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Decades of research show that people with schizophrenia have an increased risk of death from cancer; however, the relationship between schizophrenia and cancer incidence remains less clear. This population-based study investigates the incidence of seven common types of cancer among people with a hospital diagnosis of schizophrenia and accounting for the effects of age, sex and calendar time.
This population-based study used 1990–2013 data from three nationwide Swedish registries to calculate the incidence (in total, by age group and by sex) of any cancer and of lung, oesophageal, pancreatic, stomach, colon, (in men) prostate and (in women) breast cancer in 111 306 people with a hospital diagnosis of schizophrenia. The incidence in people with diagnosed schizophrenia was compared with the incidence in the general population. Risk estimates accounted for the effects of calendar time.
In 1 424 829 person-years of follow-up, schizophrenia did not confer an overall higher cancer risk (IRR 1.02, 95% CI 0.91–1.13) but was associated with a higher risk for female breast (IRR 1.19, 95% CI 1.12–1.26), lung (IRR 1.42, 95% CI 1.28–1.58), oesophageal (IRR 1.25, 95% CI 1.07–1.46) and pancreatic (IRR 1.10, 95% CI 1.01–1.21) and a lower risk of prostate (IRR 0.66, 95% CI 0.55–0.79) cancer. Some age- and sex-specific differences in risk were observed.
People with schizophrenia do not have a higher overall incidence of cancer than people in the general population. However, there are significant differences in the risk of specific cancer types overall and by sex calling for efforts to develop disease-specific prevention programmes. In people with schizophrenia, higher risk generally occurs in those <75 years.
Sedentary behaviour can be associated with poor mental health, but it remains unclear whether all types of sedentary behaviour have equivalent detrimental effects.
To model the potential impact on depression of replacing passive with mentally active sedentary behaviours and with light and moderate-to-vigorous physical activity. An additional aim was to explore these relationships by self-report data and clinician diagnoses of depression.
In 1997, 43 863 Swedish adults were initially surveyed and their responses linked to patient registers until 2010. The isotemporal substitution method was used to model the potential impact on depression of replacing 30 min of passive sedentary behaviour with equivalent durations of mentally active sedentary behaviour, light physical activity or moderate-to-vigorous physical activity. Outcomes were self-reported depression symptoms (cross-sectional analyses) and clinician-diagnosed incident major depressive disorder (MDD) (prospective analyses).
Of 24 060 participants with complete data (mean age 49.2 years, s.d. 15.8, 66% female), 1526 (6.3%) reported depression symptoms at baseline. There were 416 (1.7%) incident cases of MDD during the 13-year follow-up. Modelled cross-sectionally, replacing 30 min/day of passive sedentary behaviour with 30 min/day of mentally active sedentary behaviour, light physical activity and moderate-to-vigorous activity reduced the odds of depression symptoms by 5% (odds ratio 0.95, 95% CI 0.94–0.97), 13% (odds ratio 0.87, 95% CI 0.76–1.00) and 19% (odds ratio 0.81, 95% CI 0.93–0.90), respectively. Modelled prospectively, substituting 30 min/day of passive with 30 min/day of mentally active sedentary behaviour reduced MDD risk by 5% (hazard ratio 0.95, 95% CI 0.91–0.99); no other prospective associations were statistically significant.
Substituting passive with mentally active sedentary behaviours, light activity or moderate-to-vigorous activity may reduce depression risk in adults.
Exercise improves cardiorespiratory fitness (CRF) and reduces depressive symptoms in people with depression. It is unclear if changes in CRF are a predictor of the antidepressant effect of exercise in people with depression.
To investigate whether an increase in CRF is a predictor of depression severity reduction after 12 weeks of exercise (trial registration: DRKS study ID, DRKS00008745).
The present study includes participants who took part in vigorous (n = 33), moderate (n = 38) and light (n = 39) intensity exercise and had CRF information (as predicted maximal oxygen uptake, V̇O2max) collected before and after the intervention. Depression severity was measured with the Montgomery–Åsberg Depression Rating Scale (MADRS). V̇O2max (L/min) was assessed with the Åstrand–Rhyming submaximal cycle ergometry test. The main analysis was conducted pooling all exercise intensity groups together.
All exercise intensities improved V̇O2max in people with depression. Regardless of frequency and intensity of exercise, an increase in post-treatment V̇O2max was significantly associated with reduced depression severity at follow-up (B = −3.52, 95% CI −6.08 to −0.96); adjusting for intensity of exercise, age and body mass index made the association stronger (B = −3.89, 95% CI −6.53 to −1.26). Similarly, increased V̇O2max was associated with higher odds (odds ratio = 3.73, 95% CI 1.22–11.43) of exercise treatment response (≥50% reduction in MADRS score) at follow-up.
Our data suggest that improvements in V̇O2max predict a greater reduction in depression severity among individuals who were clinically depressed. This finding indicates that improvements in V̇O2max may be a marker for the underpinning biological pathways for the antidepressant effect of exercise.
Physical activity (PA) may be therapeutic for people with severe mental illness (SMI) who generally have low PA and experience numerous life style-related medical complications. We conducted a meta-review of PA interventions and their impact on health outcomes for people with SMI, including schizophrenia-spectrum disorders, major depressive disorder (MDD) and bipolar disorder. We searched major electronic databases until January 2018 for systematic reviews with/without meta-analysis that investigated PA for any SMI. We rated the quality of studies with the AMSTAR tool, grading the quality of evidence, and identifying gaps, future research needs and clinical practice recommendations. For MDD, consistent evidence indicated that PA can improve depressive symptoms versus control conditions, with effects comparable to those of antidepressants and psychotherapy. PA can also improve cardiorespiratory fitness and quality of life in people with MDD, although the impact on physical health outcomes was limited. There were no differences in adverse events versus control conditions. For MDD, larger effect sizes were seen when PA was delivered at moderate-vigorous intensity and supervised by an exercise specialist. For schizophrenia-spectrum disorders, evidence indicates that aerobic PA can reduce psychiatric symptoms, improves cognition and various subdomains, cardiorespiratory fitness, whilst evidence for the impact on anthropometric measures was inconsistent. There was a paucity of studies investigating PA in bipolar disorder, precluding any definitive recommendations. No cost effectiveness analyses in any SMI condition were identified. We make multiple recommendations to fill existing research gaps and increase the use of PA in routine clinical care aimed at improving psychiatric and medical outcomes.
Exercise has mood-enhancing effects and can improve cognitive functioning, but the effects in first-episode psychosis (FEP) remain understudied. We examined the feasibility and cognitive effects of exercise in FEP.
Multi-center, open-label intervention study. Ninety-one outpatients with FEP (mean age = 30 years, 65% male) received usual care plus a 12-week supervised circuit-training program, consisting of high-volume resistance exercises, aerobic training, and stretching. Primary study outcome was cognitive functioning assessed by Cogstate Brief Battery (processing speed, attention, visual learning, working memory) and Trailmaking A and B tasks (visual attention and task shifting). Within-group changes in cognition were assessed using paired sample t tests with effect sizes (Hedges’ g) reported for significant values. Relationships between exercise frequency and cognitive improvement were assessed using analysis of covariance. Moderating effects of gender were explored with stratified analyses.
Participants exercised on average 13.5 (s.d. = 11.7) times. Forty-eight percent completed 12 or more sessions. Significant post-intervention improvements were seen for processing speed, visual learning, and visual attention; all with moderate effect sizes (g = 0.47–0.49, p < 0.05). Exercise participation was also associated with a positive non-significant trend for working memory (p < 0.07). Stratified analyses indicated a moderating effect of gender. Positive changes were seen among females only for processing speed, visual learning, working memory, and visual attention (g = 0.43–0.69). A significant bivariate correlation was found between total training frequency and improvements in visual attention among males (r = 0.40, p < 0.05).
Supported physical exercise is a feasible and safe adjunct treatment for FEP with potential cognitive benefits, especially among females.
Neurological, visual and hearing deviations have been observed in the offspring of parents with schizophrenia. This study test whether children to parents hospitalized with schizophrenia have increased the likelihood of childhood neurological disorder.
Among all parents in Sweden born 1950–1985 and with offspring born 1968–2002: 7107 children with a parent hospitalized for schizophrenia were compared to 172 982 children with no parents hospitalized for schizophrenia or major depression, as well as to 32 494 children with a parent hospitalized for major depression as a control population with another severe psychiatric outcome. We estimated relative risks (RR) and two-sided 95% confidence intervals calculated from Poisson regression.
Children to parents with schizophrenia were more likely than controls to have been hospitalized before the age of 10 with a diagnosis of cerebral palsy, RR = 1.76 (95% CI: 1.15–2.69); epilepsy, RR = 1.78 (95% CI: 1.33–2.40), combined neurological disease, RR = 1.33 (95% CI: 1.11–1.60) and certain diseases of the eye, RR = 1.92 (95% CI: 1.17–3.15) and ear, RR = 1.18 (95% CI: 1.05–1.32). Similar disease-risk-pattern was found for children to parents hospitalized with a diagnosis of major depression. A specific risk increase for strabismus RR = 1.21 (95%CI: 1.05–1.40) was found for off-spring with parental depression.
Compared with children to healthy parents, children to parents with schizophrenia have increased risk of a variety of neurological disorders as well as visual and hearing disorders at an early age. The risk increase was not specific to schizophrenia but was also seen in children to parents with a diagnosis of major depression.
The socio-cultural behaviour of Scandinavian Mesolithic hunter-gatherers has been difficult to understand due to the dearth of sites thus far investigated. Recent excavations at Kanaljorden in Sweden, however, have revealed disarticulated human crania intentionally placed at the bottom of a former lake. The adult crania exhibited antemortem blunt force trauma patterns differentiated by sex that were probably the result of interpersonal violence; the remains of wooden stakes were recovered inside two crania, indicating that they had been mounted. Taphonomic factors suggest that the human bodies were manipulated prior to deposition. This unique site challenges our understanding of the handling of the dead during the European Mesolithic.
Given the important health benefits of physical activity (PA) and the higher risk for physical inactivity in people with anxiety, and the high prevalence of anxiety and low PA among the elderly, there is a need for research to investigate what factors influence PA participation among anxious older individuals. We investigated PA correlates among community-dwelling adults aged ≥ 65 years with anxiety symptoms in six low- and middle-income countries.
Cross-sectional data from the World Health Organization's Study on Global Ageing and Adult Health were analyzed. PA level was assessed by the Global Physical Activity Questionnaire. 980 participants with anxiety (mean age 73.3 years; 62.4% females) were grouped into those who do and do not (low PA) meet the 150 minutes of moderate-to-vigorous PA per week recommendation. Associations between PA and the correlates were examined using multivariable logistic regressions.
The prevalence of low PA was 44.9% (95% CI = 39.2–50.7%). Older age, male gender, less consumption of alcohol, mild cognitive impairment, pain, a wide range of somatic co-morbidities, slow gait, weak grip strength, poor self-rated health, and lower levels of social cohesion were identified as significant positive correlates of low PA.
Our data illustrate that a number of sociodemographic and health factors are associated with PA levels among older people with symptoms of anxiety. The promotion of social cohesion may increase the efficacy of public health initiatives, while from a clinical perspective, somatic co-morbidities, cognitive impairment, pain, muscle strength, and slow gait need to be considered.
People who have schizophrenia die earlier from somatic diseases than do people in the general population, but information about cardiovascular deaths in people who have schizophrenia is limited. We analysed mortality in all age groups of people with schizophrenia by specific cardiovascular diseases (CVDs), focusing on five CVD diagnoses: coronary heart disease, acute myocardial infarction, cerebrovascular disease, heart failure and cardiac arrhythmias. We also compared hospital admissions for CVDs in people who had schizophrenia with hospital admissions for CVDs in the general population.
This national register study of 10 631 817 people in Sweden included 46 911 people who were admitted to the hospital for schizophrenia between 1 January 1987 and 31 December 2010. Information from national registers was used to identify people who had schizophrenia and obtain data about mortality, causes of death, medical diagnoses and hospitalisations.
CVDs were the leading cause of death in people who had schizophrenia (5245 deaths), and CVDs caused more excess deaths than suicide. The mean age of CVD death was 10 years lower for people who had schizophrenia (70.5 years) than the general population (80.7 years). The mortality rate ratio (MRR) for CVDs in all people who had schizophrenia was 2.80 (95% confidence interval (CI) 2.73–2.88). In people aged 15–59 years who had schizophrenia, the MRR for CVDs was 6.16 (95% CI 5.79–6.54). In all people who had schizophrenia, the MRR for coronary heart disease was 2.83 (95% CI 2.73–2.94); acute myocardial infarction, 2.62 (95% CI 2.49–2.75); cerebrovascular disease, 2.4 (95% CI 2.25–2.55); heart failure, 3.25 (95% CI 2.94–3.6); and cardiac arrhythmias, 2.06 (95% CI 1.75–2.43). Hospital admissions for coronary heart disease were less frequent in people who had schizophrenia than in the general population (admission rate ratio, 0.88 (95% CI 0.83–0.94). In all age groups, survival after hospital admission for CVD was lower in people who had schizophrenia than in the general population.
People who had schizophrenia died 10 years earlier from CVDs than did people in the general population. For all five CVD diagnoses, mortality risk was higher for those with schizophrenia than those in the general population. Survival after hospitalisation for CVDs in people who had schizophrenia was comparable with that of people in the general population who were several decades older.
Evidence-based treatment of depression continues to grow, but successful treatment and maintenance of treatment response remains limited.
To compare the effectiveness of exercise, internet-based cognitive–behavioural therapy (ICBT) and usual care for depression.
A multicentre, three-group parallel, randomised controlled trial was conducted with assessment at 3 months (post-treatment) and 12 months (primary end-point). Outcome assessors were masked to group allocation. Computer-generated allocation was performed externally in blocks of 36 and the ratio of participants per group was 1:1:1. In total, 945 adults with mild to moderate depression aged 18–71 years were recruited from primary healthcare centres located throughout Sweden. Participants were randomly assigned to one of three 12-week interventions: supervised group exercise, clinician-supported ICBT or usual care by a physician. The primary outcome was depression severity assessed by the Montgomery–Åsberg Depression Rating Scale (MADRS).
The response rate at 12-month follow-up was 84%. Depression severity reduced significantly in all three treatment groups in a quadratic trend over time. Mean differences in MADRS score at 12 months were 12.1 (ICBT), 11.4 (exercise) and 9.7 (usual care). At the primary end-point the group × time interaction was significant for both exercise and ICBT. Effect sizes for both interventions were small to moderate.
The long-term treatment effects reported here suggest that prescribed exercise and clinician-supported ICBT should be considered for the treatment of mild to moderate depression in adults.
The purpose of this project is to describe the use of the Swedish National Diabetes Register (NDR) in clinical practice in a Swedish county and to specifically monitor the diabetes care routines at two separate primary health-care centres (PHCC) with a special focus on older patients.
According to Swedish law, all health-care units have to maintain a system for quality evaluation and improvement. As the NDR holds the most important quality indicators, implementation of the NDR in primary care was carried out by an implementation project in 2002–2005.
Initially, a digital questionnaire about NDR routines was sent to all PHCC. Statistics about hemoglobin adult 1c (HbA1c) and blood pressure (BP) was presented for the diabetes teams at two centres who were also interviewed. The responses became the basis for a focus group interview with both teams together, with data subject to content analysis.
The study showed that reporting to the NDR has become a compulsory routine in primary care. The diabetes nurse specialist was responsible for the practical management of the register and used the NDR for continuous monitoring of the patients. Most centres used the NDR’s statistics for evaluation and analyses annually. The diabetes nurse adapted the visits to the patient’s wishes and general condition. Only in terms of target values for HbA1c and BP did they accept slightly higher values for the older patients. Since the NDR was implemented, the registration rate has remained at 75% and has not increased. The reason given was that patients with diabetes living in nursing homes are checked up by the municipal nurse who does not use the NDR. However, the risk of omitting older patients in the NDR could be considerably decreased if data could be transferred from the electronic patient record.
There is limited information published on the specific financial costs of completed and/or attempted suicide in bipolar patients. In the last 15 years, only 6 studies were published. Their results vary considerably due to differences in methods used. Also, information on cost for pure manic versus mixed episodes is lacking. This is surprising, since studies have shown that suicidal behaviour is more common among patients with depressive symptoms than with pure mania, and this difference increases considerably when the mixed-features specifier is applied.
We conducted a registry study with the aim to expand the epidemiological information on suicidal behaviour by episode type in bipolar disorder, and its associated costs.
Health data were retrieved from the Swedish Patient Register. Data covered the period 1990–2014 and included the number of discharged patients with bipolar diagnosis, hospital re-admissions, and attempted and/or completed suicides. Moreover, we retrieved data on suicide and cause of death from the Swedish Cause of Death register. Analyses were done for the whole sample and stratified by subtypes (mania, depression and mixed forms).
First results will be presented at the EPA meeting.
This is a nation-wide Swedish study of completed and attempted suicide in bipolar patients. The hypothesis we will test is that there is a substantial variation between different bipolar disorder subtypes, and that most of the expenditures due to suicidal behaviour in bipolar disorder are linked to mixed forms, mania in combination with depression.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Depression is common and tends to be recurrent. Alternative treatments are needed that are non-stigmatising, accessible and can be prescribed by general medical practitioners.
To compare the effectiveness of three interventions for depression: physical exercise, internet-based cognitive–behavioural therapy (ICBT) and treatment as usual (TAU). A secondary aim was to assess changes in self-rated work capacity.
A total of 946 patients diagnosed with mild to moderate depression were recruited through primary healthcare centres across Sweden and randomly assigned to one of three 12-week interventions (trail registry: KCTR study ID: KT20110063). Patients were reassessed at 3 months (response rate 78%).
Patients in the exercise and ICBT groups reported larger improvements in depressive symptoms compared with TAU. Work capacity improved over time in all three groups (no significant differences).
Exercise and ICBT were more effective than TAU by a general medical practitioner, and both represent promising non-stigmatising treatment alternatives for patients with mild to moderate depression.
Many materials can only be recycled a limited number of times because of physical
degradation (paper and board), chemical degradation (plastics), or impurities (several
metals). Management of the quality of materials is a key to high long-term recycling rates
and, hence, to the sustainable future. This key includes several elements, such as:
retaining the quality of materials in the production and use of products; retaining the
quality of materials in the recycling processes; and using high-quality materials only
when it is required. Pinch analysis is a set of methods to optimize physical flows by
taking the quality into account. It was originally developed for minimizing the energy
demand in process industries. It has been adapted for optimization also of water and
solvents flows. A Japanese research group applied part of the method on flows of steel
within Japan and globally. We present a pilot study that illustrates how all the elements
of the basic pinch approach can be applied to global systems of material flows. Our
material pinch analysis (MPA) distinguishes between three categories of steel
applications, each with its own requirements on the material quality: rolled steel,
sections and re-bar. Copper in wiring etc. increases the copper content of steel recycled
from machinery and eventually restricts the recyclability of the steel in a global system
where steel use does not increase. This is important because an MPA is mainly relevant
when impurities or other quality aspects restrict the recycling rate. Our quantitative
results should not be considered accurate reflections of the reality, because the pilot
study is to a large extent based on assumptions and crude data. However, the model gives a
first indication that the maximum recycling rate of steel is approximately 80% in a
potential future when steel use does not increase, unless technology is improved. A full
MPA with more thorough data collection would more accurately define the maximum long-term
recycling rate and the minimum quantity of ore-based material. In addition, a full MPA
would give information on for what applications ore-based material should be used, and
what scrap flows should be discarded rather than recycled. Such information can be
important for policy-making aiming at increased resource efficiency. If it is important
for policy-making it is also likely to be important to industrial companies that can be
affected by policies.
In Sweden, quality indicators in health care have been the basis for developing National Quality Registers. The Swedish National Diabetes Register (NDR) – one of the largest diabetes registers globally – was introduced in primary health care (PHC) in the county of Östergötland by an implementation project, 2002–2005.
The aim of the present paper was to investigate, by using the results of the NDR, whether the registration led to sustained outcomes of medical results of diabetes care in PHC in the county during the period 2005–2009.
HbA1c, blood pressure (BP), albuminuria and low-density lipoprotein-cholesterol were registered online in the NDR. In 2005 and 2006, goal achievement for HbA1c was measured and compared between PHC centres (PHCC) within the county. In 2007, achievements to national goals were compared between the PHCCs within the county and with those Swedish counties that had attained a sufficiently high registration rate. In 2008 and 2009, the average county results were compared with the corresponding national average measurements for all 21 Swedish counties combined.
In 2005, a clear improvement trend for HbA1c and BP was shown within the county. In 2007–2009, goal achievements in the county studied were slightly better than the other counties measured and the country as a whole in almost every comparison.
The present study has shown association between medical results and registration in the NDR. As the project was primarily a quality improvement work, the results have continuously influenced the development of diabetes care. Both the health professions and the county council now have – in the NDR – an effective and rapid method for evaluation and follow-up of diabetes care. The systematic documentation, followed by comparisons and analyses, create ideas for care improvements.
Hepatitis E infections in humans are usually acquired in endemic countries in Asia or Africa. In Sweden 17 cases infected in Europe, between 1993 and 2009, were identified. All had clinical hepatitis E with unknown source of infection. Hepatitis E virus (HEV) was identified in faecal samples from 63 piglets in 12 pig farms in Sweden. HEV was also identified in blood from 13 out of 159 investigated Swedish wild boars from nine counties. Partial HEV genomes from humans, pigs and wild boars were sequenced and compared by phylogeny. The results showed close relatedness between HEV strains from piglets from the same farm and from wild boars from the same county. HEV strains from humans showed relatedness with strains from pigs and wild boars from the same county. This study showed that HEV strains form geographical clusters in the phylogenetic tree. The methods used in this study may thus be used for tracing the origin of an infecting strain. Furthermore, this study indicated that there are endemic sources of human HEV infections in Sweden.
Farmers' attitudes towards viability of specific conservation practices or actions strongly impact their decisions on adoption and change. This review of ‘attitude’ information reveals a wide range of perceptions about what conservation means and what the impacts of adoption will mean in economic and environmental terms. Farmers operate in a tight financial situation, and in parts of the world they are highly dependent on government subsidies, and cannot afford to risk losing that support. Use of conservation practices is most effective when these are understood in the context of the individual farm, and decisions are rooted in land and resource stewardship and long-term concerns about health of the farm and the soil. The attitudes of farmers entering agri-environmental schemes decide the quality of the result. A model is developed to show how attitudes of the farmer, the farming context and agri-environmental schemes interact and thus influence how the farming community affects nature and biodiversity. As new agri-environmental schemes are planned, agricultural development specialists need to recognize the complexity of farmer attitudes, the importance of location and individual farmer circumstances, and the multiple factors that influence decisions. We provide these insights and the model to conservation biologists conducting research in farming areas, decision makers who develop future agri-environmental schemes, educators training tomorrow's extension officers and nature conservationists, and researchers dealing with nature conservation issues through a combination of scientific disciplines.
In bipolar disorder, hospital treatment is generally required in acute manic episodes, due to lack of compliance and adherence to treatment, and in episodes with marked depressive symptoms, especially suicidal ideation. Analyzing patterns of hospital admission rates is important in order to estimate treatment outcomes in both the acute and remitting phases of the disease. The aim of this study was to analyze secular trends in admissions and re-admissions for bipolar disorder in Sweden.
For bipolar disorder and its subdiagnoses, the number of admissions, length of stay and days in hospital during 1997-2005 was calculated. Readmission rates over five years were calculated for patients discharged for the first and the second time during 2000.
The number of admissions for patients with bipolar disorder in Sweden increased from around 3,500 to more than 4,000, partly explained by increasing rates of first admissions. Three fourths were readmissions. Hospital days increased, since the length of stay was not reduced. Manic episodes represented half the hospitalizations, depressive a quarter, and mixed ten percent. Patients with their second admission had 1.9 readmissions during five years, compared to 1.2 for patients with their first admission in 2000.
Physicians should consider early and effective treatment with long term outcomes in mind. The progressive course is clearly shown by the increasing rates of readmissions after the second admission compared to the first. The increasing number of first admissions is an indication that more patients have received a bipolar disorder diagnosis.