1,721,121 research outputs found
Efficacy and effectiveness of antipsychotics in schizophrenia: network meta-analyses combining evidence from randomised controlled trials and real-world data
No full textBackground: There is debate about the generalisability of results from randomised clinical trials (RCTs) to real-world settings. Studying outcomes of treatments for schizophrenia can shed light on this issue and inform treatment guidelines. We therefore compared the efficacy and effectiveness of antipsychotics for relapse prevention in schizophrenia and estimated overall treatment effects using all available RCT and real-world evidence. Methods: We conducted network meta-analyses using individual participant data from Swedish and Finnish national registries and aggregate data from RCTs. The target population was adults (age >18 and 1 means superior effectiveness in real-world to RCTs), except for LAI versus oral comparisons (HR ratio 0·73 [0·53-0·99], indicating superior effectiveness in real-world data relative to RCTs). The real-world network meta-analysis showed clozapine was most effective, followed by olanzapine LAI. The RCT network meta-analysis exhibited heterogeneity and inconsistency. The joint real-world and RCT network meta-analysis identified olanzapine as the most efficacious antipsychotic amongst those present in both RCTs and the real world registries. Interpretation: LAI antipsychotics perform slightly better in the real world than according to RCTs. Otherwise, RCT evidence was in line with real-world evidence for most between-drug comparisons, but RCTs might overestimate effectiveness of antipsychotics observed in routine care settings. Our results further the understanding of the generalisability of RCT findings to clinical practice and can inform preferential prescribing guidelines. Funding: None
Childhood adversity and common mental disorders in young employees in Sweden : is the association affected by early adulthood occupational class?
No full textBackground: 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
Prevention of depression and suicide in Primary Health Care settings: a systematic review of the evidence
No full textSuicidalt beteende bland unga i Europa – kan vi förstå tidstrenderna och skillnaderna mellan olika länder?
Full text linkI många Europeiska länder utgör suicidalt beteende (suicidförsök och suicid) bland unga ett betydande folkhälsoproblem. Förekomst varierar starkt mellan dessa länder men har också fluktuerat mycket över tid. Efter stigande trender i ett flertal europeiska länder under 1980-och 90 talet, har suicidtalen hos unga under de senaste 15 åren stabiliserats i huvuddelen av länderna. Under samma tidsperiod har suicidförsökstalen bland unga visat stigande trender i ett antal länder, däribland Sverige. I denna artikel summerar vi den internationella diskussionen kring potentiella förklaringar till de observerade trenderna. Tänkbara förklaringar inkluderar förändringar i klassifikationssystem, ökad prevalens av depression och andra psykiska sjukdomar, ändrade psykosociala och socio-ekonomiska förhållanden, kulturella förändringar och nya tillvägagångssätt vid suicidalt beteende. Även en kort genomgång av evidensbaserade suicidpreventionsmetoder ges
Childhood adversity and risk of later labor market marginalization in young employees in Sweden
No full textBackground The present study examined the independent and combined effects of childhood adversity (CA) and occupational class on the risk of future labor market marginalization (LMM) in young employees in Sweden. Occupational class (non-manual/manual workers) was also explored as a potential mediator. Methods This population-based longitudinal cohort study included 556 793 employees, 19-29 years, residing in Sweden in 2009. CAs included parental death, parental mental and somatic disorders, parental separation, household public assistance, single-parent household and residential instability. Measures of LMM included long-term unemployment (LTU), long-term sickness absence (LTSA) and disability pension. Estimates of risk of each LMM measure, between 2010 and 2016 were calculated as hazard ratios (HRs) with 95% confidence intervals (CIs), using a Cox regression analysis. Results Those exposed to CA had an elevated risk for all measures of LMM. Manual workers with a history of household public assistance had the highest risk estimates compared to non-manual workers with no CAs [adjusted HR spanning from 1.59 (LTSA) to 2.50 (LTU)]. Regardless of occupational class, the risk of LMM grew higher with increasing number of CAs (e.g. adjusted HR of LMM in manual workers with 3+ CAs: 1.87, 95% CI: 1.81-1.94). These patterns persisted after adjustments for a range of confounders, including psychiatric and somatic morbidity. Last, we found a small but significant mediating effect of occupational class in the association between CA and LMM. Conclusions Information on CAs are important determinants of LMM in young adults, and especially in manual workers
Prevalence and predictors of healthcare use for psychiatric disorders at 9 years after a first episode of psychosis : a Swedish national cohort study
Full text linkBACKGROUND: Psychotic disorders are known to exhibit heterogeneity with regards to illness course and prognosis, yet few studies have examined long-term healthcare use. OBJECTIVE: To determine the prevalence and predictors of healthcare use for psychiatric disorders at 9 years after the first episode of psychosis (FEP). METHODS: National registers were used to identify all Swedish residents aged 18-35 years with FEP between 2006 and 2013. The 12-month period-prevalence of secondary healthcare use was determined at each year of the 9-year follow-up, categorised according to main diagnosis (psychotic disorder vs other psychiatric disorder vs none vs censored). Multinomial logistic regression models were used to examine associations between baseline characteristics and healthcare use at 9 years and derive predicted probabilities and 95% CIs for the four outcome groups, for each predictor variable. FINDINGS: Among 7733 individuals with FEP, 31.7% were treated in secondary healthcare for psychotic disorders at the 9-year follow-up, 24.1% were treated for other psychiatric disorders, 35.7% did not use healthcare services for psychiatric disorders and 8.5% were censored due to death/emigration. Having an initial diagnosis of schizophrenia was associated with the highest probability of secondary healthcare use for psychotic disorder at 9 years (0.50, 95% CI (0.46 to 0.54)] followed by inpatient treatment at first diagnosis (0.37, 95% CI (0.35 to 0.38)). CONCLUSION: Although 56% of individuals with FEP were treated for psychiatric disorders in secondary healthcare 9 years later, a substantial proportion were treated for non-psychotic disorders. CLINICAL IMPLICATIONS: Individuals with an initial diagnosis of schizophrenia, who received their first diagnosis in inpatient settings, may need more intensive treatment to facilitate remission and recovery
Disability pension and mortality in individuals with specific somatic and mental disorders : examining differences between refugees and Swedish-born individuals
No full textBackground More than half a million refugees have arrived to Sweden during the last decade. The aim was to investigate differences between refugees and Swedish-born individuals regarding different specific somatic and mental disorders, and subsequent disability pension and mortality. Methods All refugees (n=239 742) and Swedish-born individuals (n=4 133 898), aged 19-60 years, resident in Sweden on 31st of December in 2009 were included in this population-based prospective cohort study. Data from six nationwide Swedish registers were linked by the unique anonymised identification number. HRs with 95% CIs were computed for disability pension and mortality 2010-2013 by Cox regression models. Results Compared with their Swedish-born counterparts with mental or somatic diagnoses, refugees with these diagnoses had a higher risk of subsequent disability pension and a lower risk of mortality. Highest estimates for disability pension were seen for refugees with neoplasm (HR: 1.72; 95% CI: 1.56 to 1.91), musculoskeletal disorders (HR: 1.57; 95% CI: 1.47 to 1.67), diseases of the circulatory system (HR: 1.33; 95% CI: 1.22 to 1.45), depressive disorders (HR: 1.31; 95% CI: 1.21 to 1.41) and diabetes mellitus (HR: 1.30; 95% CI: 1.15 to 1.47). The risk of mortality was lowest for refugees with regard to bipolar disorders (HR: 0.37; 95% CI: 0.16 to 0.82), post-traumatic stress disorder (HR: 0.37; 95% CI: 0.25 to 0.54) and least pronounced in regard to neoplasm (HR: 0.69; 95% CI: 0.61 to 0.77) compared with Swedish-born with similar disorders. Conclusion Refugees have a generally higher risk of disability pension compared with Swedish-born with specific somatic and mental disorders. Despite this, refugees with all specific disorders have lower risk estimates of mortality, probably due to a healthy selection. The higher risk of disability pension might therefore be due to other causes besides poor health
Suicidalt beteende bland unga med aktivitetsersättning
Full text linkI denna studie analyserades samband mellan att ha aktivitetsersättning i tidig vuxen ålder och suicidalt beteende, samt hur sådana samband utvecklats över tid. Vi använde individdata från rikstäckande register och utgick från tre kohorter: samtliga unga vuxna som var 19-23 år och folkbokförda i Sverige år 1995, 2000 respektive 2005. Risken för suicidförsök och suicid under de efterföljande fem åren studerades för varje kohort. I samtliga kohorter förelåg en kraftig överrisk för såväl suicidförsök som suicid hos unga med aktivitetsersättning. Från 1995 till 2005 mer än fördubblades antalet unga med aktivitetsersättning, medan antalet suicidförsök och suicidförsök i denna grupp fyrdubblades. Det finns ett påtagligt behov av regelbunden uppföljning av unga med aktivitetsersättning, för att säkerställa att de får rätt insatser
Representation and Outcomes of Individuals With Schizophrenia Seen in Everyday Practice Who Are Ineligible for Randomized Clinical Trials.
Full text linkImportance
Most evidence about efficacy and safety of antipsychotics in schizophrenia spectrum disorders relies on randomized clinical trials (RCTs). However, owing to their strict eligibility criteria, RCTs represent only a part of the real-world population (ie, unselected patients seen in everyday clinical practice), which may result in an efficacy-effectiveness gap.
Objective
To quantify the proportion of real-world individuals with schizophrenia spectrum disorders who would be ineligible for participation in RCTs, and to explore whether clinical outcomes differ between eligible and ineligible individuals.
Design, Setting, and Participants
This study applied eligibility criteria typically used in RCTs for relapse prevention in schizophrenia spectrum disorders to real-world populations. Individuals with diagnoses of schizophrenia spectrum disorders recorded in national patient registries in Finland and Sweden were identified. Individuals who had used antipsychotics continuously for 12 weeks in outpatient care were selected. Individuals were followed up for up to 1 year while they were receiving maintenance treatment with any second-generation antipsychotic (excluding clozapine). Follow-up was censored at treatment discontinuation, initiation of add-on antipsychotics, death, and end of database linkage.
Main Outcomes and Measures
Proportions of RCT-ineligible individuals with schizophrenia spectrum disorders owing to any and specific RCT exclusion criteria. The risk of hospitalization due to psychosis within 1-year follow-up in ineligible vs eligible persons were compared using hazard ratios (HR) and corresponding 95% CIs.
Results
The mean (SD) age in the Finnish cohort (n = 17 801) was 47.5 (13.8) years and 8972 (50.4%) were women; the mean (SD) age in the Swedish cohort (n = 7458) was 44.8 (12.5) years and 3344 (44.8%) were women. A total of 20 060 individuals (79%) with schizophrenia spectrum disorders would be ineligible for RCTs (Finnish cohort: 14 221 of 17 801 [79.9%]; Swedish cohort: 5839 of 7458 [78.3%]). Most frequent reasons for ineligibility were serious somatic comorbidities and concomitant antidepressant/mood stabilizer use. Risks of hospitalization due to psychosis was higher among ineligible than eligible individuals (Finnish cohort: 18.4% vs 17.2%; HR, 1.14 [95% CI, 1.04-1.24]; Swedish cohort: 20.1% vs 14.8%; HR, 1.47 [95% CI, 1.28-1.92]). The largest risks of hospitalization due to psychosis were observed in individuals ineligible owing to treatment resistance, tardive dyskinesia, and history of suicide attempts. Finally, with more ineligibility criteria met, larger risks of hospitalization due to psychosis were observed in both countries.
Conclusions and Relevance
RCTs may represent only about a fifth of real-world individuals with schizophrenia spectrum disorders. Underrepresented (ineligible) patients with schizophrenia spectrum disorders have moderately higher risks of admission due to psychosis while receiving maintenance treatment than RCT-eligible patients. These findings set the stage for future studies targeting real-world populations currently not represented by RCTs
Association of Socio-Demographic Factors, Sick-Leave and Health Care Patterns with the Risk of Being Granted a Disability Pension among Psychiatric Outpatients with Depression
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