Agnieszka Butwicka

Risks of Psychiatric Disorders and Suicide Attempts in Children and Adolescents With Type 1 Diabetes: A Population-Based Cohort Study

OBJECTIVE To assess the risk of psychiatric disorders and suicide attempts in children with type 1 diabetes and their healthy siblings. RESEARCH DESIGN AND METHODS We performed a population-based case-cohort study of individuals born in Sweden between 1973 and 2009. Children with type 1 diabetes (n = 17,122) and their healthy siblings (n = 18,847) were identified and followed until their 18th birthday. Their risk of psychiatric disorders was compared with that of matched control subjects. RESULTS The risk of psychiatric morbidity in children with type 1 diabetes compared with the general population was tripled within 6 months after the onset of diabetes (hazard ratio [HR] 3.0 [95% CI 2.7–3.4]) and doubled within the total observation period (HR 2.1 [95% CI 2.0–2.2]). An increased risk was noted in suicide attempts (HR 1.7 [95% CI 1.4–2.0]) and in most categories of psychiatric disorders. The risk of psychiatric disorders in probands declined from HR 2.7 (95% CI 2.2–3.3) for those in the cohort born 1973–1986 to 1.9 (95% CI 1.8–2.0) in those born 1997–2009. The risk for any psychiatric disorders among siblings of patients with type 1 diabetes was estimated to be HR 1.1 (95% CI 1.0–1.1), and there was no increased risk in any of the specific category of disorders. CONCLUSIONS Children with type 1 diabetes are at high risk of psychiatric disorders, which seems to be a consequence of the disease rather than due to a common familial etiology. The results support recommendations on comprehensive mental health surveillance in children with type 1 diabetes, especially in recently diagnosed children.

Congenital adrenal hyperplasia and risk for psychiatric disorders in girls and women born between 1915 and 2010: A total population study

Congenital adrenal hyperplasia (CAH) is a chronic condition and individuals are exposed to elevated androgen levels in utero as a result of the endogenous cortisol deficiency. Prenatal androgen exposure has been suggested to influence mental health, but population based studies on psychiatric morbidity among girls and women with CAH are lacking. Therefore, we performed a cohort study based on Swedish nationwide registers linked with the national CAH register. Girls and women with CAH due to 21-hydroxylase deficiency (n = 335) born between January 1915 and January 2010 were compared with aged-matched female (n = 33500) and male controls (n = 33500). Analyses were stratified by phenotype [salt wasting (SW), simple virilizing (SV), and non-classical type (NC)] and by CYP21A2 genotype subgroups (null, I2splice, I172N, and P30L). Results are presented as estimated risks (OR, 95%CI) of psychiatric disorders among girls and women with CAH compared with age-matched controls. Any psychiatric diagnoses were more common in CAH females compared with female and male population controls [1.9 (1.4-2.5), and 2.2 (1.7-2.9)]. In particular, the risk of alcohol misuse was increased compared with female and male population controls [2.8 (1.7-4.7) and 2.1 (1.2-3.5)], and appeared most common among the girls and women with the most severe null genotype [6.7 (2.6-17.8)]. The risk of stress and adjustment disorders was doubled compared with female population controls [2.1 (1.3-3.6)]. Girls and women with CAH have an increased risk of psychiatric disorders in general and substance use disorders in particular compared with unexposed females, with the highest risk among those with the most severe genotype. Prenatal androgen exposure and deficient endogenous cortisol and/or adrenaline production may provide explanations for these findings, but other factors related to CAH cannot be excluded.

Increased Psychiatric Morbidity in Men With Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency

CONTEXT Reports on psychiatric morbidity in males with congenital adrenal hyperplasia (CAH) are lacking. OBJECTIVE The aim was to study psychiatric disorders in CAH males. DESIGN, SETTING, AND PARTICIPANTS We studied males with CAH (21-hydroxylase deficiency, n = 253; CYP21A2 mutations known, n = 185), and compared them with controls (n = 25 300). Data were derived through linkage of national population-based registers. We assessed the subgroups of CYP21A2 genotype separately (null, I2splice, I172N, P30L, and NC), as well as outcomes before and after the introduction of national neonatal screening in 1986. MAIN OUTCOME MEASURES Psychiatric disorders including attempted and completed suicide (suicidality) were reviewed. RESULTS Psychiatric disorders (suicidality not included), suicidality, and alcohol misuse were increased in CAH males compared with controls (odds ratios, 1.5, 2.3, and 1.9; 95% confidence intervals, 1.1-2.2, 1.1-5.0, and 1.0-3.5, respectively). In the null genotype group, no increased rates were seen; in the I2splice group, psychiatric disorders, personality disorders, and alcohol misuse were increased; in the I172N group, suicide attempt and drug misuse were increased; and in the P30L and NC groups, psychotic disorders were increased. In CAH males born before the neonatal screening, the rates of psychiatric disorders and suicidality were increased, but only psychotic disorders increased in those born afterward. There was no increased risk for any neurodevelopmental disorder. CONCLUSIONS CAH males have an increased psychiatric morbidity. Psychiatric morbidity was not raised in the most severe genotype group. Late diagnosis of CAH may explain some of the findings. Those born before the introduction of neonatal screening were more affected, which may be explained by the higher age.

Psychiatric disorders and suicide attempts in Swedish survivors of the 2004 southeast Asia tsunami: a 5 year matched cohort study

BACKGROUND Survivors of natural disasters are thought to be at an increased risk of psychiatric disorders, however the extent of this risk, and whether it is linked to pre-existing psychopathology, is not known. We aimed to establish whether Swedish survivors of tsunamis from the 2004 Sumatra-Andaman earthquake had increased risks of psychiatric disorders and suicide attempts 5 years after repatriation. METHODS We identified Swedish survivors repatriated from southeast Asia (8762 adults and 3742 children) and 864 088 unexposed adults and 320 828 unexposed children matched for sex, age, and socioeconomic status. We retrieved psychiatric diagnoses and suicide attempts from the Swedish patient register for the 5 years after the tsunami (from Dec 26, 2004, to Jan 31, 2010) and estimated hazard ratios (HRs), then adjusted for pre-tsunami psychiatric disorders, and, for children, for parental pre-tsunami disorders. FINDINGS Exposed adults were more likely than unexposed adults to receive any psychiatric diagnosis (547 [6·2%] vs 47 734 [5·5%]; adjusted HR 1·21, 95% CI 1·11-1·32), particularly stress-related disorders (187 [2·1%] vs 8831 [1·0%]; 2·27, 1·96-2·62) and suicide attempts (38 [0·43%] vs 2752 [0·32%]; 1·54, 1·11-2·13), but not mood or anxiety disorders. Risk of psychiatric diagnoses did not differ between exposed and unexposed children and adolescents (248 [6·6] vs 22 081 [6·9%]; 0·98, 0·86-1·11), although exposed children and adolescents had a higher risk for suicide attempts with uncertain intent (1·43; 1·01-2·02) and stress-related disorders (1·79; 1·30-2·46), mainly during the first 3 months after the tsunami. INTERPRETATION The 2004 tsunami was, independently of previous psychiatric morbidity, associated with an increased risk of severe psychopathology, mainly stress-related disorders and suicide attempts, in children and adults. Survivors of natural disasters should be targeted with early interventions and active long-term follow-up to prevent, detect, and alleviate psychiatric disorders that might follow. FUNDING The Swedish Council for Working Life and Social Research, Swedish Board of Health and Welfare, Polish Ministry of Science and Higher Education, Swedish Society for Medical Research.

Symptom clusters in obsessive–compulsive disorder (OCD): influence of age and age of onset

Obsessive–compulsive disorder (OCD) is an ailment of heterogeneous nature. It is believed that the age of onset determines the subtype of juvenile OCD. The objective of our study was to evaluate the rates of symptoms’ contents and the age of manifestation of the various OCD symptoms in adolescents and adults with early and late onset of disorder. Both authors independently reviewed the medical charts of patients treated for OCD between 1999 and 2007 in a psychiatric university hospital. Patients were evaluated using the Yale–Brown obsessive–compulsive scale check list (Y-BOCS). The patients were grouped as adolescents (group 1), adults with late onset (group 2) and adults with early onset (group 3). Chi2 was used for nominal variables and the non-parametric Kruskal–Wallis ANOVA for continuous comparisons due to deviations from normality of distribution. A total of 132 patients were enrolled in the study (44 group 1, 43 group 2 and 45 group 3). There were no differences in gender distribution. Religious, sexual and miscellaneous obsessions were more frequent and somatic less frequent in group 1 than in group 2. Contamination compulsions were most seldom found in group 1. Cleaning obsessions were more frequent in group 3 than in group 1. Checking were the rarest and miscellaneous, the most often compulsion among adolescents in comparison to other groups. The symptoms’ content in adolescents differed from those observed in adult, both with early and later onset of the disease. The age at onset influences the rates of adult patients’ compulsions.

Efficacy of Metabolic and Psychological Screening for Mood Disorders Among Children With Type 1 Diabetes

OBJECTIVE To compare the diagnostic accuracy and time expenditure of screening models based on glycated hemoglobin (HbA1c) level and psychometric measures for mood disorder (MD) among children with type 1 diabetes. RESEARCH DESIGN AND METHODS With semistructured clinical interviews (Schedule for Affective Disorders and Schizophrenia for Children–Present and Lifetime version, 120 min/patient) as a reference for diagnosing MD, including major depressive disorder (MDD), we tested 163 subjects, aged 8 to 18 years, with type 1 diabetes. We evaluated four screening approaches: 1) Children’s Depression Inventory (CDI) at 30 min/patient, 2) HbA1c level, 3) HbA1c level plus CDI, and 4) HbA1c level plus Childrens Depression Rating Scale (CDRS) at 40 min/patient. These tests were conducted with all participants, and the total time expenditure for all four approaches was calculated as the total time needed to implement successfully the screening for MD or MDD in the center. RESULTS HbA1c performed on par with individual psychometric tests in diagnosing MD or MDD. The HbA1c plus CDRS model was the best screening procedure for both MD and MDD, with diagnostic thresholds for HbA1c established at 8.7% and 9.0%, respectively. Cutoff points for CDRS assessed after filtering by HbA1c were 26 (MD) and 30 (MDD) points. Center-wide application of this procedure would result in an 83% reduction of the examination time necessary for the psychiatrist for MD screening and a 91% reduction for MDD screening, as compared with standard screening with CDI. CONCLUSIONS Use of HbA1c level followed by CDRS is a time-efficient procedure to screen for MD in children with type 1 diabetes.

Psychiatric Disorders and Health-Related Quality of Life in Children With Type 1 Diabetes Mellitus

BACKGROUND Type 1 diabetes mellitus (T1DM) is a chronic condition with major effect on health-related quality of life (HRQoL) and mental health. In 1990s, high rates of psychiatric disorders were reported among children with T1DM. Little is known, however, about current prevalence of psychiatric disorders in children with T1DM and the relation between psychiatric diagnosis and HRQoL. OBJECTIVE The aim of the study was to determine the prevalence of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) psychiatric disorders and the association between psychiatric comorbidity and HRQoL in the pediatric population with T1DM. METHODS We conducted a cross-sectional study of 207 children, aged 8-18 years, diagnosed with T1DM. The presence of psychiatric disorders has been assessed by the standard diagnostic interview according to Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria. HRQoL was measured by the general and diabetes mellitus-specific modules of the Paediatric Quality of Life Inventory. RESULTS Of the evaluated patients, 26.6% (N = 55) met the criteria for psychiatric disorders at the time of evaluation. The most common diagnoses were anxiety (N = 32; 15.5%) and mood disorders (N = 8; 3.9%). One-third of the patients (N = 66, 31.9%) met the criteria for at least 1 psychiatric diagnosis in their lifetime. The presence of psychiatric disorders was related to an elevated hemoglobin A1c level (8.6% vs 7.6%) and a lowered HRQoL level in the general pediatric quality of life inventory. In the diabetes mellitus-specific pediatric quality of life inventory, children with psychiatric disorders revealed more symptoms of diabetes mellitus, treatment barriers, and lower adherence than children without psychiatric disorders. CONCLUSIONS T1DM in children is associated with a very high prevalence of psychiatric comorbidity, which is related to elevated hemoglobin A1c and lower HRQoL levels.

Increased Risk for Substance Use-Related Problems in Autism Spectrum Disorders: A Population-Based Cohort Study.

Despite limited and ambiguous empirical data, substance use-related problems have been assumed to be rare among patients with autism spectrum disorders (ASD). Using Swedish population-based registers we identified 26,986 individuals diagnosed with ASD during 1973–2009, and their 96,557 non-ASD relatives. ASD, without diagnosed comorbidity of attention deficit hyperactivity disorder (ADHD) or intellectual disability, was related to a doubled risk of substance use-related problems. The risk of substance use-related problems was the highest among individuals with ASD and ADHD. Further, risks of substance use-related problems were increased among full siblings of ASD probands, half-siblings and parents. We conclude that ASD is a risk factor for substance use-related problems. The elevated risks among relatives of probands with ASD suggest shared familial (genetic and/or shared environmental) liability.

Maternal depressive symptoms predict acute hospitalization among children with type 1 diabetes

The aim of this study is to examine the impact of a mothers depressive symptoms on the risk of hospital admission of her child due to severe hypoglycemia or diabetic ketoacidosis.

Celiac Disease Is Associated with Childhood Psychiatric Disorders: A Population-Based Study

Objectives To determine the risk of future childhood psychiatric disorders in celiac disease, assess the association between previous psychiatric disorders and celiac disease in children, and investigate the risk of childhood psychiatric disorders in siblings of celiac disease probands. Study design This was a nationwide registry‐based matched cohort study in Sweden with 10 903 children (aged <18 years) with celiac disease and 12 710 of their siblings. We assessed the risk of childhood psychiatric disorders (any psychiatric disorder, psychotic disorder, mood disorder, anxiety disorder, eating disorder, psychoactive substance misuse, behavioral disorder, attention‐deficit hyperactivity disorder [ADHD], autism spectrum disorder [ASD], and intellectual disability). HRs of future psychiatric disorders in children with celiac disease and their siblings was estimated by Cox regression. The association between previous diagnosis of a psychiatric disorder and current celiac disease was assessed using logistic regression. Results Compared with the general population, children with celiac disease had a 1.4‐fold greater risk of future psychiatric disorders. Childhood celiac disease was identified as a risk factor for mood disorders, anxiety disorders, eating disorders, behavioral disorders, ADHD, ASD, and intellectual disability. In addition, a previous diagnosis of a mood, eating, or behavioral disorder was more common before the diagnosis of celiac disease. In contrast, siblings of celiac disease probands were at no increased risk of any of the investigated psychiatric disorders. Conclusions Children with celiac disease are at increased risk for most psychiatric disorders, apparently owing to the biological and/or psychological effects of celiac disease.