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Pharmacological treatment patterns for bipolar disorder have changed during recent years, but for better or worse? To investigate the comparative real-world effectiveness of antipsychotics and mood stabilisers in bipolar disorder. Register-based cohort study including all Finnish residents aged 16-65 with a diagnosis of bipolar disorder from in-patient care, specialised out-patient care, sickness absence and disability pensions registers between 1996 and 2018, with a mean follow-up of 9.3 years (s.d. = 6.4). Antipsychotic and mood stabiliser use was modelled using the PRE2DUP method and risk for hospital admission for psychiatric and non-psychiatric reasons when using versus not using medications was estimated using within-individual Cox models. Among 60 045 individuals (56.4% female; mean age 41.7 years, s.d. = 15.8), the five medications associated with lowest risk of psychiatric admissions were olanzapine long-acting injection (LAI) (aHR = 0.54, 95% CI 0.37-0.80), haloperidol LAI (aHR = 0.62, 0.47-0.81), zuclopenthixol LAI (aHR = 0.66, 95% CI 0.52-0.85), lithium (aHR = 0.74, 95% CI 0.71-0.76) and clozapine (aHR = 0.75, 95% CI 0.64-0.87). Only ziprasidone (aHR = 1.26, 95% CI 1.07-1.49) was associated with a statistically higher risk. For non-psychiatric (somatic) admissions, only lithium (aHR = 0.77, 95% CI 0.74-0.81) and carbamazepine (aHR = 0.91, 95% CI 0.85-0.97) were associated with significantly reduced risk, whereas pregabalin, gabapentin and several oral antipsychotics, including quetiapine, were associated with an increased risk. Results for a subcohort of first-episode patients (26 395 individuals, 54.9% female; mean age 38.2 years, s.d. = 13.0) were in line with those of the total cohort. Lithium and certain LAI antipsychotics were associated with lowest risks of psychiatric admission. Lithium was the only treatment associated with decreased risk of both psychiatric and somatic admissions.

Evidence on the role of co-occurring psychiatric disorders in mortality associated with psychotic depression is limited. To estimate the risk of cause-specific mortality in psychotic depression compared with severe non-psychotic depression while controlling for comorbid psychiatric disorders. This cohort study used routine data from nationwide health registers in Finland. Eligible participants had their first diagnosis for psychotic depression or for severe non-psychotic depression between the years 2000 and 2018, had no pre-existing diagnoses for schizophrenia spectrum disorders or bipolar disorder, and were aged 18-65 years at the index diagnosis. Causes of death were defined by ICD-10 codes. The follow-up time was up to 18 years. We included 19 064 individuals with incident psychotic depression and 90 877 individuals with incident non-psychotic depression. Half (1199/2188) of the deaths in those with psychotic depression occurred within 5 years from the index diagnosis and the highest relative risk was during the first year after the diagnosis. Compared with individuals with non-psychotic depression, those with psychotic depression had a higher risk of all-cause mortality (adjusted hazard ratio, aHR = 1.59, 95% CI 1.48-1.70), suicides (aHR = 2.36, 95% CI 2.11-2.64) and fatal accidents (aHR 1.63, 95% CI 1.26-2.10) during the subsequent 5-year period after the index diagnosis. Psychotic symptoms markedly added to the mortality risk associated with severe depression after controlling for psychiatric comorbidity. Prompt treatment and enhanced monitoring for psychotic symptoms is warranted in all patients with severe depression to prevent deaths because of suicides and other external causes.

Despite uncertain benefits, antidepressants are used in the management of personality disorders (PDs). We investigated the association between antidepressants and two adverse outcomes - suicidal behaviour and violent crimes - in individuals with PDs. We used nationwide Danish healthcare registries to identify all individuals with a diagnosed PD aged 18-64 years from 2007 to 2016. Antidepressant use was identified using dispensed prescriptions. Individuals were followed up for healthcare presentations of suicidal behaviour and separately for police-recorded charges of violent crimes. We applied a within-individual design comparing rates of suicidal behaviour and violent crimes during time periods of antidepressant treatment with periods without treatment. Subgroup analyses were performed according to PD clusters, individual antidepressants, specific PDs, psychiatric comorbidities, and history of suicidal behaviour and violent crime. The cohort included 167,319 individuals with a diagnosed PD, 19,519 (12%) of whom were prescribed antidepressants and presented at least one outcome event during follow-up, making them eligible for within-individual analyses. Overall, we found an association with lower rates of suicidal behavior during periods of antidepressant treatment, compared with periods when individuals were not on antidepressants (incidence rate ratio 0.86, 95% CI 0.84-0.89). However, this association was modified by specific PDs, individual antidepressants, comorbidities, and past history. For violent crimes, we did not observe consistent associations in any direction. Antidepressants were associated with lower rates of suicidal behaviour, but less clearly in violent crimes. Types of PDs, individual antidepressants, and comorbidities modified these associations.

BackgroundBipolar disorder (BD) is associated with increased mortality, but evidence on cause-specific mortality is limited.ObjectiveTo investigate cause-specific premature excess mortality in BD.MethodsFinnish nationwide cohort study of individuals with and without a diagnosis of BD who were aged 15–64 years during 2004–2018. Standardised mortality ratios (SMRs) with 95% CIs were calculated for BD using the mortality rates in the Finnish general population without BD as weights. Causes of death were defined by the International Classification of Diseases, 10th revision codes.FindingsOf the included 47 018 individuals with BD, 3300 (7%) died during follow-up. Individuals with BD had sixfold higher mortality due to external causes (SMR: 6.01, 95% CI: 5.68, 6.34) and twofold higher mortality due to somatic causes (SMR: 2.06, 95% CI: 1.97, 2.15). Of the deaths due to external causes, 83% (1061/1273) were excess deaths, whereas 51% (1043/2027) of the deaths due to somatic causes were excess. About twice the number of potential years of life were lost in excess due to external causes than due to somatic causes. Alcohol-related causes contributed more to excess mortality than deaths due to cardiovascular disease.ConclusionExternal causes of death contributed more to the mortality gap than somatic causes after controlling for age-specific background general population mortality.Clinical implicationA balanced consideration between therapeutic response, different treatment options and risk of cause-specific mortality is needed to prevent premature mortality in BD and to reduce the mortality gap.

Long-term patterning of non-employment among problem drinkers is poorly understood. We determined the level and timing of non-employment, and the relative contribution of various types of non-employment among middle-aged persons who died of alcohol-related causes. We conducted a longitudinal retrospective register-based study of Finnish men and women aged 45-64 years who died of alcohol-related causes (n = 15,552) or other causes (n = 39,166) in the period 2000-07, or who survived (n = 204,422) until the end of 2007. We traced back the number of days in employment and non-employment for up to 17 years before death or before the end of the study period for the survivors. The majority (≥56%) of persons who died of alcohol-related causes were in employment up to ten years before death. Over the 17-year period before death, those who died of alcohol-related causes were in employment on average two years less (mean 6.3 years, 95%CI 6.2-6.4) than those dying of other causes (8.2, 8.1-8.3), and five years less than survivors (11.6, 11.5-11.7), when sex and age were adjusted for. The relative role of various types of non-employment differed markedly across the two mortality groups. Among those who died of alcohol-related causes, unemployment accounted for 54% of the total burden of non-employment, in comparison with 29% among those who died of other causes. In contrast, disability pension accounted for 41% of the total burden of non-employment among those who died of alcohol-related causes, but 65% among those who died of other causes. The results indicate the feasibility of preventing movement out of employment among middle-aged men and women with severe alcohol-related harm, provided that they are identified early on during their working careers and offered effective interventions.

Long-term employment trajectories of young problem drinkers are poorly understood. We constructed retrospective labour market participation histories at ages 18-34 of 64 342 persons born in 1969-1982. Beginning from the year of each subject's 18th birthday, we extracted information from the records of Statistics Finland on educational attainment, main type of economic activity, months in employment, and months in unemployment for a minimum of seven years (range 7-16 years). We used information on the timing of alcohol-related hospitalizations and deaths in the same period to define problem drinkers with early onset limited course, early onset persistent course, and late onset problem drinking. Early onset limited course problem drinkers improved their employment considerably by age, whereas early onset persistent problem drinkers experienced a constant decline in their employment by age. From the age of 18 to 34, early onset persistent problem drinkers were in employment merely 12% of the time, in comparison with 39% among the early onset limited course problem drinkers, and 58% among the general population. These results indicate that young adults who were retrospectively defined as having early onset persistent course problem drinking were extensively marginalized from the labour market early on during their life course, and that their employment trajectory was significantly worse compared to other problem drinkers.

Background: This study aims to examine whether the Swedish-speaking minority in Finland differ from the Finnish-speaking majority in respect to alcohol consumption and, whether such differences could be explained by aspects of social capital measured by both individual and area level variables. Methods: This cross-sectional dataset consisted of 17 352 Finnish speakers (baseline response rate 40%) and 2018 Swedish speakers (baseline response rate 37%), aged 25–59 years. Multilevel logistic regression models were used to analyse the differences in alcohol consumption between the language groups, and to adjust for several potential individual and area level confounders. Results: Finnish-speaking men and women reported more frequent drunkenness, suffered more frequent hangovers, and had alcohol-induced pass-outs significantly more often than men and women in the Swedish-speaking population. Demographic, social, or environmental factors did not explain the observed differences in drinking patterns between these groups. Active social participation, social engagement, and trust in others were significantly related to drinking patterns only among Finnish speakers, but not among Swedish speakers. Conclusions: Drinking patterns are likely to have a direct impact on the health differences between the two populations, especially in relation to alcohol-related acute harm. It seems unlikely that the effect of social capital on the health differences between the two populations would be mediated through drinking patterns.

BackgroundLinks among poor sleep and cancer risk behaviors have been largely overlooked in the context of cancer prevention and behavioral medicine. The goal of this scoping review was to determine the extent and nature of experimental studies conducted with healthy adult populations that tested the associations among poor sleep and cancer risk behaviors.MethodElectronic databases and major sleep journals were searched to identify experimental studies in healthy adult samples published through January 2018. Studies examined associations among eight pairings of manipulated behaviors and outcomes (“independent variable (IV)-outcome pairs”): the impact of sleep manipulations on physical activity (PA), diet, alcohol consumption, and tobacco use outcomes; and the impact of PA, diet, alcohol consumption, and tobacco use manipulations on sleep outcomes. Studies were characterized in terms of sample characteristics; study design; IV type, dose, and duration; and outcome measurement and duration.ResultsAbstracts of 5697 papers and 345 full texts were screened. Eighty-eight studies describing 125 comparisons met inclusion criteria. Only two studies tested the association between tobacco use and sleep; none tested whether sleep influenced alcohol consumption. Sample sizes were typically small, most studies used crossover designs, and studies tended to include younger and more male participants. Within each IV-outcome pair, there was substantial heterogeneity in how behaviors were manipulated, outcome measurement, and type of control group. Few studies assessed mechanisms.ConclusionThere is a need for larger experimental studies with more representative samples. Overall, heterogeneity and limitations in study designs make it difficult to synthesize evidence across studies.

Experiences in the first 1000 days of life have a crucial influence on child development and health. Universal health services provide support for families during this time, but new unassessed components are often added. We systematically reviewed the evidence for interventions in high-income countries designed to improve child development by enhancing health professional contact with parents in the very early years. We searched Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ASSIA, LiLACS, Sociological Abstracts, Social Services Abstract, OpenGrey, ClinicalTrials.gov, UK Clinical Trials Gateway, and the WHO International Clinical Trials Registry Platform for studies published in any language between Jan 1, 1996, and Dec 17, 2014, using subject headings and key words with the following search structure: [health OR parenting professionals OR known programme names] AND [child development OR emotional/behavioural OR language OR cognitive outcomes]. We hand searched eight journals and 47 programme or organisation websites. We included randomised controlled trials (RCTs) that examined professional interventions designed to augment existing universal health-care provision from the antenatal period to 2 years post partum. Primary outcomes were motor, cognitive, and language development, and social and emotional wellbeing, measured to 3 years of age. Results were reported by narrative synthesis, because of heterogeneity in intervention design and outcome measurement. Of 12 473 studies identified, 21 RCTs met eligibility criteria. 15 had a high or unclear risk of bias as judged by Cochrane criteria. There was limited evidence for intervention effectiveness: some positive effects were seen in one of five studies for motor development, four of ten for language development, four of seven for cognitive development, and five of 18 for social and emotional wellbeing. However, most positive effects were in studies at high or unclear risk of bias, within-study effects were inconsistent, and negative effects were also seen. Intervention content and intensity varied greatly, but this was not associated with effectiveness. The quality of evidence overall was low as judged by GRADE criteria. Evidence that interventions to enhance universal health services up to 2 years postpartum are effective for improving child development is weak. There is an urgent need for more robust assessment of existing interventions, and to develop and evaluate novel interventions to enhance the universal offer. Public Health Wales.

ObjectiveTo investigate the risk of hospitalisation for major chronic diseases across representative transport, rescue and security industries.MethodsWe performed a register-based study of 624 571 workers from six industries in Denmark between 2000 and 2005, followed up hospitalisation for chronic diseases up to 17 years, and compared with a 20% random sample of the economically active population.ResultsHR from the Cox regression models showed that seafarers had higher risk of lung cancer (men: 1.54, 95% CI 1.31 to 1.81; women: 1.63, 95% CI 1.13 to 2.36), and male seafarers had higher risk of diabetes (1.32, 95% CI 1.21 to 1.43) and oral cancer (1.51, 95% CI 1.21 to 1.88). Men and women in land transport had increased risk of diabetes (men: 1.68, 95% CI 1.63 to 1.73; women 1.55, 95% CI 1.40 to 1.71) and chronic respiratory disease (men: 1.21, 95% CI 1.16 to 1.25; women 1.42, 95% CI 1.32 to 1.53). Among women, a higher risk of gastrointestinal cancer was observed in aviation (1.53, 95% CI 1.23 to 1.89) and police force (1.29, 95% CI 1.01 to 1.65), oral cancer in defence forces (1.83, 95% CI 1.20 to 2.79), and chronic respiratory disease in rescue service (1.47, 95% CI 1.21 to 1.77), while men in defence forces, police force and rescue service had mainly lower risk of these chronic diseases.ConclusionsWe observed considerable health disparities from chronic diseases across transport, rescue and security industries, with workers in seafaring and land transport generally bearing the greatest relative burden.