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The aim of this study was to assess the role of the patient’s background and perceived healthcare-related factors in symptoms of acute stress after lung cancer diagnosis. The study population consisted of 89 individuals referred for diagnostic work-up at Landspitali National University Hospital in Iceland and subsequently diagnosed with lung cancer. Before diagnosis, the patients completed questionnaires on sociodemographic characteristics, pre-diagnostic distress (Hospital Anxiety and Depression Scale), social support, and resilience. At a median of 16 days after diagnosis, the patients reported symptoms of acute stress on the Impact of Event Scale-Revised (IES-R) and experience of communication and support from healthcare professionals and family during the diagnostic period. Patients were on average 68 years and 52% reported high levels of post-diagnostic acute stress (IES-R > 23) while 24% reported symptoms suggestive of clinical significance (IES-R > 32). Prior history of cancer (β = 6.7, 95% CI: 0.1 to 13.3) and pre-diagnostic distress were associated with higher levels of post-diagnostic acute stress (β = 8.8, 95% CI: 2.7 to 14.9), while high educational level (β = − 7.9, 95% CI: − 14.8 to − 1.1) was associated with lower levels. Controlling for the abovementioned factors, the patients’ perception of optimal doctor-patient (β = − 9.1, 95% CI: − 14.9 to − 3.3) and family communication (β = − 8.6, 95% CI: − 14.3 to − 2.9) was inversely associated with levels of post-diagnostic acute stress after lung cancer diagnosis. A high proportion of patients with newly diagnosed lung cancer experience high levels of acute traumatic stress of potential clinical significance. Efforts to improve doctor-patient and family communication may mitigate the risk of these adverse symptoms.

Adverse childhood experiences (ACEs) have consistently been associated with elevated risk of multiple adverse health outcomes, yet their contribution to coping ability and psychiatric resilience in adulthood is unclear. Participants were 19,613 women in the Icelandic Stress- And-Gene-Analysis cohort with complete data on 13 ACEs measured with the ACE-International Questionnaire. Self-reported coping ability was measured with the Connor-Davidson Resilience Scale and psychiatric resilience was operationalized as absence of psychiatric morbidity. Compared to women with 0 ACEs, women with ≥ 5 ACEs had 33% lower prevalence of high coping ability (PR=0.67, 95% CI 0.60,0.74) and 56% lower prevalence of high psychiatric resilience (PR=0.44; 95% CI 0.41,0.48). Specific ACEs including emotional neglect, bullying, sexual abuse and mental illness of household member were consistently associated with reduced adult resilience. We observed only slightly attenuated associations after controlling for adult socioeconomic factors and social support in adulthood, indicating that adult resilience may be largely determined in childhood.

Body dysmorphic disorder (BDD) is a relatively common disorder characterized by a preoccupation with nonexistent or slight defects in appearance. BDD usually begins during childhood or adolescence. The preoccupation with the perceived appearance defect typically occurs for many hours a day and is often followed by repetitive behaviours (for example mirror checking and skin picking). The weighted prevalence of BDD in a community sample is around 2%, but it is higher in clinical settings and in cosmetic and dermatological settings. BDD leads to significant distress and/or impairment at work or school and is highly comorbid with major depressive disorder, alcohol or substance use disorder, social anxi-ety disorder and obsessive compulsive disorder and often leads to suicidal ideation. Research suggests that cognitive behavioral therapy (CBT) and SSRI medication are most effective for BDD. However, cosmetic and dermatological treatments rarely improve BDD, and are often harmful. This review contains information on how to screen and diagnose BDD. Further research on BDD and effective treatment for this often imparing disorder is needed.

Background Additional interventions are needed for survivors of psychological trauma because of several barriers to and limitations of existing treatment options (eg, need to talk about the trauma in detail). Case studies are an important step in exploring the development of novel interventions, allowing detailed examination of individual responses to treatment over time. Here, we present a case study that aims to test a novel intervention designed to disrupt memory reconsolidation, taking a single-symptom approach by focusing on intrusive memories of a traumatic event. Objective This study aims to examine a novel brief cognitive intervention to reduce the number of intrusive memories of trauma in an Icelandic setting and to extend previous studies by examining long-term effects for up to 3 months. The intervention was guided by a clinical psychologist and comprised a brief memory reminder, followed by Tetris gameplay with mental rotation, targeting one memory at a time in each session. Methods This was a single case study in Iceland with a woman in her 50s (drawn from an epidemiological study of trauma) with subthreshold posttraumatic stress disorder and a diagnosis of obsessive-compulsive disorder and social anxiety disorder. The participant had four different intrusive memories from a traumatic event that happened in her childhood. The primary outcome was the change in the number of intrusive memories from baseline to intervention phase and to follow-ups. The number of intrusions was monitored in a daily diary for 4 weeks preintervention, 8 weeks during the intervention, and 1 week at 1-month and 3-month follow-ups. Intrusions were targeted one by one over six intervention sessions, creating four repetitions of an AB design (ie, length of baseline A and intervention phase B varied for each memory). We examined changes in both the total number of intrusions (summed across all four memories) and individually for each memory. In addition, we explored whether having fewer intrusive memories would have an impact on functioning, posttraumatic stress, and depression or anxiety symptoms. Results The total number of intrusions per week was 12.6 at baseline, 6.1 at the intervention phase (52% reduction from baseline), 3.0 at the 1-month follow-up (76% reduction), and 1.0 at the 3-month follow-up (92% reduction). Reductions in the symptoms of posttraumatic stress and depression were observed postintervention. Sleep, concentration, stress, and functioning improved. The participant considered the gameplay intervention acceptable and helpful in that she found that the memories disappeared while she was playing. Conclusions This guided brief cognitive intervention reduced the number of intrusive memories over the intervention phase and follow-ups. The brief memory reminder was well tolerated, removing the need to discuss trauma in detail. The next steps require an extension to more cases and exploring remote delivery of the intervention.

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.

Introduction To date, increased attention has focused on how early psychological support after trauma may reduce suffering and limit the chronicity of psychological problems such as posttraumatic stress disorder (PTSD). However, few studies have assessed the reach or effectiveness of post-disaster interventions. The population of Iceland is frequently exposed to natural disasters and since 1995 extensive psychosocial support has been provided to disaster survivors in the country. The aim of this study is to assess the implementation, utilization, and perception of psychosocial support offered in the wake of three natural disasters in Iceland and to assess the association between utilization of support and PTSD symptoms. Method Three population-based studies on inhabitants affected by avalanches in 1995 (n = 399), an earthquake in 2008 (n = 1301) and a volcanic eruption in 2010 (n = 1615) were utilized. Follow-up time varied from 2 months post-disaster (earthquake) to 16 years post-disaster (avalanches). Questionnaire data was used in all three cohorts to assess utilization of psychosocial support and psychological morbidity. Response rate in the studies ranged from 71% to 82%. PTSD symptoms were assessed with validated measurement tools in all studies. Pearson's chi-square tests were used to compare utilization and perception of psychosocial support with regard to PTSD symptoms. Results Utilization of psychosocial support varied between disaster cohorts (16% after the 2008 earthquake; 26% after the 2010 eruption and 37% after 1995 avalanches). Satisfaction with support increased over the years, with 53% of respondents reporting being satisfied or very satisfied with the support after the 1995 avalanches; 68% after the 2008 earthquake and 82% after the 2010 eruption. Only in the disaster cohort with the shortest follow-up time (2 months) were PTSD symptoms negatively associated with utilization of psychosocial support (earthquake cohort; p Conclusions The Icelandic national plan for psychosocial support has developed considerably since services were first formally offered in 1995. Results indicate that satisfaction with received psychosocial support has increased among disaster-affected populations from 1995, when services were first offered, to the year 2010, after the psychosocial plan had undergone substantial improvements. Furthermore, utilization of psychological support appears to be contingent on the severity of the disaster. Further studies are needed to assess the effectiveness of coordinated empirically informed assistance.

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.

Publisher's version (útgefin grein), Background: More than 500 million people worldwide live within exposure range of an active volcano and children are a vulnerable subgroup of such exposed populations. However, studies on the effects of volcanic eruptions on children’s health beyond the first year are sparse. Objective: To examine the effect of the 2010 Eyjafjallajökull eruption on physical and mental health symptoms among exposed children in 2010 and 2013 and to identify potential predictive factors for symptoms. Method: In a population-based prospective cohort study, data was collected on the adult population (N = 1615) exposed to the 2010 Eyjafjallajökull eruption and a non-exposed group (N = 697). The exposed group was further divided according to exposure level. All participants answered questionnaires assessing their children´s and their own perceived health status in 2010 and 2013. Results: In 2010, exposed children were more likely than non-exposed children to experience respiratory symptoms (medium exposed OR 1.47; 95% CI 1.07–2.03; high exposed OR 1.52; 95% CI 1.03–2.24) and anxiety/worries (medium exposed OR 2.39; 95% CI 1.67–3.45; high exposed OR 2.77; 95% CI 1.81–4.27). Both genders had an increased risk of symptoms of anxiety/worries but only exposed boys were at increased risk of experiencing headaches and sleep disturbances compared to non-exposed boys. Within the exposed group, children whose homes were damaged were at increased risk of experiencing anxiety/worries (OR 1.62; 95% CI 1.13–2.32) and depressed mood (OR 1.55; 95% CI 1.07–2.24) than children whose homes were not damaged. Among exposed children, no significant decrease of symptoms was detected between 2010 and 2013. Conclusions: Adverse physical and mental health problems experienced by the children exposed to the eruption seem to persist for up to a three-year period post-disaster. These results underline the importance of appropriate follow-up for children after a natural disaster., The data collections were funded by a grant from the Icelandic government in 2010. The preparation of this paper was also supported by the Nordic Centre of Excellence for Resilience and Societal Security (NORDRESS) which is funded by the NordForsk (grant number 68825)

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.

Background: Traumatic life events have been associated with increased risk of various psychiatric disorders, even suicidality. Our aim was to investigate the association between different traumatic life events and suicidality, by type of event and gender. Methods: Women attending a cancer screening programme in Iceland (n = 689) and a random sample of men from the general population (n = 709) were invited to participate. In a web-based questionnaire, life events were assessed with the Life Stressor Checklist – Revised, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criterion was used to identify traumatic life events. Reports of lifetime suicidal thoughts, self-harm with suicidal intent and suicide attempt were considered as lifetime suicidality. We used Poisson regression, adjusted for demographic factors, to express relative risks (RRs) as a measure of the associations between traumatic events and suicidality. Results: Response rate was 66% (922/1398). The prevalence of lifetime traumatic events was 76% among women and 77% among men. Lifetime suicidality was 11% among women and 16% among men. An overall association of having experienced traumatic life events with suicidality was observed [RR 2.05, 95% confidence interval (CI) 1.21–3.75], with a stronger association for men (RR 3.14, 95% CI 1.25–7.89) than for women (RR 1.45, 95% CI 0.70–2.99). Increased likelihood for suicidality was observed among those who had experienced interpersonal trauma (RR 2.97, 95% CI 1.67–5.67), childhood trauma (RR 4.09, 95% CI 2.27–7.36) and sexual trauma (RR 3.44, 95% CI 1.85–6.37), with a higher likelihood for men. In addition, an association between non-interpersonal trauma and suicidality was noted among men (RR 3.27, 95% CI 1.30–8.25) but not women (RR 1.27, 95% CI 0.59–2.70). Conclusion: Findings indicate that traumatic life events are associated with suicidality, especially among men, with the strongest association for interpersonal trauma.

Background Violence against women has become a global public health threat. Data on the potential impact of exposure to violence on cardiovascular disease are scarce. Methods and Results We evaluated the association between exposure to violence and subclinical cardiovascular disease in 634 disease‐free women from the Mexican Teachers' Cohort who responded to violence‐related items from the Life Stressor Checklist and underwent measures of carotid artery intima‐media thickness in 2012 and 2013. We defined exposure to violence as having ever been exposed to physical and/or sexual violence. Intima‐media thickness was log‐transformed, and subclinical carotid atherosclerosis was defined as intima‐media thickness ≥0.8 mm or plaque. We used multivariable linear and logistic regression models adjusted for several potential confounders. Mean age was 48.9±4.3 years. Close to 40% of women reported past exposure to violence. The lifetime prevalence of sexual violence was 7.1%, and prevalence of physical violence was 23.5% (7.7% reported both sexual and physical violence). Relative to women with no history of violence, exposure to violence was associated with higher intima‐media thickness (adjusted mean percentage difference=2.4%; 95% confidence interval 0.5, 4.3) and subclinical atherosclerosis (adjusted odds ratio=1.60; 95% confidence interval 1.10, 2.32). The association was stronger for exposure to physical violence, especially by mugging or physical assault by a stranger (adjusted mean % difference=4.6%; 95% confidence interval 1.8, 7.5, and odds ratio of subclinical carotid atherosclerosis=2.06; 95% confidence interval 1.22, 3.49). Conclusions Exposure to violence, and in particular assault by a stranger, was strongly associated with subclinical cardiovascular disease in Mexican middle‐aged women.

ObjectiveThe 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. MethodsIn 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. ResultsAltogether, 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). ConclusionOur 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. Copyright (c) 2013 John Wiley & Sons, Ltd. (Less)

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

Background : Every year a substantial number of children are affected by natural disasters worldwide. However, data are scarce on long-term psychological impact of natural disasters on children’s health. Identifying risk factors and outcomes associated with the long-term sequelae of posttraumatic stress disorder (PTSD) can provide a gateway to recovery as well as enhancement of preventive measures. Objective : Among childhood avalanche survivors, we aimed to investigate risk factors for PTSD symptoms and the relationship between socioeconomic status (SES) and PTSD symptoms in adulthood. Methods : Childhood survivors (aged 2–19 at the time of exposure) of two avalanches were identified through nationwide registers 16 years later. The Posttraumatic Diagnostic Scale was used to assess current PTSD symptoms. One-way ANOVA was used to explore PTSD symptoms by background and trauma-specific factors, as well as associations with current SES. Predictors of PTSD symptoms were examined by multivariable regression analysis. Results : Response rate was 66% (108/163). Results from univariate ANOVA analysis revealed that female sex was associated with PTSD symptoms ( F =5.96, p

BACKGROUND: There is a scarcity of data on the association of sexual violence and women's subsequent obstetric outcomes. Our aim was to investigate whether women exposed to sexual violence as teenagers (12-19 years of age) or adults present with different obstetric outcomes than women with no record of such violence. METHODS: We linked detailed prospectively collected information on women attending a Rape Trauma Service (RTS) to the Icelandic Medical Birth Registry (IBR). Women who attended the RTS in 1993-2010 and delivered (on average 5.8 years later) at least one singleton infant in Iceland through 2012 formed our exposed cohort (n = 1068). For each exposed woman's delivery, nine deliveries by women with no RTS attendance were randomly selected from the IBR (n = 9126) matched on age, parity, and year and season of delivery. Information on smoking and Body mass index (BMI) was available for a sub-sample (n = 792 exposed and n = 1416 non-exposed women). Poisson regression models were used to estimate Relative Risks (RR) with 95% confidence intervals (CI). RESULTS: Compared with non-exposed women, exposed women presented with increased risks of maternal distress during labor and delivery (RR 1.68, 95% CI 1.01-2.79), prolonged first stage of labor (RR 1.40, 95% CI 1.03-1.88), antepartum bleeding (RR 1.95, 95% CI 1.22-3.07) and emergency instrumental delivery (RR 1.16, 95% CI 1.00-1.34). Slightly higher risks were seen for women assaulted as teenagers. Overall, we did not observe differences between the groups regarding the risk of elective cesarean section (RR 0.86, 95% CI 0.61-1.21), except for a reduced risk among those assaulted as teenagers (RR 0.56, 95% CI 0.34-0.93). Adjusting for maternal smoking and BMI in a sub-sample did not substantially affect point estimates. CONCLUSION: Our prospective data suggest that women with a history of sexual assault, particularly as teenagers, are at increased risks of some adverse obstetric outcomes. 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.

Background : The prevalence of smoking during pregnancy in Western societies has decreased in the last decades, whereas prevalence of overweight and obesity has increased. Our objective was to study secular trends and patterns of smoking and body weight among pregnant women in Iceland, during a period of dramatic changes in the nation’s economy. Methods : On the basis of the Medical Birth Registry, we used a random sample of 1329 births between 1 January 2001 and 31 December 2010. Information on smoking, body mass index and background factors during pregnancy was retrieved from the Medical Birth Register and maternity records. Trends in smoking, overweight, obesity and body mass index were assessed using logistic and linear regression analyses. Logistic regression analysis was used to examine the annual odds of smoking and obesity and by socio-demographic characteristics. Results : We found a decrease in the prevalence of continued smoking during pregnancy from 12.4% in 2001 to 7.9% in 2010 [odds ratio (OR) = 0.94, 95% confidence interval (CI) (0.88–1.00)], particularly among women with Icelandic citizenship [OR = 0.92, 95% CI (0.86–0.98)], whereas no changes in obesity [OR = 1.02, 95% CI (0.96–1.07)] were observed. The highest prevalence of maternal smoking and obesity was observed in 2005–06. Conclusion : Our results indicate that smoking during pregnancy decreased among Icelandic women in 2001–10, whereas an initial increase in obesity prevalence seemed to level off towards the end of the observation period. Interestingly, we found that both of these maternal risk factors reached their highest prevalence in 2005–06, which coincides with a flourishing period in the nation’s economy.

Background Data on the potential influence of macroeconomic recessions on maternal diseases during pregnancy are scarce. We aimed to assess potential change in prevalence of pregnancy-induced hypertensive disorders (preeclampsia and gestational hypertension) during the first years of the major national economic recession in Iceland, which started abruptly in October 2008. Methods and Findings Women whose pregnancies resulted in live singleton births in Iceland in 2005–2012 constituted the study population (N = 35,211). Data on pregnancy-induced hypertensive disorders were obtained from the Icelandic Medical Birth Register and use of antihypertensive drugs during pregnancy, including β-blockers and calcium channel blockers, from the Icelandic Medicines Register. With the pre-collapse period as reference, we used logistic regression analysis to assess change in pregnancy-induced hypertensive disorders and use of antihypertensives during the first four years after the economic collapse, adjusting for demographic and pregnancy characteristics, taking aggregate economic indicators into account. Compared with the pre-collapse period, we observed an increased prevalence of gestational hypertension in the first year following the economic collapse (2.4% vs. 3.9%; adjusted odds ratio [aOR] 1.47; 95 percent confidence interval [95%CI] 1.13–1.91) but not in the subsequent years. The association disappeared completely when we adjusted for aggregate unemployment rate (aOR 1.04; 95% CI 0.74–1.47). Similarly, there was an increase in prescription fills of β-blockers in the first year following the collapse (1.9% vs.3.1%; aOR 1.43; 95% CI 1.07–1.90), which disappeared after adjusting for aggregate unemployment rate (aOR 1.05; 95% CI 0.72–1.54). No changes were observed for preeclampsia or use of calcium channel blockers between the pre- and post-collapse periods. Conclusions Our data suggest a transient increased risk of gestational hypertension and use of β-blockers among pregnant women in Iceland in the first and most severe year of the national economic recession.

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.

OBJECTIVES: The study aimed to determine whether exposure to a volcanic eruption was associated with increased prevalence of physical and/or mental symptoms. DESIGN: Cohort, with non-exposed control group. SETTING: Natural disasters like volcanic eruptions constitute a major public-health threat. The Icelandic volcano Eyjafjallajökull exposed residents in southern Iceland to continuous ash fall for more than 5 weeks in spring 2010. This study was conducted during November 2010-March 2011, 6-9 months after the Eyjafjallajökull eruption. PARTICIPANTS: Adult (18-80 years of age) eruption-exposed South Icelanders (N=1148) and a control population of residents of Skagafjörður, North Iceland (N=510). The participation rate was 72%. MAIN OUTCOME MEASURES: Physical symptoms in the previous year (chronic), in the previous month (recent), General Health Questionnaire (GHQ-12) measured psychological morbidity. RESULTS: The likelihood of having symptoms during the last month was higher in the exposed population, such as; tightness in the chest (OR 2.5; 95% CI 1.1 to 5.8), cough (OR 2.6; 95% CI 1.7 to 3.9), phlegm (OR 2.1; 95% CI 1.3 to 3.2), eye irritation (OR 2.9; 95% CI 2.0 to 4.1) and psychological morbidity symptoms (OR 1.3; 95% CI 1.0 to 1.7). Respiratory symptoms during the last 12 months were also more common in the exposed population; cough (OR 2.2; 95% CI 1.6 to 2.9), dyspnoea (OR 1.6; 95% CI 1.1 to 2.3), although the prevalence of underlying asthma and heart disease was similar. Twice as many in the exposed population had two or more symptoms from nose, eyes or upper-respiratory tract (24% vs 13%, p

Objective: To examine the associations between the 2008 economic collapse in Iceland and smoking behaviour at the national and individual levels. Design: A population-based, prospective cohort study based on a mail survey (Health and Wellbeing in Iceland) assessed in 2007 and 2009. Setting: National mail survey. Participants: Representative cohort (n=3755) of Icelandic adults. Main outcome measure: Smoking status. Results: A significant reduction in the prevalence of smoking was observed from 2007 (pre-economic collapse) to 2009 (postcollapse) in both males (17.4–14.8%; p 0.01) and females (20.0–17.5%; p 0.01) in the cohort (n=3755). At the individual level of analysis, male former smokers experiencing a reduction in income during the same period were less likely to relapse (OR 0.37; 95% CI 0.16 to 0.85). Female smokers were less likely to quit over time compared to males (OR 0.65; 95% CI 0.45 to 0.93). Among male former smokers who experienced an increase in income between 2007 and 2009, we observed an elevated risk of smoking relapse (OR 4.02; 95% CI 1.15 to 14.00). Conclusions: The national prevalence of smoking in Iceland declined following the 2008 economic crisis. This could be due to the procyclical relationship between macro-economic conditions and smoking behaviour (ie, hard times lead to less smoking because of lower affordability), or it may simply reflect a continuation of trends already in place prior to the crisis. In individual-level analysis, we find that former smokers who experienced a decline in income were less likely to relapse; and conversely, an increase in income raises the risk. However, caution is warranted since these findings are based on small numbers.

Objective To estimate physical and mental health effects of the Eyjafjallajökull volcanic eruption on nearby residents. Design Cross-sectional study. Setting The Icelandic volcano Eyjafjallajökull erupted on 14 April 2010. The eruption lasted for about 6 weeks and was explosive, ejecting some 8 million tons of fine particles into the atmosphere. Due to prevailing winds, the ash spread mostly to the south and south-east, first over the rural region to the south, later over the Atlantic Ocean and Europe, closing European air space for several days. Participants Residents (n=207) of the most ash-exposed rural area south and east of the volcano. Methods The study period was from 31 May to 11 June 2010. Participants were examined by a physician. To ascertain respiratory health, standardised spirometry was performed before and after the use of a bronchodilator. All adult participants answered questionnaires about mental and physical health, their children's health and the use of protective equipment. Results Every other adult participant reported irritation in eyes and upper airway when exposed to volcanic ash. Adults (n=26) and children (n=5) with pre-existing asthma frequently reported worsening of their symptoms. No serious health problems requiring hospitalisation could be attributed to the eruption. The majority of the participants reported no abnormal physical or mental symptoms to the examining physician. Compared to an age- and gender-matched reference group, the ash-exposed participants reported lower smoking rates and were less likely to have ventilation impairment. Less than 10% of the participants reported symptoms of stress, anxiety or depression. Conclusions Short-term ash exposure was associated with upper airway irritation symptoms and exacerbation of pre-existing asthma but did not contribute to serious health problems. The exposure did not impair respiratory function compared to controls. Outdoor use of protective glasses and face masks was considered protective against irritation in eyes and upper airway., Article summary Article focus Exposure to volcanic ash and gases can have adverse effects on respiratory health. Natural hazards, such as volcanic eruptions, can be stressful events. Value of preventive measures for those exposed to a volcanic eruption. Key messages The short-term effects of ash exposure were associated with irritation in eyes and upper airway and exacerbation of pre-existing asthma but did not contribute to serious health problems or impair respiratory function as compared to controls. Participants with pre-existing respiratory and mental conditions need special attention and are more prone to developing symptoms following exposure to volcanic eruptions and volcanic ash. The use protective glasses and face masks prevented or relieved irritation symptoms from the eyes and upper airway. Strengths and limitations of this study The whole population living within a confined area close to the volcano was contacted, and the response rate was high (93%) minimising the risk of selection bias, though some sensitive individuals had probably left the area, and some older individuals did not participate in the survey. Standardised methods were used in measuring respiratory function, and questionnaires were also standardised, allowing for comparisons with other studies. Results from the spirometry were compared to those from an age- and gender-matched Icelandic control group from a previous study, which had been performed using identical methods. The population was small (N=207), and due to stressful circumstances during the test period, not all participants completed the questionnaire, which limited the statistical power of our analyses.

Objective 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. Method 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. Results 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). Conclusions 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. Copyright © 2011 John Wiley & Sons, Ltd.

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.

ObjectiveTo test if patients recovering from COVID-19 are at increased risk of mental morbidities and to what extent such risk is exacerbated by illness severity.DesignPopulation-based cross-sectional study.SettingIceland.ParticipantsA total of 22 861 individuals were recruited through invitations to existing nationwide cohorts and a social media campaign from 24 April to 22 July 2020, of which 373 were patients recovering from COVID-19.Main outcome measuresSymptoms of depression (Patient Health Questionnaire), anxiety (General Anxiety Disorder Scale) and posttraumatic stress disorder (PTSD; modified Primary Care PTSD Screen for DSM-5) above screening thresholds. Adjusting for multiple covariates and comorbidities, multivariable Poisson regression was used to assess the association between COVID-19 severity and mental morbidities.ResultsCompared with individuals without a diagnosis of COVID-19, patients recovering from COVID-19 had increased risk of depression (22.1% vs 16.2%; adjusted relative risk (aRR) 1.48, 95% CI 1.20 to 1.82) and PTSD (19.5% vs 15.6%; aRR 1.38, 95% CI 1.09 to 1.75) but not anxiety (13.1% vs 11.3%; aRR 1.24, 95% CI 0.93 to 1.64). Elevated relative risks were limited to patients recovering from COVID-19 that were 40 years or older and were particularly high among individuals with university education. Among patients recovering from COVID-19, symptoms of depression were particularly common among those in the highest, compared with the lowest tertile of influenza-like symptom burden (47.1% vs 5.8%; aRR 6.42, 95% CI 2.77 to 14.87), among patients confined to bed for 7 days or longer compared with those never confined to bed (33.3% vs 10.9%; aRR 3.67, 95% CI 1.97 to 6.86) and among patients hospitalised for COVID-19 compared with those never admitted to hospital (48.1% vs 19.9%; aRR 2.72, 95% CI 1.67 to 4.44).ConclusionsSevere disease course is associated with increased risk of depression and PTSD among patients recovering from COVID-19.