Mats Hallgren

Physical exercise and internet-based cognitive-behavioural therapy in the treatment of depression: randomised controlled trial

BACKGROUND 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. AIMS 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. METHOD 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%). RESULTS 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). CONCLUSIONS 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.

Can we predict the onset of first-episode psychosis in a high-risk group?

Treating individuals in the prodromal phase preceding a first psychotic episode has long been a goal of clinicians, the aim being to prevent or minimize the harm inflicted by a psychosis. Before embarking on such a preventive approach, it is first necessary to characterize the features of impending psychosis. We have defined a set of criteria, based on various state and trait risk factors, to identify subjects likely to undergo transition to psychosis within a short time. We prospectively followed up 23 subjects fulfilling these criteria. Subjects were assessed monthly on measures of psychopathology for 12 months. Eleven of the 23 subjects (48 %) made the transition to frank psychosis in the study period; the majority developed schizophrenia-like psychoses. Aberrant results on measures of psychopathology were found before the onset of psychosis. Our results indicate that it is possible to identify individuals who have a high likelihood of onset of psychosis within a brief follow-up period and that there are detectable mental state changes in this group prior to onset of psychosis. This finding lays the foundation for early treatment in an attempt to prevent, delay or minimize the severity of first psychotic episodes.

Sedentary behavior and physical activity levels in people with schizophrenia, bipolar disorder and major depressive disorder: a global systematic review and meta-analysis

People with severe mental illness (schizophrenia, bipolar disorder or major depressive disorder) die up to 15 years prematurely due to chronic somatic comorbidities. Sedentary behavior and low physical activity are independent yet modifiable risk factors for cardiovascular disease and premature mortality in these people. A comprehensive meta‐analysis exploring these risk factors is lacking in this vulnerable population. We conducted a meta‐analysis investigating sedentary behavior and physical activity levels and their correlates in people with severe mental illness. Major electronic databases were searched from inception up to April 2017 for articles measuring sedentary behavior and/or physical activity with a self‐report questionnaire or an objective measure (e.g., accelerometer). Random effects meta‐analyses and meta‐regression analyses were conducted. Sixty‐nine studies were included (N=35,682; 39.5% male; mean age 43.0 years). People with severe mental illness spent on average 476.0 min per day (95% CI: 407.3‐545.4) being sedentary during waking hours, and were significantly more sedentary than age‐ and gender‐matched healthy controls (p=0.003). Their mean amount of moderate or vigorous physical activity was 38.4 min per day (95% CI: 32.0‐44.8), being significantly lower than that of healthy controls (p=0.002 for moderate activity, p<0.001 for vigorous activity). People with severe mental illness were significantly less likely than matched healthy controls to meet physical activity guidelines (odds ratio = 1.5; 95% CI: 1.1‐2.0, p<0.001, I2=95.8). Lower physical activity levels and non‐compliance with physical activity guidelines were associated with male gender, being single, unemployment, fewer years of education, higher body mass index, longer illness duration, antidepressant and antipsychotic medication use, lower cardiorespiratory fitness and a diagnosis of schizophrenia. People with bipolar disorder were the most physically active, yet spent most time being sedentary. Geographical differences were detected, and inpatients were more active than outpatients and those living in the community. Given the established health benefits of physical activity and its low levels in people with severe mental illness, future interventions specifically targeting the prevention of physical inactivity and sedentary behavior are warranted in this population.

Drinking less but greater harm: could polarized drinking habits explain the divergence between alcohol consumption and harms among youth?

AIMS This paper describes changes in alcohol consumption among Swedish youth over the past decade with the aim of exploring the polarization hypothesis, which asserts that while a majority of young drinkers have reduced their alcohol consumption, a subgroup have increased their drinking substantially, resulting in greater harm. METHODS We analysed repeated cross-sectional self-report data from 45,841 15-16-year olds and 40,889 18-19-year-old high-school students living in the Stockholm municipality between 2000 and 2010. The questionnaire assessed alcohol and drug use, and risk factors for alcohol misuse. Changes over time at different levels of consumption are presented by age and gender. RESULTS We find evidence of a polarization effect in youth drinking, with consumption reducing significantly over the past 10 years among all young people, except the heaviest drinkers, where consumption and binge drinking tended to increase. The dispersion in per capita consumption also increased over time, indicating more heavy drinkers. The total number of risk factors for alcohol misuse decreased among most survey participants from 2000 to 2010, but with variability between years. CONCLUSION Polarized drinking habits are a likely explanation for the recent divergence between per capita alcohol consumption, which has decreased, and alcohol-related hospitalizations, which have increased sharply among Swedish youth in recent years. We suggest that ongoing social changes could be affecting young people in the form of greater disparities, which are associated with a higher incidence of social problems generally, including heavy drinking.

The use of Alcohol Use Disorders Identification Test (AUDIT) in detecting alcohol use disorder and risk drinking in the general population: validation of AUDIT using schedules for clinical assessment in neuropsychiatry

BACKGROUND The alcohol use disorders identification test (AUDIT) and AUDIT-Consumption (AUDIT-C) are commonly used in population surveys but there are few validations studies in the general population. Validity should be estimated in samples close to the targeted population and setting. This study aims to validate AUDIT and AUDIT-C in a general population sample (PART) in Stockholm, Sweden. METHODS We used a general population subsample age 20 to 64 that answered a postal questionnaire including AUDIT who later participated in a psychiatric interview (n = 1,093). Interviews using Schedules for Clinical Assessment in Neuropsychiatry was used as criterion standard. Diagnoses were set according to the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Agreement between the diagnostic test and criterion standard was measured with area under the receiver operator characteristics curve (AUC). RESULTS A total of 1,086 (450 men and 636 women) of the interview participants completed AUDIT. There were 96 individuals with DSM-IV-alcohol dependence, 36 DSM-IV-Alcohol Abuse, and 153 Risk drinkers. AUCs were for DSM-IV-alcohol use disorder 0.90 (AUDIT-C 0.85); DSM-IV-dependence 0.94 (AUDIT-C 0.89); risk drinking 0.80 (AUDIT-C 0.80); and any criterion 0.87 (AUDIT-C 0.84). CONCLUSIONS In this general population sample, AUDIT and AUDIT-C performed outstanding or excellent in identifying dependency, risk drinking, alcohol use disorder, any disorder, or risk drinking.

Physical activity and anxiety: A perspective from the World Health Survey

BACKGROUND Despite the known benefits of physical activity (PA) among people with anxiety, little is known about PA levels in people with anxiety at the population level. This study explored the global prevalence of anxiety and its association with PA. METHODS Cross-sectional, community-based data from the World Health Survey was analyzed. Prevalence of anxiety was estimated for 237,964 individuals (47 countries). PA was categorized as low, moderate, and high based on the International Physical Activity Questionnaire (short form). The association between PA and anxiety was assessed by multivariable logistic regression. RESULTS The overall global prevalence of anxiety was 11.4% (47 countries). Across 38 countries with available data on PA, 62.5%, 20.2%, and 17.3% of the sample engaged in high, moderate, and low levels of PA respectively. The prevalence of low physical activity in those with and without anxiety was 22.9% vs. 16.6% (p<0.001) (38 countries, n=184,920). In the pooled model adjusted for socio-demographics, depression, and country, individuals engaging in low PA (vs. high PA) had 1.32 (95% CI=1.17-1.47) times higher odds for anxiety than those with high PA. Female sex, older age, lower education and wealth, and depression were also associated with low PA. At the individual country level, there was a significant positive association between low PA and anxiety in 17 of the 38 countries. CONCLUSION Low PA levels are associated with increased prevalence of anxiety. There is a need for longitudinal research to establish the directionality of the relationships observed.

Exercise as treatment for alcohol use disorders: systematic review and meta-analysis

Objectives To conduct a systematic review and meta-analysis investigating effects of exercise for people with alcohol use disorders (AUDs) across multiple health outcomes. We also investigated the prevalence and predictors of dropout from exercise studies in AUDs. Design Systematic review and random effects meta-analysis with meta-regression analyses. Data sources 3 major electronic databases were searched from inception until April 2016 for exercise intervention studies in adults with AUDs. Eligibility criteria Studies of acute exercise in people with AUDs; and randomised and non-randomised trials examining effects of long-term (≥2 weeks) exercise. Results 21 studies and 1204 unique persons with AUDs (mean age 37.8 years, mean illness duration 4.4 years) were included. Exercise did not reduce daily alcohol consumption (standardised mean difference (SMD) =−0.886, p=0.24), or the Alcohol Use Disorders Identification Test (AUDIT) total scores (SMD=−0.378, p=0.18). For weekly consumption (n=3 studies), a statistically significant difference was observed favouring exercise (SMD=−0.656, p=0.04), but not after adjustment for publication bias (SMD=−0.16, 95% CI −0.88 to 0.55). Exercise significantly reduced depressive symptoms versus control (randomised controlled trials (RCTs) =4; SMD=−0.867, p=0.006, I2=63%) and improved physical fitness (VO2) (RCTs=3; SMD=0.564, p=0.01, I2=46%). The pooled dropout rate was 40.3% (95% CI 23.3% to 60.1%) which was no different to control conditions (OR=0.73, p=0.52). Dropouts were higher among men (β=0.0622, p<0.0001, R2=0.82). Limitations It was not possible to investigate moderating effects of smoking. Conclusions Available evidence indicates exercise appears not to reduce alcohol consumption, but has significant improvements in other health outcomes, including depression and physical fitness. Additional long-term controlled studies of exercise for AUDs are required.

Exercise, Physical Activity, and Sedentary Behavior in the Treatment of Depression: Broadening the Scientific Perspectives and Clinical Opportunities

Research exploring links between exercise and depression now span several decades, yet several clinically relevant research questions remain unanswered. This opinion article briefly describes the status of selected research issues from the exercise depression literature and offer insights into research areas that are currently lacking. We draw particular attention to the potential of research exploring links between sedentary behavior and depression.

Alcohol consumption and harm among elderly Europeans: falling between the cracks

The ageing of Europe means that the absolute number of older Europeans with alcohol use disorders will rise and the consequences of these changes must be considered early. However, little is currently known about the health, social and economic impacts of alcohol consumption by this cohort. We do know that the elderly are more sensitive to alcohol’s negative health effects compared to younger adults and are more prone to fall injuries.1 Research also suggests that alcohol use disorders among the elderly are frequently misdiagnosed or overlooked.2 Significant shifts in global and European Union trade policies have resulted in lower average alcohol prices and greater alcohol availability as the EU has expanded, resulting in higher average consumption levels across most age groups.3 As part of its’ Council of the European Union presidency in 2009, the Swedish National Institute of Public Health (SNIPH) commissioned a report to examine alcohol consumption trends and alcohol-related harms among the elderly (aged ≥60 years) from 10 EU Member States (Czech Republic, Finland, Germany, Italy, Latvia, Poland, the UK, Slovenia, Spain and Sweden).4 For the first time, the survey revealed important trends in alcohol consumption and harm among the elderly, with implications for European public health policy. It was found that elderly Europeans drink in less hazardous ways …

Validity of the 12-item version of the General Health Questionnaire in detecting depression in the general population

OBJECTIVES The 12-item version of the General Health Questionnaire (GHQ-12) is frequently used to measure common mental disorder in public health surveys, but few population-based validations have been made. We validated the GHQ-12 against structured psychiatric interviews of depression using a population-based cohort in Stockholm, Sweden. METHODS We used a population-based cohort of 484 individuals in Stockholm, Sweden (participation rate 62%). All completed the GHQ-12 and a semi-structured psychiatric interview. Last month DSM-III-R symptoms were used to classify major and minor depression. Three scoring methods for GHQ-12 were assessed, the Standard, Likert and Corrected method. Discriminatory ability was assessed with area under the receiver operating characteristic (ROC) curve. RESULTS A total of 9.5% had a major or minor depression. The area under the ROC curve was for the Standard method 0.73 (0.65-0.82), the Likert method 0.80 (0.72-0.87) and the Corrected method 0.80 (0.73-0.87) when using major or minor depression as standard criterion. Adequate sensitivity and specificity for separating those with or without a depressive disorder was reached at ≥12 Likert scored points (80.4 and 69.6%) or ≥6 Corrected GHQ points (78.3 and 73.7%). Sensitivity and specificity was at ≥2 Standard scored points 67.4% and 74.2%. CONCLUSION When scored using the Likert and Corrected methods, the GHQ-12 performed excellently. When scored using the Standard method, performance was acceptable in detecting depressive disorder in the general population. The GHQ-12 appears to be a good proxy for depressive disorder when used in public health surveys.