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Background Economic downturns have been associated with increased suicide rates. The 2008 global financial crisis varied across countries but hit Iceland relatively hard. We aimed to study potential changes in suicide rates in Iceland during this major economic transition. Methods Data were retrieved on all suicides in Iceland during 2002–14. The study period was divided into a pre-collapse period (2002–08) and a post-collapse period (2008–14). Poisson regression models were used to estimate the association between pre-to-post economic collapse and suicide rates, expressed as risk ratios (RR) with 95% confidence intervals (CIs). Analyses were stratified by age and sex. Results A total of 470 suicides were recorded during the study period. The mean age at death was 45 years and 75% were males. The overall suicide rates per 100 000 were 13.3 pre-collapse and 15 post-collapse revealing no overall differences in pre-to-post collapse (RR 1.12; CI 0.94–1.35). This was true for both men and women (RR 1.18; CI 0.96–1.46 and RR 0.96; CI 0.67–1.38, respectively). An increase in the unemployment rate was not associated with the overall suicide rate (RR 1.07; CI 0.86–1.33), and neither were changes in gross domestic product (RR 1.29; CI 0.94–1.79) or balance of trade (RR 1.08; CI 0.96–1.22). Conclusion The economic collapse and rising unemployment rates in Iceland did not result in an overall increase in suicide rates. A strong welfare system and investing in social protection during the economic crisis may have mitigated suicide risk.

Background In recent decades, millions of refugees and migrants have fled wars and sought asylum in Europe. The aim of this study was to quantify the risk of mortality and major diseases among migrants during the 1991–2001 Balkan wars to Sweden in comparison to other European migrants to Sweden during the same period. Methods and findings We conducted a register-based cohort study of 104,770 migrants to Sweden from the former Yugoslavia during the Balkan wars and 147,430 migrants to Sweden from 24 other European countries during the same period (1991–2001). Inpatient and specialized outpatient diagnoses of cardiovascular disease (CVD), cancer, and psychiatric disorders were obtained from the Swedish National Patient Register and the Swedish Cancer Register, and mortality data from the Swedish Cause of Death Register. Adjusting for individual-level data on sociodemographic characteristics and emigration country smoking prevalence, we used Cox regressions to contrast risks of health outcomes for migrants of the Balkan wars and other European migrants. During an average of 12.26 years of follow-up, being a migrant of the Balkan wars was associated with an elevated risk of being diagnosed with CVD (HR 1.39, 95% CI 1.34–1.43, p < 0.001) and dying from CVD (HR 1.45, 95% CI 1.29–1.62, p < 0.001), as well as being diagnosed with cancer (HR 1.16, 95% CI 1.08–1.24, p < 0.001) and dying from cancer (HR 1.27, 95% CI 1.15–1.41, p < 0.001), compared to other European migrants. Being a migrant of the Balkan wars was also associated with a greater overall risk of being diagnosed with a psychiatric disorder (HR 1.19, 95% CI 1.14–1.23, p < 0.001), particularly post-traumatic stress disorder (HR 9.33, 95% CI 7.96–10.94, p < 0.001), while being associated with a reduced risk of suicide (HR 0.68, 95% CI 0.48–0.96, p = 0.030) and suicide attempt (HR 0.57, 95% CI 0.51–0.65, p < 0.001). Later time period of migration and not having any first-degree relatives in Sweden at the time of immigration were associated with greater increases in risk of CVD and psychiatric disorders. Limitations of the study included lack of individual-level information on health status and behaviors of migrants at the time of immigration. Conclusions Our findings indicate that migrants of the Balkan wars faced considerably elevated risks of major diseases and mortality in their first decade in Sweden compared to other European migrants. War migrants without family members in Sweden or with more recent immigration may be particularly vulnerable to adverse health outcomes. Results underscore that persons displaced by war are a vulnerable group in need of long-term health surveillance for psychiatric disorders and somatic disease., Edda Bjork Thordardottir and co-workers study health outcomes among migrants from the former Yugoslavia to Sweden., Author summary Why was this study done? Understanding the toll of war on the health of migrants is a highly relevant and pressing issue in light of the global humanitarian crisis, with more people than ever affected by forced displacement. The 1991–2001 Balkan wars were marked by war crimes such as genocide, ethnic cleansing, rape, and torture. More than 100,000 adults and children migrated to Sweden from the former Yugoslavia during the Balkan wars. What did the researchers do and find? Using Swedish registry data, we assessed morbidity and mortality among 104,770 migrants to Sweden from former Yugoslavia during the Balkan wars and 147,430 migrants from 24 other European countries immigrating to Sweden from 1991 to 2001. We found that compared to other European migrants, being a migrant of the Balkan wars was associated with an elevated risk of overall psychiatric disorders, particularly post-traumatic stress disorder, along with a reduced risk of suicide and suicide attempt. Being a migrant of the Balkan wars was also associated with being diagnosed with and dying from both cancer and cardiovascular disease. Later migration to Sweden and having no first-degree relatives in Sweden at immigration was associated with the greatest risk elevation of psychiatric disorders and cardiovascular disease among migrants fleeing armed conflict. What do these findings mean? These findings indicate that being a war migrant may be associated with considerable elevations in post-traumatic stress disorder as well as risks of cardiovascular- and cancer-related morbidities and mortality, particularly among those migrating late in the wars and without family members. War migrants are a particularly vulnerable group that health professionals should monitor over the long term. Host countries should make availability and accessibility of healthcare and social services to war migrants a priority. Potential limitations of this study include lack of information about health status at the time of immigration as well as behavioral factors possibly contributing to increased disease risk such as smoking and alcohol consumption.

Objective Negative intrusive thoughts about one's prostate cancer have been associated with depressive mood and impaired quality of life among prostate cancer patients. However, little is known about possible predictors for negative intrusive thoughts among this group. We aimed to identify health- and care-related predictors for such thoughts among a population of men newly diagnosed with prostate cancer and undergoing radical prostatectomy. Methods In the LAPPRO-trial, 3154 men (80%) answered study-specific questionnaires at admission and 3 months after surgery. Questions concerned socio-demographics, health, uncertainty, preparedness for symptoms, and the outcome—negative intrusive thoughts. Associations between variables were analyzed by log-binominal and multivariable approach. Results The strongest predictor of negative intrusive thoughts at admission to surgery was uncertainty of cure, followed by binge drinking, poor physical health, antidepressant medication, not being prepared for urinary symptoms, age under 55, and physical pain. Reporting it not probable to obtain urinary symptoms after surgery lowered the odds. Negative intrusive thoughts before surgery were the strongest predictor for such thoughts 3 months later followed by uncertainty of cure, physical pain, younger age, living alone, and poor self-reported physical health. Conclusions Our findings showed an association of preoperative uncertainty of cure as well as low preparedness for well-known surgery-induced symptoms with higher occurrence of negative intrusive thoughts about prostate cancer. Future studies should examine if interventions designed to have healthcare professionals inform patients about their upcoming prostatectomy reduce patients' negative intrusive thoughts and thereby, improve their psychological well-being.

Aims: On 29 May 2008, an earthquake struck in South Iceland. The aim of this study was to explore the trajectories of post-traumatic stress, depressive and anxiety symptoms among exposed inhabitants during the first year following the earthquake, as well as predictors for symptomology. Methods: This was a longitudinal cohort study based on a sample that was randomly selected from the earthquake-stricken area ( n = 1301). Participants answered a questionnaire assessing demographic and disaster-related factors 2 months after the earthquake. In addition, symptoms of post-traumatic stress disorder (PTSD), depression and anxiety were assessed 2, 4, 8 and 12 months post-disaster. Results: Two months after the earthquake, 5.2% of the participants reported PTSD symptoms, 6.7% depression and 6.4% anxiety symptoms. When comparing first and last time points only, we found a significant decrease in anxiety ( p = 0.05), particulary among females ( p = 0.05), those with a primary education ( p = 0.01), prior history of accidents/disasters ( p = 0.02) and those experiencing damage to their home ( p = 0.02). No significant trends were found when the development of other symptoms between the four time points was assessed. Conclusions: Findings indicate a reduction in anxiety symptoms between 2 and 12 months post-disaster, with PTSD and depression symptoms remaining fairly constant across time. No trends in symptomology were observed over time. The results highlight the need for continued monitoring of those affected by disasters and the identification of subgroups at risk in the aftermath of natural disasters.

Aim: Volcanic eruptions and other natural disasters may affect survivor’s physical and mental health. The aim of this study was to examine the mental health effects of the 2010 Eyjafjallajökull volcanic eruption in Iceland on nearby residents, by exposure level and experience. Methods: This population-based study included 1615 residents living in an area close to the Eyjafjallajökull volcano at the time of the eruption and a sample of 697 residents from a non-exposed area. All participants received a questionnaire 6–9 months after the eruption assessing mental health (GHQ-12, PSS-4 and PC-PTSD). The exposed group also received questions related to the experience of the eruption. Results: Replies were received from 1146 participants in the exposed group (71%) and 510 participants in the non-exposed group (73%). Compared to the non-exposed group, participants living in the high-exposed area were at increased risk of experiencing mental distress (GHQ) 6–9 months following the eruption (odds ratio (OR) 1.45%; 95% confidence interval (CI) 1.11–1.90). High-exposed participants were furthermore at increased risk of experiencing symptoms of post-traumatic stress disorder (PTSD) compared to those living in the low-exposed area (OR 3.71; 95% CI 1.34–15.41). We further found that those who had direct experience of the eruption were more likely to suffer from symptoms of mental distress, PTSD symptoms and perceived stress, compared to those less exposed. Conclusions: The findings indicate that screening for these factors (e.g. experience of the event) could potentially aid in identifying those most vulnerable to developing psychological morbidity after this unique type of disaster.

BACKGROUND: Macroeconomic downturns have been associated with increased suicide rates. This study examined potential changes in suicide attempts and self-harm in Iceland during a period of major economic transition (2003-12). METHODS: Data were retrieved from the National University Hospital in Reykjavik (population size: 204.725), containing all ICD-10 diagnoses connected to potential suicidal behaviour. Poisson regression models were used to compare attendance rates before and after the 2008 economic collapse. RESULTS: During the study period, a total of 4537 attendances of 2816 individuals were recorded due to suicide attempts or self-harm. We noted a significant change in total attendance rates among men, characterized by an annual increase in attendance rate pre-collapse of 1.83 per 100.000 inhabitants and a decrease of 3.06 per 100.000 inhabitants post-collapse (P = 0.0067). Such pattern was not observed among women. When restricting to first attendances only, we found a reduced incidence post-crisis among both men (RR: 0.85; 0.76-0.96) and women (RR: 0.86; 0.79-0.92). We further found 1% increase in unemployment rate and balance of trade to be associated with reduced attendance rates among men (RR: 0.84; 0.76-0.93 and RR: 0.81; 0.75-0.88, respectively) but not among women. CONCLUSION: These data suggest no overall increase in attendance rates due to suicide attempts or self-harm following the 2008 Icelandic economic collapse. In fact, a high-point in self-harm and suicide attempts was observed among men at the height of the economic boom and a decrease in new attendances among both men and women after the economic collapse.© The Author 2016. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. Language: en

Aim To investigate the association between couples’ communication before the wife’s death to cancer and the widower’s feelings of guilt and regret after the loss, in a population-based data. Methods Men (n = 907) younger than 80 years and living in Sweden, who had lost their wives due to cancer, were asked 4–5 years after their loss to answer an anonymous postal questionnaire it included questions about the couple’s end-of-life communication during the last 3 months of life and the widower’s feelings of guilt or regret during the first 6 months after the wife’s death. Results During the last 3 months of their wives’ lives, men who had not talked about the impending death with their wives had a higher risk of experiencing feelings of guilt than men who did talk (relative risk (RR) 2.0, 95% confidence interval [CI] 1.2–3.4). Men who were not able to spend as much time as they wished with their wives had an increase in the risk of having feelings of guilt twice that of men who spent time (RR 2.0 95% CI 1.5–2.7). Men who did not talk with their wives about how they could cope practically or emotionally after the death had elevated risks of guilt feelings compared with men who talked (RR 1.8, 95% CI 1.0–3.0; RR 1.7, 95% CI 1.0–2.9, respectively). Men who realised it was too late to discuss the impending death had an increased risk of guilt feelings (RR 4.3, 95% CI 2.9–6.6). Men who thought that not everything had been brought to closure before their wives’ deaths had 3.3 times increased risk of guilt feeling (RR 3.3, 95% CI 1.7–6.4). Conclusions A man who does not have end-of-life discussions with his wife during the last 3 months before her death from cancer may be subject to a significantly greater risk of experiencing feelings of guilt or regret in widowhood than men who did engage in such discussions.

Background: If we can learn how to increase preparedness before the death of a loved one, we can possibly decrease the next-of-kin’s long-term morbidity. Methods: In a population-based study, 691 of 907 (76%) men in Sweden who lost a wife to cancer 4–5 years earlier answered an anonymous questionnaire about their preparedness at the time of their wife’s death as well as potential predictors for preparedness. Results: A final logistic regression model indicates following predictors for preparedness, among others: the length of the widower’s intellectual awareness time before his wife’s death [relative risk (RR) 4.1, confidence interval (CI) 2.7– 6.1], the widower could take in the information that his wife’s disease could not be cured (RR 3.5, CI 2.3–5.2), the couple had arranged their economical affairs (RR 1.5, CI 1.3–1.7), the wife had stayed at a palliative care unit during her last months of life (RR 1.2, CI 1.1–1.4) and health care personnel supported the husband to participate in his wife’s care (RR 1.6, CI 1.3–2.1). Conclusions: We identified several care-related factors that may influence the preparedness of men before their wife’s death to cancer. These factors can be considered in future intervention studies aiming at influencing preparedness before the death of a loved one.

The aim of this study was to determine if the order of questions in a study on men who have lost a wife in cancer affects self-assessed measures of psychological morbidity. Data were collected from 76 men who had lost a wife owing to cancer in the breast, ovary or colon in 1999. They were randomly allocated to one of two questionnaires with identical content but varying design. One version began with questions about the wife’s disease and ended with the respondent’s current wellbeing (morbidity-last group). The other version had a reversed order (morbidity-first group). Results showed that the design of the questionnaire affected self-assessed psychological morbidity; all relative risks for these measures were above 1.0 in the morbidity-last group. The highest relative risk was obtained for anxiety (as measured by HADS), 3.4 (0.8-15.0), and depression (as measured by a visual-digital scale), 3.1 (1.2-8.5). Psychological morbidity is assessed as higher when questions appear in the end, rather than the beginning, of a bereavement-related questionnaire. In order to avoid a detrimental bias in a study on bereavement, psychological morbidity is probably best measured first in such a questionnaire.

There is a scarcity of data on mental health effects of the global economic recession. In this study, we investigated potential change in self-reported levels of psychological stress in the Icelandic population as a result of the major national economic collapse that occurred in 2008. We used a national cohort of 3,755 persons who responded to a survey administered in 2007 and 2009, including demographic questions and a stress measure (the 4-item Perceived Stress Scale). We used repeated-measures analysis of variance and logistic regression models to assess change in mean stress levels and risk of high stress levels (>90th percentile) in 2009 as compared with 2007. Age-adjusted mean stress levels increased between 2007 and 2009 (P = 0.004), though the increase was observed only for women (P = 0.003), not for men (P = 0.34). Similarly, the odds ratios for experiencing high stress levels were increased only among women (odds ratio (OR) = 1.37), especially among women who were unemployed (OR = 3.38), students (OR = 2.01), had middle levels of education (OR = 1.65), or were in the middle income bracket (OR = 1.59). The findings indicate that psychological stress may have increased following the economic collapse in Iceland, particularly among females in economically vulnerable groups.

Objectives To examine the long-term development of physical and mental health following exposure to a volcanic eruption. Design Population-based prospective cohort study. Setting In spring 2010, the Icelandic volcano Eyjafjallajokull erupted. Data were collected at 2 time points: in 2010 and 2013. Participants Adult residents in areas close to the Eyjafjallajokull volcano (N=1096), divided according to exposure levels, and a non-exposed sample (n=475), with 80% participation rate in 2013. Main outcome measures Physical symptoms in the previous year (chronic) and previous month (recent), and psychological distress (General Health Questionnaire-12-item version, GHQ-12), perceived stress (Perceived Stress Scale, PSS-4) and post traumatic stress disorder (PTSD) symptoms (Primary Care PTSD, PC-PTSD). Results In the exposed group, certain symptoms were higher in 2013 than in 2010, for example, morning phlegm during winter (OR 2.14; 95% CI 1.49 to 3.06), skin rash/eczema (OR 2.86; 95% CI 1.76 to 4.65), back pain (OR 1.45; 95% CI 1.03 to 2.05) and insomnia (OR 1.53; 95% CI 1.01 to 2.30), in addition to a higher prevalence of regular use of certain medications (eg, for asthma (OR 2.80; 95% CI 1.01 to 7.77)). PTSD symptoms decreased between 2010 and 2013 (OR 0.33; 95% CI 0.17 to 0.61), while the prevalence of psychological distress and perceived stress remained similar. In 2013, the exposed group showed a higher prevalence of various respiratory symptoms than did the non-exposed group, such as wheezing without a cold (high exposure OR 2.35; 95% CI 1.27 to 4.47) and phlegm (high exposure OR 2.81; 95% CI 1.48 to 5.55), some symptoms reflecting the degree of exposure (eg, nocturnal chest tightness (medium exposed OR 3.09; 95% CI 1.21 to 10.46; high exposed OR 3.42; 95% CI 1.30 to 11.79)). Conclusions The findings indicate that people exposed to a volcanic eruption, especially those most exposed, exhibit increased risk of certain symptoms 3–4 years after the eruption.

The focus of this study was on the impact of spousal loss on the development of chronic pain thereafter. More specifically, the aim was to investigate the effect of experiencing low preparedness before a wife's death and the widower's chronic pain 4-5 years after loss.In a population-based study in the years 2004-2005, anonymous questionnaires were sent out to 907 men in Sweden who had lost a wife to cancer in 2000 and 2001. The questionnaires contained questions on the man's preparedness for his wife's death and his physical and psychological health at follow-up.Altogether, 691 out of 907 questionnaires were retrieved (76%). Younger widowers (38-61 years old) with a low degree of preparedness for their wife's death had an increased risk of experiencing symptoms of chronic pain (odds ratio 6.67; 2.49-17.82) 4-5 years after loss. The same results did not apply for older widowers (62-80 years old) (odds ratio 0.81; 0.32-2.05). Widowers who experienced chronic pain were at an increased risk for psychological morbidity, depression (relative risk [RR] 2.21; 1.31-3.74), anxiety (RR 2.11; 1.33-3.37), and sleep disorders (RR 2.19; 1.30-3.69).Our data suggest that low preparedness for a wife's death may increase risk of chronic pain among younger widowers 4-5 years after loss. In addition, we found comorbidity between psychological symptoms and chronic pain among widowers. These findings call for studies on possible mechanisms in the association between low preparedness and morbidity and on how to increase preparedness for a wife's death to cancer.

This study investigated the long-term risk of psychological morbidity for men after losing a wife to cancer. A further aim of the study was to investigate if being in a new relationship at the time of follow-up affects the risk of psychological morbidity.In a population-based cohort study, we collected data from 907 men in Sweden who lost a wife to cancer in the breast, ovary or colon 4-5 years earlier. A control group of 330 married men was also included.Six hundred ninety-one of the widowers (76%) and 262 of the controls (79%) answered a questionnaire. Widowers in a new relationship had a similar risk of psychological morbidity compared with a control group of married men. However, compared with widowers in a new relationship, single widowers reported increased risks of (among other symptoms) the following: depression (RR 2.2, confidence interval [CI] 1.5-3.2), anxiety (RR 1.6, CI 1.1-2.5) emotional numbness (RR 2.2, CI 1.7-2.8), and waking up at night with anxiety (RR 2.2, CI 1.4-3.7).Men who lost a wife to cancer in Sweden in 2000 or 2001 and are single 4-5 years later have increased risks of psychological morbidity, both compared with widowers who are in a new relationship at the time of follow-up and with married men. Further scientific effort is needed for improved understanding of the most likely underlying mechanisms; that is, that enhanced emotional support of a new relationship after the loss of a wife protects against psychological morbidity, or alternatively, that the healthiest widowers enter a new relationship.

The authors examined the impact of a widower's preparedness before his wife's death from cancer on his risk of long-term morbidity. In a population-based study, 691 (76%) of 907 Swedish men who lost a wife to breast, ovarian, or colon cancer in 2000 or 2001 answered an anonymous questionnaire in 2004 or 2005 measuring preparedness at the time of the wife's death and psychological well-being at follow-up. Men aged 38-61 years with a low degree of preparedness at the time of their spouse's death had increased risk of psychological morbidity and other symptoms, such as anxiety (adjusted relative risk (aRR) = 2.1, 95% confidence interval (CI): 1.0, 4.3), a heightened startle response (aRR = 5.3, 95% CI: 1.2, 23.6), emotional numbness (aRR = 2.1, 95% CI: 1.2, 3.6), little or no grief resolution (aRR = 2.7, 95% CI: 1.3, 5.4), and sleep disorders (aRR = 2.3, 95% CI: 1.2, 4.3), 4-5 years after the loss. For older widowers (aged 62-80 years), a low degree of preparedness increased the risk of having repeated painful memories (aRR = 2.8, 95% CI: 1.5, 5.2) and a heightened startle response (aRR = 5.7, 95% CI: 1.5, 21.4) at follow-up. These results show that to improve the long-term psychological well-being of widowers, it may be fruitful to identify care-related facilitators and inhibitors of preparedness.

Background: Depression often develops undetected; to make treatment possible, a single-item screening question may be useful.Patients and methods: We attempted to compare the accuracy of the single-item question 'Are you depressed?' with the seven-item Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) among 1192 Swedish testicular cancer survivors.Results: We obtained information from 974 men (82%). Fifty-nine men (6%) answered 'Yes' to the question 'Are you depressed?' while 118 (12%) answered 'I don't know' and 794 (82%) answered 'No'. Among the 794 men who answered 'No' to the question 'Are you depressed?', 790 (99.5%) were not considered as depressed according to HADS-D 11+. Of those answering 'Yes', 34% (20/59) were identified as depressed according to the same cut-off. Sensitivity of 'Yes' compared with HADS-D > or =11 was 61%, rising to 88% when 'Yes' and 'I don't know' were combined.Conclusion: In a population of men with a prevalence of depression similar to that of the normal population, almost none of those responding 'No' to the written question 'Are you depressed?' were depressed according to HADS-D > or =11. Adding the category 'I don't know' increases sensitivity in detecting depression.

Aim To investigate if a cancer patient’s unrelieved symptoms during the last 3 months of life increase the risk of long-term psychological morbidity in the surviving widower. Methods Men (n = 907) younger than 80 years and living in Sweden, who had lost their wives due to cancer, were asked 4–5 years after their loss to answer an anonymous postal questionnaire that included questions about their current psychological morbidity and their wives’ unrelieved symptoms during the last 3 months of life. Results If the wife suffered unrelieved anxiety or pain during the last 3 months of her life, then the widowers had a higher risk of sleep-related problems 4–5 years after the loss. When the wife had suffered from anxiety, the relative risks (RR) for the widowers’ sleep-related problems were: difficulty falling asleep (RR 1.7, 95% CI 1.0–3.0) and waking up at night with anxiety (RR 4.9, 95% CI 1.5–15.7). When the wife had unrelieved pain, the widowers years later had an increased risk of difficulty falling asleep at night (RR 1.8, 95% CI 1.0–3.3). Conclusions The unrelieved patients’ end-of-life problems increase the risk of widowers’ long-term mental suffering. Efficient and effective diagnoses and treatment of pain and anxiety in terminally ill cancer patients are critical for both patients and their surviving widowers.

Purpose Awareness of the cancer patient's terminal state decreases the risk of psychological morbidity of the bereaved. We wanted to determine whether male spouses of cancer patients who died from their disease had received information that the illness was incurable and to determine their preferences of disclosure. Participants and Methods The study included 907 widowers whose wives had died of cancer. In an anonymous questionnaire, we asked whether the widower had received information that his wife's illness was incurable and about his attitudes towards receiving this information. Results Six hundred ninety-one widowers (76%) participated. Eighty percent of the widowers reported that they were told that the wife's cancer was incurable, and 21% reported that they had been informed within 1 week before the patient's death. Although 14% of the widowers did not think the next of kin should be told immediately when the patient's cancer is beyond cure, 39% of the men did not want the patient to be immediately informed. Furthermore, 71% of the men who were never informed about the incurable illness believed that the next of kin should receive that information immediately. Conclusion Although a large majority of men prefer an immediate disclosure about the incurable stage of their wife's illness, 41% of the husbands received this information during the last week of the patient's life or not at all. These findings indicate that there is room for improvement in the level of communication between health providers and the husbands of women with incurable cancer.

We investigated the feasibility of using single-item visual-digital scales for measuring anxiety and depression for research purposes within the oncology and palliative care setting. Data were retrieved from five nationwide postal questionnaires comprising 3030 individuals (response rate 76%): cancer patients, widows/parents who had lost their husband/child to cancer and population controls. All questionnaires contained the Center for Epidemiological Studies Depression scale (CES-D) and Spielberger's State-Trait Anxiety Inventory (STAI-T) as well as seven-point Visual-Digital Scales (VDS) assessing anxiety and depression. Each stepwise increased score on the VDS-depression provided a statistically significant increase in the mean score on CES-D (Spearman's r=0.582). The VDS-anxiety correlated with mean scores on STAI-T (Spearman's r=0.493), however, not all stepwise increased scores on the VDS-anxiety gave a statistically significant increase on the STAI-T. Positive- and negative predictive values were 51% and 91% for VDS-depression and 64% and 80% for VDS-anxiety. Missing data for STAI-T were 7% and 9% for CES-D; the corresponding figures were 2% for the VDS-depression and 3% for VDS-anxiety. With low attrition and agreement with psychometric scales, the Visual-Digital Scales are a feasible alternative for research in the oncology setting. However, the high negative predictive value and the low positive predictive value suggest that the visual- digital scales mainly detect the absence of the symptoms.

Summary Background We aimed to study care-related determinants of when parents gain awareness of their child's impending death to cancer, and whether the duration of this awareness affects the parents' long-term morbidity. Methods Between August 2001 and October 2001, 449 of 561 (80%) parents who had lost a child due to any malignancy in Sweden between Jan 1, 1992, and Dec 31, 1997 (identified on the Swedish Causes of Death Register), answered a 365-item postal questionnaire designed to ascertain when, before the child's actual death, they had become intellectually and emotionally aware of the child's impending death (awareness time). The primary endpoints were intellectual awareness time (defined as time between intellectual realisation that a disease is fatal and the actual time of death) and emotional awareness time (defined as time between emotional realisation that a disease is fatal and the actual time of death). Parents' awareness of less than 24 h was referred to as a short awareness time. Findings 436 parents answered the question about intellectual awareness and 433 parents answered the question about emotional awareness. 112 parents (26%) reported a short intellectual awareness time and 195 parents (45%) reported a short emotional awareness time. The risk of having short intellectual awareness time was increased if parents had absence of information on their child's fatal condition (mothers relative risk [RR] 3·6 [95% CI 2·3–5·5]; fathers 2·9 [1·8–4·5]) and if curative treatment was used towards the end of life (mothers 4·1 [2·6–6·5]; fathers 2·7 [1·7–4·2]). The risk of short emotional awareness time was increased if parents had absence of information indicating the child would die (mothers 1·5 [1·1–2·0]; fathers 1·8 [1·3–2·5]) and absence of talks about death with the other parent (mothers 1·5 [1·1–2·0]; fathers 1·7 [1·2–2·2]). Compared with fathers who had longer emotional awareness time, fathers with short emotional awareness time had an increased risk of depression (adjusted RR 1·8 [1·0–3·3]) and absence from employment due to sick leave or early retirement (RR 8·5 [1·1–67·8]) at follow-up. This difference was not noted for mothers. Interpretation Health-care professionals can influence parents' intellectual and emotional awareness of a child's impending death due to cancer. Short emotional awareness increases the risk of long-term depression in bereaved fathers.

To investigate the risk of self-injury in parentally cancer-bereaved youth compared with their nonbereaved peers.Population-based study of cancer-bereaved youth and a random sample of matched population controls.Sweden in 2009 and 2010.A total of 952 youth (74.8%) confirmed to be eligible for the study returned the questionnaire: 622 (73.1%) of 851 eligible young adults who lost a parent to cancer between the ages of 13 and 16 years, in 2000 to 2003, and 330 (78.4%) of 451 nonbereaved peers.Cancer bereavement or nonbreavement during the teenage years.Unadjusted and adjusted odds ratios (ORs) of self-injury after January 1, 2000.Among cancer-bereaved youth, 120 (19.5%) reported self-injury compared with 35 (10.6%) of their nonbereaved peers, yielding an OR of 2.0 (95% CI, 1.4-3.0). After controlling for potential confounding factors in childhood (eg, having engaged in self-destructive behavior, having been bullied, having been sexually or physically abused, having no one to share joys and sorrows with, and sex), the adjusted OR was 2.3 (95% CI, 1.4-3.7). The OR for suicide attempts was 1.6 (95% CI, 0.8-3.0).One-fifth of cancer-bereaved youth reported self-injury, representing twice the odds for self-injury in their nonbereaved peers, regardless of any of the adjustments we made. Raised awareness on a broad basis in health care and allied disciplines would enable identification and support provision to this vulnerable group.