Jonna Perälä

Quality of life of people with schizophrenia, bipolar disorder and other psychotic disorders

BACKGROUND Health utility and quality of life (QoL) are increasingly important outcome measures in healthcare and health economics. AIMS To compare the loss of subjective QoL and utility-based health-related quality of life (HRQoL) associated with psychotic disorders. METHOD A representative sample of 8028 Finns was screened for psychotic disorders and bipolar I disorder. Lifetime psychotic disorders were diagnosed using the Structured Clinical Interview for DSM-IV and/or case records. Health-related quality of life was measured with EQ-5D and 15D, and QoL was measured with a 10-point scale. RESULTS Schizoaffective disorder was associated with the largest losses of QoL and HRQoL, with bipolar I disorder associated with similar or smaller losses than schizophrenia. Current depressive symptoms explained most of the losses. CONCLUSIONS Depressive symptoms are the strongest predictors of poor QoL/HRQoL in psychotic disorders. Subjective loss of QoL associated with psychotic disorders may be smaller than objective loss of functioning suggests. The EQ-5D is problematic as an outcome measure in psychotic disorders.

Mental disorders in young adulthood

BACKGROUND The effect of mental disorders may be particularly detrimental in early adulthood, and information on mental disorders and their correlates in this age group is important. METHOD A questionnaire focusing on mental health was sent to a nationally representative two-stage cluster sample of 1863 Finns aged 19 to 34 years. Based on a mental health screen, all screen-positives and a random sample of screen-negatives were asked to participate in a mental health assessment, consisting of the Structured Clinical Interview for DSM-IV (SCID-I) interview and neuropsychological assessment. We also obtained case-notes from all lifetime mental health treatments. This paper presents prevalences, sociodemographic associations and treatment contacts for current and lifetime mental disorders. RESULTS Forty percent of these young Finnish adults had at least one lifetime DSM-IV Axis I disorder, and 15% had a current disorder. The most common lifetime disorders were depressive disorders (17.7%) followed by substance abuse or dependence (14.2%) and anxiety disorders (12.6%). Of persons with any lifetime Axis I disorder, 59.2% had more than one disorder. Lower education and unemployment were strongly associated with current and lifetime disorders, particularly involving substance use. Although 58.3% of persons with a current Axis I disorder had received treatment at some point, only 24.2% had current treatment contact. However, 77.1% of persons with a current Axis I disorder who felt in need of treatment for mental health problems had current treatment contact. CONCLUSIONS Mental disorders in young adulthood are common and often co-morbid, and they may be particularly harmful for education and employment in this age group.

Antidepressant utilisation patterns and determinants of short-term and non-psychiatric use in the Finnish general adult population

BACKGROUND The aim was to study utilisation patterns and determinants of antidepressant use in the general population >30 years, especially short-term use or use not related to known psychiatric morbidity. METHODS Participants from a cross-sectional population-based Finnish Health 2000 Study (2000--2001) were linked with the National Prescription Register and National Care Register for Health Care. Within a representative sample (N=7112) of the adult population (>30 years), 12-month DSM-IV depressive, anxiety, and alcohol use disorders were assessed with the M-CIDI. Utilisation patterns of antidepressants were categorised to short-term, intermittent and continuous use. Factors predicting short-term use or use not related to known psychiatric morbidity were investigated. RESULTS Of Finnish adults 7.1% had used antidepressants in 2000, of which two-thirds reported a physician-diagnosed mental disorder; a third (35%) had major depressive or anxiety disorder during the previous 12 months. In terms of utilisation pattern, 43% were long-term users, 32% intermittent users and 26% short-term users. Short-term use was related to care by a general practitioner and having no known mental disorder. A quarter of all users had no known psychiatric morbidity. This type of user was most common among the older age groups, and inversely related to being single, on disability pension and using mental health services. LIMITATIONS Not all psychiatric indications for antidepressant use could be explored. CONCLUSIONS Depression remains the main indication for antidepressant use. About a quarter of users had no known psychiatric indication and the indication remained unclear. Short-term and non-psychiatric use are more commonly prescribed for the elderly.

Cognitive functioning in a population-based sample of young adults with a history of non-psychotic unipolar depressive disorders without psychiatric comorbidity

BACKGROUND There is evidence for cognitive dysfunction in unipolar depression among middle-aged and elderly patients, but cognitive functioning among depressed young adults has scarcely been systematically investigated. The aims of the present study were to examine cognitive functioning among depressed young adults identified from the general population and to determine whether cognitive deficits vary as a function of different disorder characteristics, such as severity and age at onset. METHODS Performance in verbal and visual short-term memory, verbal long-term memory and learning, attention, processing speed, and executive functioning was compared between a population-based sample of 21-35-year-olds with a lifetime history of non-psychotic unipolar depressive disorders without psychiatric comorbidity (n=68) and healthy controls derived from the same population (n=70). RESULTS Depressed young adults were not found to be impaired in any of the assessed cognitive functions, except for some suggestion of mildly compromised verbal learning. Nevertheless, younger age at depression onset was associated with more impaired executive functioning. LIMITATIONS The results may slightly underestimate of the true association between depression and cognitive impairments in the young adult population due to possible dropout of participants. Additionally, the problem of multiple testing was not entirely corrected. CONCLUSION The findings from this study indicate that a lifetime history of non-psychotic unipolar depressive disorders among young adults without psychiatric comorbidity may be associated only with minimal cognitive deficits, even when some residual depressive symptoms are prevalent. However, early-onset depression may represent a more severe form of the disorder, associated with more cognitive dysfunction.

Body composition in psychotic disorders: a general population survey.

BACKGROUND The literature suggests an association between obesity and schizophrenia but fat mass and fat-free mass, which have been shown to be more predictive of all-cause mortality than only waist circumference and obesity [body mass index (BMI) 30 kg/m2], have not been reported in psychotic disorders. We examined the detailed body composition of people with different psychotic disorders in a large population-based sample. METHOD We used a nationally representative sample of 8082 adult Finns aged 30 years with measured anthropometrics (height, weight, waist circumference, fat percentage, fat-free mass and segmental muscle mass). Psychiatric diagnoses were based on a consensus procedure utilizing the Structured Clinical Interview for DSM-IV (SCID)-interview, case-notes and comprehensive register data. RESULTS Schizophrenia (including schizo-affective disorder) was associated with obesity [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.5-3.6], abdominal obesity (waist circumference 88 cm for women, 102 cm for men) (OR 2.2, 95% CI 1.3-3.6) and with higher fat percentage (mean difference 3.8%, 95% CI 2.0-5.7%), adjusted for age and gender, than in the remaining sample. The associations between schizophrenia and low fat-free mass and decreased muscle mass on trunk and upper limbs became statistically significant after adjusting for BMI. After further adjusting for current antipsychotic medication, education, diet and smoking, schizophrenia remained associated with obesity (OR 1.9, 95% CI 1.1-3.6) and abdominal obesity (OR 3.8, 95% CI 1.5-9.4). Participants with affective psychoses did not differ from the general population. CONCLUSIONS Individuals with schizophrenia have metabolically unfavorable body composition, comprising abdominal obesity, high fat percentage and low muscle mass. This leads to increased risk of metabolic and cardiovascular diseases.

Inflammation in psychotic disorders: a population-based study.

We investigated inflammatory markers in psychotic disorders and their association with metabolic comorbidity, antipsychotic medication, smoking, alcohol use, physical condition, and mood. From the population-based Finnish Health 2000 study, we identified all persons with schizophrenia (n=45), other nonaffective psychosis (ONAP) (n=57), affective psychosis (n=37) and chose controls matched by age, sex, and region of residence. We found that persons with schizophrenia had significantly higher sIL-2Rα, IL-1RA and C-reactive protein (CRP), persons with ONAP significantly higher IL-1RA and CRP and persons with affective psychosis almost significantly higher TNF-α compared to their matched controls. Current antipsychotic use was associated with elevated IL-1RA and CRP. After taking metabolic and lifestyle-related variables that associated with inflammatory markers into account, only antipsychotic medication remained associated with elevated IL-1RA and TNF-α which are markers related to the activation of innate immune system. CRP was influenced by both antipsychotic medication and nonaffective psychosis. sIL-2Rα, a marker of T-cell activation, was associated with depressive symptoms, schizophrenia, and affective psychosis. We conclude that in persons with psychotic disorders, activation of mononuclear phagocyte system was mostly related to metabolic comorbidity and antipsychotic medication use, whereas T-cell activation had a more direct relationship with both psychotic disorders and depressive symptoms.

Alcohol-induced psychotic disorder and delirium in the general population

BACKGROUND Epidemiological data on alcohol-induced psychotic disorder and delirium (alcohol-induced psychotic syndrome, AIPS) are scarce. AIMS To investigate the epidemiology of AIPS, the risk factors for developing AIPS among people with alcohol dependence, and mortality associated with alcohol dependence with or without AIPS, in a sample drawn from the general population of Finland. METHOD A general population sample of 8028 persons were interviewed with the Composite International Diagnostic Interview and screened for psychotic disorders using multiple sources. Best-estimate diagnoses of psychotic disorders were made using the Structured Clinical Interview for DSM-IV Axis I Disorders and case notes. Data on hospital reatments and deaths were collected from national registers. RESULTS The lifetime prevalence was 0.5% for AIPS and was highest (1.8%) among men of working age. Younger age at onset of alcohol dependence, low socioeconomic status, fathers mental health or alcohol problems and multiple hospital treatments were associated with increased risk of AIPS. Participants with a history of AIPS had considerable medical comorbidity, and 37% of them died during the 8-year follow-up. CONCLUSIONS Alcohol-induced psychotic disorder is a severe mental disorder with poor outcome.

Type 2 diabetes among persons with schizophrenia and other psychotic disorders in a general population survey

Schizophrenia and other psychotic disorders are associated with increased risk of developing type 2 diabetes. However, previous studies are mainly based on clinical samples where the comorbidity may be stronger. We investigated in a general population survey the prevalence of type 2 diabetes in persons with psychotic disorders and in users of antipsychotic medication. The study was based on a nationally representative two-stage cluster sample of 8,028 persons aged 30 or over from Finland. Diagnostic assessment of psychotic disorders combined SCID-I interview and case note data. Prevalences of type 2 diabetes, adjusting for age and sex, were estimated by calculating predicted marginals. The prevalence estimate of type 2 diabetes was 22.0% among subjects with schizophrenia, 13.4% among subjects with other nonaffective psychosis and 6.1% in subjects without psychotic disorders. Only two subjects (3.4%) with affective psychosis had type 2 diabetes. Users of all types of antipsychotic medication had increased prevalence of type 2 diabetes. Our results suggest that type 2 diabetes is a major health concern among persons with schizophrenia and other nonaffective psychotic disorders and also in users of antipsychotic medication, but persons with affective psychosis in the general population may not have increased prevalence of type 2 diabetes.

Epidemiology of suicide attempts among persons with psychotic disorder in the general population

OBJECTIVE To establish the epidemiology of suicide attempts in persons with psychotic disorder identified from the general population and to investigate the associations of suicidal behavior with other clinical characteristics and with physical violence against other people. METHOD A random sample of 9922 Finnish persons aged 18 years or over was screened for psychotic disorder using multiple sources of information. All screen positives and random sample of screen negatives were invited to an SCID interview. Diagnostic assessment, lifetime history of suicide attempts and violence against others were based on all available systematically evaluated information from the questionnaire, interview and/or case records. RESULTS Of persons with a lifetime history of any primary or substance-induced psychotic disorder (n = 264), 34.5% (women: 34.1%, men: 34.9%) had a history of at least one suicide attempt. There were no suicide attempts among persons with delusional disorder, while the rate of suicide attempts was higher among persons with substance-induced psychotic disorders (48.8%) than in persons with other psychotic disorders 41.8%) (χ(2) = 4.4, d.f. = 1, P = 0.036). Suicide attempts were associated with younger age, comorbid substance use disorders, depressive symptoms, and physical violence against other people. CONCLUSION Suicide attempts are common in all psychotic disorders except for delusional disorder. They are particularly common in substance-induced psychotic disorder and in persons with comorbid substance use disorders. They are associated with severe depressive symptoms but not with the severity of psychotic symptoms. Suicidal behavior correlates with physical violence against other people.

Skeletal status in psychotic disorders: a population-based study.

Objective: To compare the skeletal status of subjects with primary psychotic disorders with the general population by means of bone ultrasound measurements. Schizophrenia seems to be associated with low bone mineral density through a still unclear mechanism, although information on other psychotic disorders is scarce. Methods: In a nationally representative sample, quantitative ultrasound values of the heel, i.e., broadband ultrasound attenuation (BUA) and speed of sound, were measured from subjects with schizophrenia (n = 48), other nonaffective psychosis (n = 56), affective psychosis (n = 37), and from 6,100 population controls. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision lifetime psychosis diagnoses were based both on Structured Clinical Interview and case note data. Information on the most common risk factors for bone fragility was elicited through an interview, health examination, and questionnaires. In addition, serum 25-hydroxyvitamin D was measured. Results: Women with schizophrenia and men with affective psychosis had significantly lower bone ultrasound values as compared with the age- and sex-matched population controls (Z-BUA = −0.54, p = .001 and Z-BUA = −0.37, p = .04, respectively). Significantly lower vitamin D levels were observed in subjects with schizophrenia in comparison with the general population (p = .006). Schizophrenia remained an independent determinant of poor skeletal status in women even after controlling for common risk factors for osteoporosis, vitamin D status, and antipsychotic and mood-stabilizing medication (Z-BUA = −0.54, p = .002). Conclusions: In this population-based study, schizophrenia was found to be independently associated with poor skeletal status in women. AEDs = antiepileptic drugs; BUA = broadband ultrasound attenuation; BMD = bone mineral density; CI = confidence interval; DXA = dual-energy X-ray absorptiometry; ONAP = other nonaffective psychosis; QUS = quantitative ultrasound; SCID = Structured Clinical Interview; SOS = speed of sound.