Preschool-level socio-economic deprivation in relation to emotional and behavioural problems among preschool children in Sweden.

AIMS: The aim of this study was to explore the association between preschool-level socio-economic deprivation and emotional and behavioural problems among preschool children in Sweden using a multilevel approach. METHODS: In this cross-sectional study, we used data on 2267 children whose parents and preschool teachers had responded to items measuring individual-level socio-economic deprivation and the Strengths and Difficulties Questionnaire (SDQ) for assessment of emotional and behavioural problems. Further, the Socioeconomic Structure Compensation Index (SSCI), collected from Uppsala municipality, was used to assess preschool-level socio-economic deprivation. Unadjusted and adjusted multilevel logistic regression models were used to explore the relations between preschool-level socio-economic deprivation and emotional and behavioural problems. RESULTS: In unadjusted models, children who attended preschools classified as highly deprived had elevated odds for emotional symptoms (odds ratio (OR) 1.71) as rated by parents. However, this association did not remain significant after adjusting for individual-level socio-economic deprivation factors. In both unadjusted and adjusted models, children who attended preschools classified as moderately deprived had elevated odds for peer-relationship problems as rated by parents (OR 1.63; adjusted OR 1.48). There were no significant associations between preschool deprivation and emotional and behavioural problems as rated by preschool teachers. CONCLUSIONS: Swedish preschools may have a compensatory capacity in addressing children's emotional and behavioural problems, whereas preschool-level deprivation remained significantly associated with peer-relationship problems after controlling for individual-level socio-economic deprivation factors. This implies that peer-relationship problems in deprived preschools need to be addressed in a broader community context.

Eliciting a value set for the Swedish Capability-Adjusted Life Years instrument (CALY-SWE).

PURPOSE: Our aim was to elicit a value set for Capability-Adjusted Life Years Sweden (CALY-SWE); a capability-grounded quality of life instrument intended for use in economic evaluations of social interventions with broad consequences beyond health. METHODS: Building on methods commonly used in the quality-adjusted life years EQ-5D context, we collected time-trade off (TTO) and discrete choice experiment (DCE) data through an online survey from a general population sample of 1697 Swedish participants. We assessed data quality using a score based on the severity of inconsistencies. For generating the value set, we compared different model features, including hybrid modeling of DCE and TTO versus TTO data only, censoring of TTO answers, varying intercept, and accommodating for heteroskedasticity. We also assessed the models' DCE logit fidelity to measure agreement with potentially less-biased DCE data. To anchor the best capability state to 1 on the 0 to 1 scale, we included a multiplicative scaling factor. RESULTS: We excluded 20% of the TTO answers of participants with the largest inconsistencies to improve data quality. A hybrid model with an anchor scale and censoring was chosen to generate the value set; models with heteroskedasticity considerations or individually varying intercepts did not offer substantial improvement. The lowest capability weight was 0.114. Health, social relations, and finance and housing attributes contributed the largest capability gains, followed by occupation, security, and political and civil rights. CONCLUSION: We elicited a value set for CALY-SWE for use in economic evaluations of interventions with broad social consequences.

Impact of developmental coordination disorder in childhood on educational outcomes in adulthood among neonatal intensive care recipients: a register-based longitudinal cohort study.

OBJECTIVES: Developmental coordination disorder (DCD) is related to poorer educational outcomes among children and adolescents. Evidence on this association into adulthood is lacking. Therefore, we aimed to investigate whether probable DCD (pDCD) in childhood affected educational outcomes among adults, and whether this was affected by sex or a co-occurring attention deficit in childhood. DESIGN: Register-based longitudinal cohort study. SETTING: Neonatal intensive care (NIC) recipients born at Uppsala University Children's Hospital, Uppsala, Sweden, from 1986 to 1989 until they reached the age of 28. PARTICIPANTS: 185 NIC recipients. PRIMARY AND SECONDARY OUTCOME MEASURES: At the age of 6.5, 46 (24.6%) of the NIC recipients were diagnosed with pDCD. Using register-based longitudinal data, we compared participants with and without pDCD in terms of: (1) age at Upper Secondary School (USS) graduation, and (2) highest level of education achieved by age 28. RESULTS: The median age at USS graduation was 19 years, with similar graduation ages and ranges between those with or without pDCD. However, a higher proportion of participants without pDCD had graduated from USS at ages 19 and 24. By age 29, most participants had completed USS. At age 28, 33% of participants had attained a bachelor's or master's degree. Although there was no significant difference between the groups, the proportion that had attained a degree was higher among those without pDCD and women without pDCD had achieved the highest level of education. Educational outcomes remained similar for those with pDCD, regardless of childhood attention deficit. CONCLUSIONS: pDCD during childhood may have a lasting impact on educational outcomes, particularly among women. Raising awareness of DCD among parents, health and educational professionals is vital for early identification and the provision of appropriate support and interventions in schools, mitigating the potential negative consequences associated with DCD and promoting positive educational outcomes.

Economic evaluation of telemonitoring as a follow-up approach for patients with obstructive sleep apnea syndrome starting treatment with continuous positive airway pressure.

Telemonitoring of obstructive sleep apnea patients is increasingly being adopted though its cost-effectiveness evidence base is scanty. This study investigated whether telemonitoring is a cost-effective strategy compared with the standard follow-up in patients with obstructive sleep apnea who are starting continuous positive airway pressure treatment. In total, 167 obstructive sleep apnea patients were randomised into telemonitoring (n = 79) or standard follow-up (n = 88), initiated continuous positive airway pressure treatment, and were followed up for 6 months. The frequencies of healthcare contacts, related costs (in USD 2021 prices), treatment effect and compliance were compared between the follow-up approaches using generalised linear models. The cost effectiveness analysis was conducted from a healthcare perspective and the results presented as cost per avoided extra clinic visit. Additionally, patient satisfaction between the two approaches was explored. The analysis showed no baseline differences. At follow-up, there was no significant difference in treatment compliance, and the mean residual apnea-hypoapnea index. There was no difference in total visits, adjusted incidence rate ratio 0.87 (0.72-1.06). Participants in the telemonitoring arm made eight times more telephone visits, 8.10 (5.04-13.84), and about 73% fewer physical healthcare visits 0.27 (0.20-0.36). This translated into significantly lower total costs for the telemonitoring approach compared with standard follow-up, -192 USD (-346 to -41). The form of follow-up seemed to have no impact on the extent of patient satisfaction. These results demonstrate the telemonitoring of patients with obstructive sleep apnea initiating continuous positive airway pressure treatment as a cost saving strategy and can be argued as a potential worthy investment.

Health and economic outcomes of a universal early intervention for parents and children from birth to age five: evaluation of the Salut Programme using a natural experiment.

BACKGROUND: The aim of this study was to investigate the health and economic outcomes of a universal early intervention for parents and children, the Salut Programme, from birth to when the child completed five years of age. METHODS: This study adopted a retrospective observational design using routinely collected linked register data with respect to both exposures and outcomes from Västerbotten county, in northern Sweden. Making use of a natural experiment, areas that received care-as-usual (non-Salut area) were compared to areas where the Programme was implemented after 2006 (Salut area) in terms of: (i) health outcomes, healthcare resource use and costs around pregnancy, delivery and birth, and (ii) healthcare resource use and related costs, as well as costs of care of sick child. We estimated total cumulative costs related to inpatient and specialised outpatient care for mothers and children, and financial benefits paid to mothers to stay home from work to care for a sick child. Two analyses were conducted: a matched difference-in difference analysis using the total sample and an analysis including a longitudinal subsample. RESULTS: The longitudinal analysis on mothers who gave birth in both pre- and post-measure periods showed that mothers exposed to the Programme had on average 6% (95% CI 3-9%) more full-term pregnancies and 2% (95% CI 0.03-3%) more babies with a birth weight ≥ 2500 g, compared to mothers who had care-as-usual. Savings were incurred in terms of outpatient care costs for children of mothers in the Salut area ($826). The difference-in-difference analysis using the total sample did not result in any significant differences in health outcomes or cumulative resource use over time. CONCLUSIONS: The Salut Programme achieved health gains, as a health promotion early intervention for children and parents, in terms of more full-term pregnancies and more babies with a birth weight ≥ 2500 g, at reasonable cost, and may lead to lower usage of outpatient care. Other indicators point towards positive effects, but the small sample size may have led to underestimation of true differences.

Introduction of specialized heart failure nurses in primary care and its impact on readmissions.

BACKGROUND: Heart failure (HF) has a 2% prevalence in the population and is a major cause of morbidity and mortality. Multiple efforts have been made worldwide to improve quality of care and decrease unplanned readmissions for HF patients, one of which has been the introduction of specialist HF nurses (HFN) in primary health care. The present evidence on the benefits of HFN is contradicting. This study aims to evaluate the impact of a quality improvement intervention, availability of a HFN in Swedish primary care, on hospital readmissions. METHODS: All patients over the age of 65 with a HF diagnosis and with complete information on availability of a HFN were included in this retrospective register-based study. Using propensity score matching (PSM) techniques, two comparable groups of 128 patients each were created according to the exposure status, availability or no availability of a HFN. The rate of readmission was compared between the groups. RESULTS: Using PSM, 256 patients were matched, 128 in the HFN group and 128 in the no-HFN group. A total of 50% and 46.09% of patients in the HFN and no-HFN groups were readmitted, respectively. Mean number of readmissions per patient was 1.19 (SD 0.61) in the HFN group and 1.10 (SD 0.44) in the no-HFN group. Patients in the HFN had 17.6% higher odds of being readmitted during the study period, OR: 1.176 (CI: 0.716-1.932), and 3.8% lower odds of being readmitted within 30 days, OR: 0.962 (CI: 0.528-1.750). CONCLUSIONS: Availability of a HFN in primary care was not significantly associated with reduced readmissions for the patients included in this study. Further investigations are warranted looking at the impacts of availability and access to a HFN in primary care on readmissions and other patient outcomes.

Association of adolescent depression with subsequent prescriptions of anti-infectives and anti-inflammatories in adulthood: A longitudinal cohort study.

New insights into how depression is linked to physical health throughout the lifespan could potentially inform clinical decision making. The aim of this study was to explore the association of adolescent depression with subsequent prescriptions of anti-infectives and anti-inflammatories in adulthood. The study was based on the Uppsala Longitudinal Adolescent Depression Study (ULADS), a Swedish prospective cohort study initiated in 1991. Depressed (n = 321) and non-depressed (n = 218) adolescents were followed prospectively using patient registries. The associations of adolescent depression (age 16-17 years) with subsequent prescription of anti-infectives and anti-inflammatories (age 30-40 years), were analysed using generalized linear models. Sub-analyses explored the impact of diagnostic characteristics in adolescence and reception of anti-depressants prescriptions in adulthood. The results suggest that females with persistent depressive disorder in adolescence have a higher rate of future prescriptions than non-depressed peers, with adjusted incidence rate ratio of 1.42 (1.06 to 1.92) for anti-infectives and 1.72 (1.10 to 2.70) for anti-inflammatories. These associations were mainly driven by those who were also prescribed antidepressants during the same period. Associations were less robust for females with episodic or subsyndromal depression in adolescence and for males. These findings emphasize the importance of integrated mental health services at the primary healthcare level.

Adolescent depression and adult labor market marginalization: a longitudinal cohort study.

Adolescent depression is linked to adult ill-health and functional impairment, but recent research suggests that individual/contextual factors might account for this association. This study aimed to test whether the clinical heterogeneity of adolescent depression is related to marginalization from the labor market across early to middle adulthood. Data were drawn from the Uppsala Longitudinal Adolescent Depression Study, a community-based cohort initially assessed with structured clinical interviews at age 16-17. The cohort (n = 321 depressed; n = 218 nondepressed) was followed up after 2+ decades through linkage to nationwide population-based registries. Outcomes included consecutive annual data on unemployment, work disability, social welfare recipiency, and a composite marginalization measure, spanning from age 21 to 40. Longitudinal associations were examined using logistic regression analysis in a generalized estimating equations modeling framework. Subsequent depressive episodes and educational attainment in early adulthood were explored as potential pathways. The results showed that adolescent depression was associated with adult marginalization outcomes, but the strength of association varied across depressed subgroups. Adolescents with persistent depressive disorder had higher odds of all outcomes, including the composite marginalization measure (adjusted OR = 2.0, 95% CI = 1.4-2.7, p < 0.001), and this was partially (31%) mediated by subsequent depressive episodes in early adulthood. Exploratory moderation analysis revealed that entry into tertiary education mitigated the association with later marginalization, but only for adolescents with episodic major depression. In conclusion, the risk for future labor market marginalization is elevated among depressed adolescents, particularly those presenting with persistent depressive disorder. Targeted interventions seem crucial to mitigate the long-lasting impact of early-onset depression.

A pilot study of the impact of an integrated individual- and family therapy model for self-harming adolescents on overall healthcare consumption.

BACKGROUND: Self-harming behaviors in adolescents cause great suffering and can lead to considerable costs to the healthcare system. The aim of the current study was to investigate the cost of an integrated individual and family therapy (Intensive Contextual Treatment: ICT) and to compare the adolescent's healthcare consumption 1 year before and 1 year after treatment. METHOD: The study had a within group design with repeated measures. The clinical outcomes and the cost of ICT treatment are based on a sample of 49 participants who were previously enrolled in an intervention trial. Participants with significantly improved clinical outcomes (self-harm behavior, or general mental health symptoms) were defined as treatment responders. Calculation of changes in healthcare consumption is based on 25 participants who gave their consent to participate in a retrospective collection of healthcare data from medical records, including inpatient and outpatient care, and prescribed medication. RESULTS: The average estimated cost of ICT per person was €5293. There were no significant differences between the cost of healthcare consumption 1 year before and after ICT, but the results suggested that the adolescents consumed less inpatient and specialized care after treatment. There was a significantly higher cost of psychotropic medication after treatment explained by a higher consumption of central stimulants. Treatment responders (general mental health problems) reduced their consumption of healthcare resources significantly more than non-responders, especially regarding hospital visits and total health care costs. CONCLUSIONS: Good response to the ICT in terms of improved general mental health symptoms seems to be associated with reduced healthcare consumption during the post-treatment period. However, controlled studies with larger sample sizes are needed to draw causal conclusions. The results of this study should be interpreted with caution as it is based on a small sample and attrition rate was high. TRIAL REGISTRATION: This study has been registered with the ISRCTN: 15885573 .

A model for evaluating the economic value of prevention programs for illicit use of anabolic androgenic steroids.

BACKGROUND: The illicit use of anabolic androgenic steroids (AAS) has become a societal concern. We developed a decision-analytic model for assessing the cost-effectiveness of preventive interventions targeting AAS-use. We used scenario analyses to demonstrate: a) the potential health economic consequences of AAS use in Sweden, and b) the cost-effectiveness of a hypothetical preventive intervention. METHODS: A population-based cohort model compared a hypothetical preventive intervention targeting AAS with a 'no intervention' scenario, from a limited societal perspective. The model simulated how a cohort of 18 year-old males transitioned between different states and predicted their health status and complications until the age of 41. Health outcomes were estimated as quality-adjusted life-years (QALY). Costs included intervention costs, drug costs, and costs of complications. RESULTS: Total yearly costs related to AAS use amounted to nearly half a million US$, with the largest cost borne by the healthcare sector. Results suggest that AAS prevention could entail large costs and benefits with a mean incremental cost-effectiveness ratio of $550 per QALY, in a scenario where the intervention would decrease the probability of initiating AAS use by 5%. CONCLUSION: Results show large AAS related costs, and suggest that the implementation of a preventive intervention could offer good value for money given different effectiveness scenarios. This model can be used to estimate the value of interventions targeting AAS use.

Adolescent depression, early psychiatric comorbidities, and adulthood welfare burden: a 25-year longitudinal cohort study.

PURPOSE: Depression at all ages is recognized as a global public health concern, but less is known about the welfare burden following early-life depression. This study aimed to (1) estimate the magnitude of associations between depression in adolescence and social transfer payments in adulthood; and (2) address the impact of major comorbid psychopathology on these associations. METHODS: This is a longitudinal cohort study of 539 participants assessed at age 16-17 using structured diagnostic interviews. An ongoing 25-year follow-up linked the cohort (n = 321 depressed; n = 218 nondepressed) to nationwide population-based registries. Outcomes included consecutive annual data on social transfer payments due to unemployment, work disability, and public assistance, spanning from age 18 to 40. Parameter estimations used the generalized estimating equations approach. RESULTS: Adolescent depression was associated with all forms of social transfer payments. The estimated overall payment per person and year was 938 USD (95% CI 551-1326) over and above the amount received by nondepressed controls. Persistent depressive disorder was associated with higher recipiency across all outcomes, whereas the pattern of findings was less clear for subthreshold and episodic major depression. Moreover, depressed adolescents presenting with comorbid anxiety and disruptive behavior disorders evidenced particularly high recipiency, exceeding the nondepressed controls with an estimated 1753 USD (95% CI 887-2620). CONCLUSION: Adolescent depression is associated with considerable public expenditures across early-to-middle adulthood, especially for those exposed to chronic/persistent depression and psychiatric comorbidities. This finding suggests that the clinical heterogeneity of early-life depression needs to be considered from a longer-term societal perspective.

A systematic review of economic evaluations of public health interventions targeting alcohol, tobacco, illicit drug use and problematic gambling: Using a case study to assess transferability.

AIMS: To identify and assess the cost-effectiveness of public health interventions targeting the use of alcohol, illicit drugs and tobacco, as well as problematic gambling behavior (ANDTS), and consider whether the results from these evaluations are transferable to the Swedish setting. METHODS: A systematic review of economic evaluations within the area of ANDTS was conducted including studies published between January 2000 and November 2018, identified through Medline, PsychINFO, Web of Science, the National Health Service Economic Evaluation Database and Health Technology Assessment. The quality of relevant studies and the possibilities of transferring results were assessed using criteria set out by the Swedish Agency for Health Technology Assessment. RESULTS: Out of 54 relevant studies, 39 were of moderate to high quality and included in the review, however none for problematic gambling. Eighty-one out of a total of 91 interventions were cost-effective. The interventions largely focusing on taxed-based policies or screening and brief interventions. Thirteen of these studies were deemed to have high potential for transferability, with effect estimates considered relevant, and with good feasibility for implementation in Sweden. CONCLUSIONS: Interventions targeting alcohol- and illicit-drug use and tobacco use are cost-effective approaches, and results may be transferred to the Swedish setting. Caution must be taken regarding cost estimates and the quality of the evidence which the studies are based upon.

Economic Evaluations of Public Health Interventions to Improve Mental Health and Prevent Suicidal Thoughts and Behaviours: A Systematic Literature Review.

To review the literature on economic evaluations of public health interventions targeting prevention of mental health problems and suicide, to support evidence based societal resource allocation. A systematic review of economic evaluations within mental health and suicide prevention was conducted including studies published between January 2000 and November 2018. The studies were identified through Medline, PsychINFO, Web of Science, the National Health Service Economic Evaluation Database and Health Technology Assessment. The quality of relevant studies and the transferability of their results were assessed using a criterion set out by the Swedish Agency for Health Technology Assessment. Nineteen studies of moderate to high quality were included in this review, which evaluated 18 interventions in mental health and four interventions in suicide prevention. Fourteen (63%) of all interventions were cost-effective based on the conclusions from original papers. None of the studies that evaluated suicide prevention was of high quality. The interventions largely focused on psychological interventions at school, the workplace and within elderly care as well as screening and brief interventions in primary care. Nine studies (around 50% of included articles) had a high potential for transferability to the Swedish context. Public health interventions aiming to improve mental health have a high potential to be economically beneficial to society, but high-quality evidence on the cost-effectiveness of suicide prevention is limited.

Cost-effectiveness of an indicated preventive intervention for depression in adolescents: a model to support decision making.

BACKGROUND: Adolescent depression has negative health and economic outcomes in the short- and long-term. Indicated preventive interventions, in particular group based cognitive behavioural therapy (GB-CBT), are effective in preventing depression in adolescents with subsyndromal depression. However, little is known about the cost-effectiveness of these interventions. METHODS: A Markov cohort model was used to conduct cost-effectiveness analyses comparing a GB-CBT indicated preventive intervention for depression, to a no-intervention option in a Swedish setting. Taking a time horizon of 5- and 10 years, incremental differences in societal costs and health benefits expressed as differences in the proportion of cases of depression prevented, and as quality adjusted life years (QALYs) gained were estimated. Through univariate and probabilistic sensitivity analyses, the robustness of the results was explored. Costs, presented in 2018 USD, and effects were discounted at a yearly rate of 3%. RESULTS: The base-case analysis showed that GB-CBT indicated preventive intervention incurred lower costs, prevented a larger proportion of cases of depression and generated higher QALYs compared to the no-intervention option for both time horizons. Offering the intervention was even a cost saving strategy and demonstrated a probability of being cost-effective of over 95%. In the sensitivity analyses, these results were robust to the modelling assumptions. LIMITATIONS: The study considered a homogeneous cohort and assumed a constant annual decay rate of the relative treatment effect. CONCLUSIONS: GB-CBT indicated preventive interventions for depression in adolescence can generate good value for money compared to leaving adolescents with subsyndromal depression untreated.

Evaluation of the teaching recovery techniques community-based intervention for accompanied refugee children experiencing post-traumatic stress symptoms (Accompanied refugeeS In Sweden Trial; ASsIST): study protocol for a cluster randomised controlled trial.

BACKGROUND: Refugee children have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue for years after resettlement. The Accompanied refugeeS In Sweden Trial (ASsIST) aims to evaluate a community-based intervention, called 'Teaching Recovery Techniques' (TRT), for accompanied refugee minors experiencing PTSD symptoms. METHODS/DESIGN: A cluster randomised controlled trial will be conducted in which participants will be randomly allocated to one of the two possible arms: the intervention arm (n=113) will be offered the TRT programme and the waitlist-control arm (n=113) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; c.8 weeks after randomisation) and follow-up (T3; c.20 weeks after randomisation). ETHICS AND DISSEMINATION: Ethical approval was granted by the Regional Ethical Review Board in Uppsala (Ref. 2018/382) (24th February 2019). Results will be published in scientific journals. TRIAL REGISTRATION DETAILS: ISRCTN17754931. Prospectively registered on 4th June 2019.

Economic evaluations of public health interventions for physical activity and healthy diet: A systematic review.

Physical inactivity and unhealthy dietary habits are associated with an increased disease and economic burden. The aim of this systematic review was to identify economic evaluations of public health interventions targeting physical activity and healthy diet, and assess the quality and transferability of the findings to the Swedish context. A search of published economic evaluations was conducted through electronic databases including PubMed, Web of Science, PsycINFO, National Health Service Economic Evaluation Databases (NHS EED) and the Health Technology Assessment Database (HTA). An additional search was done using references of relevant systematic reviews and websites of relevant organizations were checked to find grey literature. Quality and transferability of the economic evaluations were appraised using a quality assessment tool developed by the Swedish Agency for Health Technology Assessment. Thirty-two economic evaluations, rated as moderate or high quality, of 178 interventions were included; thirteen studies targeting physical activity, thirteen targeting healthy diet and six targeting both. The interventions varied in terms of their content, setting, mode of delivery and target populations. A majority of the economic evaluations reported that the interventions were likely to be cost-effective; however, considerable variations in the methodological and reporting qualities were observed. Only half of the economic evaluations were rated to have a high probability of transferring to the Swedish context. Public health interventions targeting physical activity and dietary habits have a high potential to be cost-effective. However, decision makers should consider the variation in quality and transferability of the available evidence.

Adolescent depression and subsequent earnings across early to middle adulthood: a 25-year longitudinal cohort study.

AIMS: The few available studies on early-onset depression and future earnings offer ambiguous findings, and potential sources of heterogeneity are poorly understood. We examined the differences in adult earnings of males and females with and without a history of depressive disorder in adolescence, with specific focuses on (1) future earnings in clinical subtypes of adolescent depression; (2) the growth and distribution of earnings over time within these subgroups and (3) the mediating role of subsequent depressive episodes occurring in early adulthood. METHODS: Data were drawn from the Uppsala Longitudinal Adolescent Depression Study, a community-based cohort study initiated in Uppsala, Sweden, in the early 1990s. Comprehensive diagnostic assessments were conducted at age 16-17 and in follow-up interviews 15 years later, while consecutive data on earnings for the years 1996 to 2016 (ages 20-40) were drawn from population-based registries. The current study included participants with a history of persistent depressive disorder (PDD) (n = 175), episodic major depressive disorder (MDD) (n = 82), subthreshold depression (n = 64) or no depression (n = 218) in adolescence. The association of adolescent depression with earnings in adulthood was analysed using generalised estimating equations. Estimates were adjusted for major child and adolescent psychiatric comorbidities and parental socioeconomic status. The indirect (mediated) effect of depression in early adulthood (ages 19-30) on earnings in mid-adulthood (31-40) was estimated in mediation analysis. The study followed the 'STrengthening the Reporting of OBservational studies in Epidemiology' (STROBE) guidelines. RESULTS: Earnings across early to middle adulthood were lower for participants with a history of a PDD in adolescence than for their non-depressed peers, with an adjusted ratio of mean earnings of 0.85 (0.77-0.95) for females and 0.76 (0.60-0.95) for males. The differences were consistent over time, and more pronounced in the lower percentiles of the earnings distributions. The association was partially mediated by recurrent depression in early adulthood (48% in total; 61% for females, 29% for males). No reduction in earnings was observed among participants with episodic MDD in adolescence, while results for subthreshold depression were inconclusive. CONCLUSIONS: Our findings suggest that future earnings of adolescents with depressive disorders are contingent on the duration and natural long-term course of early-onset depression, emphasising the need for timely and effective interventions to avoid loss of human capital.

Evaluation of the Teaching Recovery Techniques community-based intervention for unaccompanied refugee youth experiencing post-traumatic stress symptoms (Swedish UnaccomPanied yOuth Refugee Trial; SUPpORT): study protocol for a randomised controlled trial.

BACKGROUND: In 2015, 162,877 persons sought asylum in Sweden, 35,369 of whom were unaccompanied refugee minors (URMs). Refugee children, especially URMs, have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue years after resettlement. The Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT) aims to evaluate a community-based intervention, called Teaching Recovery Techniques (TRT), for refugee youth experiencing PTSD symptoms. METHODS/DESIGN: A randomised controlled trial will be conducted in which participants will be randomly allocated to one of two possible arms: the intervention arm (n = 109) will be offered the TRT programme, and the waitlist-control arm (n = 109) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; about 8 weeks after randomisation) and follow-up (T3; about 20 weeks after randomisation). DISCUSSION: This study will provide knowledge about the effect and efficiency of a group intervention for URMs reporting symptoms of PTSD in Sweden. TRIAL REGISTRATION: ISRCTN, ISRCTN47820795. Prospectively registered on 20 December 2018.

Depressive disorders in adolescence, recurrence in early adulthood, and healthcare usage in mid-adulthood: A longitudinal cost-of-illness study.

BACKGROUND: Depression in adolescence is associated with increased healthcare consumption in adulthood, but prior research has not recognized the heterogeneity of depressive disorders. This paper investigated the additional healthcare usage and related costs in mid-adulthood for individuals with adolescent depression, and examined the mediating role of subsequent depression in early adulthood. METHODS: This study was based on the Uppsala Longitudinal Adolescent Depression Study, initiated in Sweden in the early 1990s. Depressive disorders were assessed in adolescence (age 16-17) and early adulthood (age 19-30). Healthcare usage and related costs in mid-adulthood (age 31-40) were estimated using nationwide population-based registries. Participants with specific subtypes of adolescent depression (n = 306) were compared with matched non-depressed peers (n = 213). RESULTS: Women with persistent depressive disorder (PDD) in adolescence utilized significantly more healthcare resources in mid-adulthood. The association was not limited to psychiatric care, and remained after adjustment for individual and parental characteristics. The total additional annual cost for a single age group of females with a history of PDD at a population level was estimated at 3.10 million USD. Depression recurrence in early adulthood mediated the added costs for psychiatric care, but not for somatic care. LIMITATIONS: Primary health care data were not available, presumably resulting in an underestimation of the true healthcare consumption. Estimates for males had limited precision due to a relatively small male proportion. CONCLUSIONS: On a population level, the additional healthcare costs incurred in mid-adulthood in females with a history of adolescent PDD are considerable. Early treatment and prevention should be prioritized.

Uppsala Longitudinal Adolescent Depression Study (ULADS).

PURPOSE: To present the Uppsala Longitudinal Adolescent Depression Study, initiated in Uppsala, Sweden, in the early 1990s. The initial aim of this epidemiological investigation was to study the prevalence, characteristics and correlates of adolescent depression, and has subsequently expanded to include a broad range of social, economic and health-related long-term outcomes and cost-of-illness analyses. PARTICIPANTS: The source population was first-year students (aged 16-17) in upper-secondary schools in Uppsala during 1991-1992, of which 2300 (93%) were screened for depression. Adolescents with positive screening and sex/age-matched peers were invited to a comprehensive assessment. A total of 631 adolescents (78% females) completed this assessment, and 409 subsequently completed a 15-year follow-up assessment. At both occasions, extensive information was collected on mental disorders, personality and psychosocial situation. Detailed social, economic and health-related data from 1993 onwards have recently been obtained from the Swedish national registries for 576 of the original participants and an age-matched reference population (N≥200 000). FINDINGS TO DATE: The adolescent lifetime prevalence of a major depressive episode was estimated to be 11.4%. Recurrence in young adulthood was reported by the majority, with a particularly poor prognosis for those with a persistent depressive disorder or multiple somatic symptoms. Adolescent depression was also associated with an increased risk of other adversities in adulthood, including additional mental health conditions, low educational attainment and problems related to intimate relationships. FUTURE PLANS: Longitudinal studies of adolescent depression are rare and must be responsibly managed and utilised. We therefore intend to follow the cohort continuously by means of registries. Currently, the participants are approaching mid-adulthood. At this stage, we are focusing on the overall long-term burden of adolescent depression. For this purpose, the research group has incorporated expertise in health economics. We would also welcome extended collaboration with researchers managing similar datasets.