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BackgroundPersistence of physical symptoms after SARS-CoV-2 infection is a major public health concern, although evidence from large observational studies remain scarce. We aimed to assess the prevalence of physical symptoms in relation to acute illness severity up to more than 2-years after diagnosis of COVID-19.MethodsThis multinational study included 64 880 adult participants from Iceland, Sweden, Denmark, and Norway with self-reported data on COVID-19 and physical symptoms from April 2020 to August 2022. We compared the prevalence of 15 physical symptoms, measured by the Patient Health Questionnaire (PHQ-15), among individuals with or without a confirmed COVID-19 diagnosis, by acute illness severity, and by time since diagnosis. We additionally assessed the change in symptoms in a subset of Swedish adults with repeated measures, before and after COVID-19 diagnosis.FindingsDuring up to 27 months of follow-up, 22 382 participants (34.5%) were diagnosed with COVID-19. Individuals who were diagnosed with COVID-19, compared to those not diagnosed, had an overall 37% higher prevalence of severe physical symptom burden (PHQ-15 score ≥ 15, adjusted prevalence ratio [PR] 1.37 [95% confidence interval [CI] 1.23-1.52]). The prevalence was associated with acute COVID-19 severity: individuals bedridden for seven days or longer presented with the highest prevalence (PR 2.25[1.85-2.74]), while individuals never bedridden presented with similar prevalence as individuals not diagnosed with COVID-19 (PR 0.92 [0.68-1.24]). The prevalence was statistically significantly elevated among individuals diagnosed with COVID-19 for eight of the fifteen measured symptoms: shortness of breath, chest pain, dizziness, heart racing, headaches, low energy/fatigue, trouble sleeping, and back pain. The analysis of repeated measurements rendered similar results as the main analysis.InterpretationThese data suggest an elevated prevalence of some, but not all, physical symptoms during up to more than 2 years after diagnosis of COVID-19, particularly among individuals suffering a severe acute illness.FundingThis work was mainly supported by grants from NordForsk (COVIDMENT, grant number 105668 and 138929) and Horizon2020 (CoMorMent, 847776). See Acknowledgements for further details on funding.Research in contextEvidence before the studyAs the majority of the global population has contracted COVID-19, persistence of physical symptoms after SARS-CoV-2 infection (LongCOVID or post COVID-19 condition) has become a major public health concern. We searched PubMed for studies assessing physical symptoms after COVID-19, published by March 22, 2023. The search term was (physical symptoms after covid) AND LitCLONGCOVID [Pubmed filter]. We reviewed 82 studies, after excluding those not on humans or not published in English. High prevalence of multiple physical symptoms, mainly fatigue, shortness of breath, headache, muscle and chest pain, has been reported, mostly based on small samples of hospitalized patients confined to three to six months after diagnosis. A comprehensive assessment of long-term prevalence of physical symptoms beyond six months after diagnosis and among non-hospitalized patients is lacking.Added value of this studyWe included 64 880 participants from the general population of four Nordic countries, of whom 22 382 had been diagnosed with COVID-19 up to 2 years earlier (Implications of the available evidenceOur findings provide timely and valuable evidence to demonstrate the constitution of Long COVID and the long-term health consequences after recovery from COVID-19 in the general population. The long-term risk of severe physical symptom burden is distinctly associated with acute illness severity, highlighting the importance of sustained monitoring of physical symptoms among the group of patients who suffered severe acute illness course.

BackgroundLittle is known regarding the mental health impact of having a significant person (family member and/or close friend) with COVID-19 of different severity.MethodsThe study included five prospective cohorts from four countries (Iceland, Norway, Sweden, and the UK) with self-reported data on COVID-19 and symptoms of depression and anxiety during March 2020-March 2022. We calculated the prevalence ratio (PR) of depression and anxiety in relation to having a significant person with COVID-19 and performed a longitudinal analysis in the Swedish cohort to describe the temporal patterns of the results.Results162,237 and 168,783 individuals were included in the analysis of depression and anxiety, respectively, of whom 24,718 and 27,003 reported a significant person with COVID-19. Overall, the PR was 1.07 (95% CI: 1.05-1.10) for depression and 1.08 (95% CI: 1.03-1.13) for anxiety among significant others of COVID-19 patients. The respective PRs for depression and anxiety were 1.04 (95% CI: 1.01-1.07) and 1.03 (95% CI: 0.98-1.07) if the significant person was never hospitalized, 1.15 (95% CI: 1.08-1.23) and 1.24 (95% CI: 1.14-1.34) if the patient was hospitalized, 1.42 (95% CI: 1.27-1.57) and 1.45 (95% CI: 1.31-1.60) if admitted to the ICU, and 1.34 (95% CI: 1.22-1.46) and 1.36 (95% CI: 1.22-1.51) if the significant person died. Individuals of hospitalized, ICU admitted, or deceased patients showed higher prevalence of depression and anxiety during the entire 12 months after the COVID-19 diagnosis of the significant person.ConclusionsClose friends and family members of critically ill COVID-19 patients show elevated prevalence of depression and anxiety throughout the first year after the diagnosis.

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.

Hair analysis of endocannabinoids and N-acylethanolamines has emerged as a promising methodological advancement for the retrospective assessment of cumulative long-term endocannabinoids and N-acylethanolamines secretion in biopsychological research of stress-related symptoms and disorders. In this study, we investigated the influence of the potential associated factors on hair endocannabinoid and N-acylethanolamine levels in 760 adult participants aged between 21 and 86 years old. Gender, age, medication intake, drug use, body mass index, waist circumference, smoking status, alcohol consumption and perceived stress were assessed through questionnaires. Hair endocannabinoid and N-acylethanolamine concentrations were measured through liquid chromatography coupled to tandem mass-spectrometry. Results identified that gender, age, BMI, waist circumference, medication and drug use, hair washing frequency as potential confounding variables of hair endocannabinoid and N-acylethanolamine levels, while no associations were observed with respect to hair dyeing, smoking status, alcohol consumption and perceived stress. The present data indicate that hair endocannabinoids and N-acylethanolamines measurement may be a useful alternative to the current circulating endocannabinoids measurements in biopsychological research with the consideration of possible confounders.

Objectives The objective of this study was to evaluate any association between culture site / culture result / pathogen and incident PsA or psoriasis. Methods Records of all samples sent for culture from a large population during a 3-year period were linked with nationwide registry data on diagnoses and death over a 15-year period. The main outcomes of interest were incident diagnoses of PsA and psoriasis, defined by International Classification of Diseases (ICD) codes. The effect of culture site, culture result (positive vs negative), and pathogen (Streptococcus vs negative culture) on the risk of developing PsA and psoriasis was calculated using Cox proportional hazards models adjusted for age and gender. Results A total of 313 235 bacterial cultures from 128 982 individuals were analysed. Comparing individuals with pharyngeal cultures to those with urine cultures, the hazard ratio for incident PsA was 8.78 [95% confidence interval (CI) 3.23, 23.91] and for incident psoriasis it was 8.00 (95% CI 5.28, 12.12). Most of the risk was concentrated in the first 50 days after the culture date. Increased risk was also found when comparing individuals with cultures from the pharynx with those with cultures from the nasopharynx and blood. An association with streptococci was not found, neither in the pharynx nor at any other site. A positive bacterial culture from any site was associated with reduced risk for both PsA and psoriasis. Conclusion There is a strong site-specific association between pharyngeal culture samples and an increased risk of PsA and psoriasis, regardless of the pathogen. This may indicate that the site of infection, rather than the pathogen, is associated with increased risk.

Study Objectives To date, few studies have assessed sleep problems among women residing in Subarctic regions. Therefore, the aim of this large-scale population-based study was to assess the prevalence of severe sleep problems and associated factors among Icelandic women, living at 63–66°N. Methods Participants were 29 681 women (18–69 years old) who took part in the Icelandic Stress-And-Gene-Analysis study in 2018–2019. Background information, health-related behavior, and mental health symptoms were assessed with an online questionnaire. The Pittsburgh Sleep Quality Index (PSQI) was used to assess severe sleep problems during the past month. Adjusting for age, marital status, number of children, education, personal income, work schedule, region, and response period, we used modified Poisson log-linear models to obtain prevalence ratios (PRs) with 95% confidence intervals (CIs). Results Overall, 24.2% of women reported severe sleep problems (PSQI >10). Women responding in the winter presented with an overall higher prevalence of severe sleep problems, compared to those responding in the summer (PR 1.21; 95% CI, 1.15 to 1.28). Severe sleep problems were more prevalent among young and late-midlife women, those who were single, had children, socio-economic challenges, worked shifts, and flexible hours. Furthermore, obesity, suboptimal health behaviors, excessive screen time, and mental health problems were associated with severe sleep problems. Conclusion Severe sleep problems are more common among women in Subarctic regions than elsewhere, particularly during winter. These findings motivate the development of preventive strategies and interventions for women in the Subarctic who suffer from sleep problems.

BACKGROUNDThe aim of this multinational study was to assess the development of adverse mental health symptoms among individuals diagnosed with COVID-19 in the general population by acute infection severity up to 16 months after diagnosis.METHODSParticipants consisted of 247 249 individuals from seven cohorts across six countries (Denmark, Estonia, Iceland, Norway, Scotland, and Sweden) recruited from April 2020 through August 2021. We used multivariable Poisson regression to contrast symptom-prevalence of depression, anxiety, COVID-19 related distress, and poor sleep quality among individuals with and without a diagnosis of COVID-19 at entry to respective cohorts by time (0-16 months) from diagnosis. We also applied generalised estimating equations (GEE) analysis to test differences in repeated measures of mental health symptoms before and after COVID-19 diagnosis among individuals ever diagnosed with COVID-19 over time.FINDINGSA total of 9979 individuals (4%) were diagnosed with COVID-19 during the study period and presented overall with a higher symptom burden of depression (prevalence ratio [PR] 1·18, 95% confidence interval [95% CI] 1·03-1·36) and poorer sleep quality (1·13, 1·03-1·24) but not with higher levels of symptoms of anxiety or COVID-19 related distress compared with individuals without a COVID-19 diagnosis. While the prevalence of depression and COVID-19 related distress attenuated with time, the trajectories varied significantly by COVID-19 acute infection severity. Individuals diagnosed with COVID-19 but never bedridden due to their illness were consistently at lower risks of depression and anxiety (PR 0·83, 95% CI 0·75-0·91 and 0·77, 0·63-0·94, respectively), while patients bedridden for more than 7 days were persistently at higher risks of symptoms of depression and anxiety (PR 1·61, 95% CI 1·27-2·05 and 1·43, 1·26-1·63, respectively) throughout the 16-month study period.CONCLUSIONAcute infection severity is a key determinant of long-term mental morbidity among COVID-19 patients.

Key features • COVIDMENT [www.covidment.is] is a NordForsk-funded research collaboration across six nations, with the overarching aim to significantly advance current knowledge on mental morbidity trajectories associated with the coronavirus disease 2019 (COVID-19) in the general population and in specific risk groups. • From March 2020 through August 2021, 392 817 individuals have been recruited to the seven COVIDMENT cohorts: the Danish Blood Donor Study (N ¼ 71 562), the Estonian Biobank COVID-19 and Mental Health Data Collection cohorts (N ¼ 13 329 and N ¼ 86 116, respectively), the Icelandic COVID-19 National Resilience Cohort (N ¼ 22 849), the Norwegian BRY.DEG2020 (N ¼ 19 343), the Norwegian Mother, Father and Child Cohort Study (N ¼ 132 486), the Scottish Generation Scotland/CovidLife (N ¼ 18 518) and the Swedish Omtanke2020 (N ¼ 28 614). Semi-harmonized questionnaire data have been collected across all COVIDMENT cohorts with longitudinal data available, e.g. through linkage to the national registers. • The average age of participants ranged from 31.8 to 58.5 years across cohorts. The prevalence of depressive symptoms above cut-off point varied considerably across cohorts (4.2–20.8%). The prevalence of depressive symptoms was highest at COVID-19 incidence of 30 cases per week per 100 000 persons, i.e. 14.3% [95% confidence interval (CI): 9.4–21.8%], which was 61.0% (95% CI: 34.0–94.1%) higher than the prevalence at COVID-19 incidence of 0 cases per week per 100 000 persons (P ¼ 1.1 x 10 ^( 6)). •

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.

ObjectivesTo assess the trends in medication use indicative of physical and psychological morbidity following the 2010 volcanic eruption in Eyjafjallajökull immediately after and during a 3-year period following the eruption.DesignPopulation-based register study.SettingEyjafjallajökull eruption in Iceland, 2007–2013.ParticipantsAll residents in Iceland who received at least one medication dispensing were identified. Residents of exposed areas were classified into exposure groups (individual-level data) and residents in other parts of Iceland were included as a non-exposed group (aggregated data).Intervention/exposureEyjafjallajökull erupted on 14 April 2010 and continued for 39 days, producing heavy ash fall in South Iceland.Main outcome measuresUsing interrupted time series analysis, we examined annual and quarterly changes in medicine use, measured as number of dispensed defined daily dose (DDD) per 1000 individuals. We calculated the level shift (immediate change) and change in slope from pre-eruption to post-eruption (long-term change) in medication dispensing.ResultsAmong exposed residents, there was a 6% decrease (95% CI -7% to -4%) in the annual number of dispensed DDDs 1-year post-eruption in the overall medication class, including analgesics (−5%, 95% CI -6% to -3%), hypnotics and sedatives (−9%, 95% CI -11% to -7%) and respiratory medications (−7%, 95% CI -9% to -5%; −8%, 95% CI -11% to -4%). Simultaneously, there was a 9% decrease (95% CI -14% to -4%) in the overall medication class among non-exposed residents. Moreover, among exposed residents, we observed change in slope of −4% (95% CI -7% to -1%) in the overall medication class, including for analgesics (−6%, 95% CI -8% to -3%) and other respiratory drugs (−10%, 95% CI -16% to -4%).ConclusionOur findings indicate that the eruption did not lead to increases in medication dispensing among residents of exposed areas, rather decreases for some medicine classes. The results should be interpreted with caution since the content of each eruption differs.

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.

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: 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.

Macroeconomic downturns have been associated with a decrease in happiness among adults. The aim of this study was to explore the secular trend in happiness among Icelandic adolescents during a period of drastic change in the national economy as well as to identify which groups were most vulnerable and most resilient during the economic crisis. The data used in this study comes from series of population-based surveys of Icelandic adolescents in 2000, 2006, 2009, and 2010. Altogether, a total of 28.484 adolescents participated in the four surveys, representing 84 % of all 14–15 year old adolescents in Iceland. Results indicated that happiness increased by 5 % in the adolescent population from 2000 to 2010 despite the economic crisis. Nevertheless, adolescents who seldom spent time with their parents or perceived difficulties in getting emotional support from parents demonstrated a decrease in happiness. Those who found it easy to get emotional support from parents were happiest at every time point (91–93 %) while those who found it difficult were unhappiest (36–50 %). The association between socio- demographic factors and happiness was explored using multiple linear regression analyses where the year of survey, gender, age, family structure, parent’s education, time spent with parents and emotional support from parents altogether explained 13 % of the happiness variance. Emotional support from parents together with time spent with parents had the largest influence on adolescent’s happiness. An overall increase in time spent with parents was detected which might explain the increase in adolescents´ happiness over time. These results indicate that good relations with parents may protect adolescents from possible negative effect of a national economic crisis.

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.