent and chronic depression. These findings can be useful in developing treatment guidelines for patients with somatic symptoms.

Background. Growing evidence indicates that depression is an important risk factor for coronary heart disease. Thus, the aim of the present study has been to investigate if young women with adolescent onset and recurrent depressive disorders have signs of carotid intima and media changes already at the age of 30. Methods. Fifteen subjects with adolescent onset recurrent depressive disorders, mean age 31.5 years, were compared to 20 healthy women with a mean age of 39.6 years. The thickness of carotid artery intima and media was assessed, using non-invasive high-frequency ultrasound (25MHz). Results. The subjects with recurrent depressive disorders had significantly thicker carotid intima, significantly thinner carotid media and significantly higher intima/media ratio despite the fact that they were about 10 years younger than the healthy women. Hypertension, obesity or smoking could not explain the results. Conclusion. Already at the age of 30, subjects with recurrent depressive disorders with adolescent onset do have early signs of carotid intima and media changes, indicating a less healthy artery wall, despite otherwise no clinical signs of cardiovascular disease.

Aim: This study aims to investigate the prevalence of somatic symptoms in depressed adolescents and in their healthy peers. A second aim is to investigate the correlation, in the depressed adolescents, between the number of somatic symptoms and severe concurrent symptoms, signs and life events. Methods: The total population of 16-17 year olds - in the city of Uppsala - was screened for depression and then interviewed using a structured interview questionnaire. Depressed subjects and matched controls were identified. A total of 177 pairs were used for pair-wise analyses of somatic symptoms. Severe symptoms, signs and life events were selected for analysing their relation to depression with somatic symptoms. Results: The adolescents with depressive disorders experienced considerably more somatic symptoms than their healthy controls. The duration and depth of the depression correlated with the number of somatic symptoms. There was a strong correlation between depression with many somatic symptoms and suicidal plans/thoughts, suicidal attempts, disruptive behaviour, as well as multiple stressful relationships. Conclusion: This study demonstrates that somatic symptoms are common in adolescent depression. Multiple somatic symptoms within depression imply a higher severity in terms of duration, depth and psychiatric comorbidity. The strong correlation with suicidal plans, suicidal attempts and disruptive behaviour is concerning.