Re-constructing parental identity after parents face their offspring's suicidal behaviour: An interview study.

INTRODUCTION: Parents are affected when their offspring engages in non-fatal suicidal behaviour. Although research exists on parents' mental and emotional state when they realise this behaviour, relatively little attention has been devoted to exploring how their parental identity is affected. PURPOSE: To explore how parents re-constructed and negotiated their parental identity after realising that their offspring was suicidal. METHOD: A qualitative exploratory design was adopted. We conducted semi-structured interviews with 21 Danish parents who self-identified as having offspring at risk of suicidal death. Interviews were transcribed, analysed thematically and interpreted by drawing on the interactionist concepts of negotiated identity and moral career. FINDINGS: Parents' perspectives on their parental identity were conceptualised as a moral career encompassing three distinct stages. Each stage was negotiated through social interaction with other people and the wider society. Entry into the first stage, disrupted parental identity, occurred when parents realised that they could lose their offspring to suicide. At this stage, parents trusted their own abilities to resolve the situation and keep their offspring safe and alive. This trust was gradually undermined by social encounters, which caused career movement. In the second stage, impasse, parents lost faith in their ability to help their offspring and to change the situation. Whereas some parents gradually resigned entirely to impasse, others regained their trust in their own abilities through social interaction in the third stage, restored parental agency. CONCLUSION: Offspring's suicidal behaviour disrupted parents' self-identity. Social interaction was fundamental if parents were to re-construct their disrupted parental identity. This study contributes with knowledge about the stages characterising the reconstructive process of parents' self-identity and sense of agency.

Relatives' experiences of providing care for individuals with suicidal behaviour conceptualized as a moral career: A meta-ethnographic study.

BACKGROUND: An increasing number of qualitative research articles have reported on relatives' experiences of providing care for individuals displaying suicidal behaviour. To contribute more fully to theory and practice, these reported experiences must be synthesized. OBJECTIVES: To identify original qualitative studies of relatives' experiences of providing care for individuals with non-fatal suicidal behaviour and to systematically review and synthesize this research using a meta-ethnographic approach. DESIGN: Systematic review and meta-ethnography. DATA SOURCES: Literature searches were undertaken in six bibliographic databases (PubMed, CINAHL, Embase, PsycINFO, Web of Science and Scopus) and limited to peer-reviewed original studies. Eligible studies reported relatives' experiences of providing care for individuals with suicidal behaviour, published in English or a Scandinavian language. REVIEW METHODS: One reviewer screened the titles, abstracts and full texts and then collaborated with another reviewer on excluding ineligible studies. A two-step strategy was used while reviewing publications: 1) appraising study quality, and 2) classifying study findings according to degree of data interpretation. This strategy was used for each study by two independent reviewers who subsequently reached a shared decision on inclusion. Noblit and Hare's methodology for translation and synthesis was followed in developing a novel theoretical interpretation of relatives' experiences. The concept of moral career was adopted in producing this synthesis. RESULTS: Of 7,334 publications screened, 12 studies were eligible for inclusion. The synthesis conveyed relatives' moral career as comprising four stages, each depicting relatives' different perspectives on life and felt identities. First, relatives negotiated conventional ideas about normalcy and positioned themselves as living abnormal family lives in the stage from normal to abnormal. The first career movement could be mediated by social interactions with professionals in the stage feeling helpful or feeling unhelpful. For some relatives, this negotiated perspective of abnormality got stuck in an impasse. They did not interact with their surroundings in ways that would enable them to renegotiate these fixed views, and this stage was named stuck in abnormality. For other relatives, career movement took place as relatives re-positioned themselves as negotiating an alternative perspective of normalcy in the stage from abnormal to normal. CONCLUSIONS: Interactions with other people facing similar difficulties enabled relatives to shift perspectives and alleviated experiences of distress.

Loneliness, health and mortality.

AIMS: Literature suggests an association between loneliness and mortality for both males and females. Yet, the linkage of loneliness to mortality is not thoroughly examined, and need to be replicated with a long follow-up time. This study assessed the association between loneliness and mortality, including associations to gender, in 1363 adult swedes. METHODS: This community-based prospective cohort study from the Swedish Lundby Study included 1363 individuals of whom 296 individuals (21.7%) were identified as lonely with use of semi-structured interviews in 1997. The cohort was followed until 2011 and survival analyses were used to estimate the relative risk of death. RESULTS: Death occurred with an incidence rate of 2.63 per 100 person-years and 2.09 per 100 person-years for lonely and non-lonely individuals, respectively. In crude analysis, loneliness was associated with a significant increased mortality risk of 27% compared with non-lonely individuals [hazard ratio (HR) 1.27; 95% CI 1.01-1.60]. Unadjusted, lonely females had a significant increased risk (HR 1.76; 95% CI 1.31-2.34) and adjusted insignificant increased mortality risk of 27% (HR 1.27; 95% CI 0.92-1.74), compared with non-lonely females. Lonely males were found to have an adjusted significant decreased risk of mortality (HR 0.50; 95% CI 0.32-0.80), compared with non-lonely males. CONCLUSIONS: Findings suggest an association between loneliness and increased risk of mortality and that gender differences may exist, which have not been previously reported. If replicated, our results indicate that loneliness may have differential physical implications in some subgroups. Future studies are needed to further investigate the influence of gender on the relationship.

Solar insolation in springtime influences age of onset of bipolar I disorder.

OBJECTIVE: To confirm prior findings that the larger the maximum monthly increase in solar insolation in springtime, the younger the age of onset of bipolar disorder. METHOD: Data were collected from 5536 patients at 50 sites in 32 countries on six continents. Onset occurred at 456 locations in 57 countries. Variables included solar insolation, birth-cohort, family history, polarity of first episode and country physician density. RESULTS: There was a significant, inverse association between the maximum monthly increase in solar insolation at the onset location, and the age of onset. This effect was reduced in those without a family history of mood disorders and with a first episode of mania rather than depression. The maximum monthly increase occurred in springtime. The youngest birth-cohort had the youngest age of onset. All prior relationships were confirmed using both the entire sample, and only the youngest birth-cohort (all estimated coefficients P < 0.001). CONCLUSION: A large increase in springtime solar insolation may impact the onset of bipolar disorder, especially with a family history of mood disorders. Recent societal changes that affect light exposure (LED lighting, mobile devices backlit with LEDs) may influence adaptability to a springtime circadian challenge.

Wake and light therapy for moderate-to-severe depression - a randomized controlled trial.

OBJECTIVE: To examine the efficacy of using wake and light therapy as a supplement to standard treatment of hospitalized patients with depression. METHOD: In this randomized, controlled study, 64 patients with moderate-to-severe depression were allocated to standard treatment or to the intervention, which additionally consisted of three wake therapy sessions in one week, 30-min daily light treatment and sleep time stabilization over the entire nine-week study period. RESULTS: Patients in the wake therapy group had a significant decrease in depressive symptoms in week one as measured by HAM-D17 , 17.39 (CI 15.6-19.2) vs. 20.19 (CI 18.3-22.09) (P = 0.04), whereas no statistically significant differences were found between the groups in weeks two to nine. At week nine, the wake therapy group had a significantly larger increase in general self-efficacy (P = 0.001), and waking up during nights was a significantly less frequent problem (1.9 times vs. 3.2) (P = 0.0008). In most weeks, significantly fewer patients in the wake therapy group slept during the daytime, and if they slept, their naps were shorter (week three: 66 min vs. 117 min P = 0.02). CONCLUSION: The antidepressant effect initially achieved could not be maintained during the nine-week study period. However, sleep and general self-efficacy improved.

Use of selective serotonin reuptake inhibitors reduces fertility in men.

Clinical review of the present data on the effects of selective serotonin reuptake inhibitors (SSRIs) on male fertility was the objective of the study. PubMed and Scopus were searched for publications in English or Danish and reviewed. Human trials, animal studies and in vitro studies were included. Use of SSRIs negatively affects semen parameters in most studies. In some studies, SSRIs are also shown to reduce DNA integrity. SSRIs can also delay ejaculation. Depression and anxiety can cause reduced libido, erectile dysfunction and delayed ejaculation as well. The use of SSRIs seems to reduce male fertility by affecting semen parameters, although most studies have a degree of confounding by indication caused by the underlying depression.

Relapse Prevention in Major Depressive Disorder After Successful Acute Electroconvulsive Treatment: a 6-month Double-blind Comparison of Three Fixed Dosages of Escitalopram and a Fixed Dose of Nortriptyline - Lessons from a Failed Randomised Trial of the Danish University Antidepressant Group (DUAG-7).

INTRODUCTION: Electroconvulsive treatment (ECT) is an effective treatment for severe depression but carries a risk of relapse in the following months. METHODS: Major depressive disorder patients in a current episode attaining remission from ECT (17-item Hamilton Depression Rating Scale (HAM-D17) score≤9) received randomly escitalopram 10 mg, 20 mg, 30 mg or nortriptyline 100 mg as monotherapies and were followed for 6 months in a multicentre double-blind set-up. Primary endpoint was relapse (HAM-D17≥16). RESULTS: As inclusion rate was low the study was prematurely stopped with only 47 patients randomised (20% of the planned sample size). No statistically significant between-group differences could be detected. When all patients receiving escitalopram were compared with those receiving nortriptyline, a marginal superiority of nortriptyline was found (p=0.08). One third of patients relapsed during the study period, and one third completed. DISCUSSION: Due to small sample size, no valid efficacy inferences could be made. The outcome was poor, probably due to tapering off of non-study psychotropic drugs after randomisation; this has implications for future study designs. ClinicalTrials.gov Identifier: NCT00660062.

Use of psychotropic drugs during pregnancy and breast-feeding.

OBJECTIVE: To write clinical guidelines for the use of psychotropic drugs during pregnancy and breast-feeding for daily practice in psychiatry, obstetrics and paediatrics. METHOD: As we wanted a guideline with a high degree of consensus among health professionals treating pregnant women with a psychiatric disease, we asked the Danish Psychiatric Society, the Danish Society of Obstetrics and Gynecology, the Danish Paediatric Society and the Danish Society of Clinical Pharmacology to appoint members for the working group. A comprehensive review of the literature was hereafter conducted. RESULTS: Sertraline and citalopram are first-line treatment among selective serotonin reuptake inhibitor for depression. It is recommended to use lithium for bipolar disorders if an overall assessment finds an indication for mood-stabilizing treatment during pregnancy. Lamotrigine can be used. Valproate and carbamazepin are contraindicated. Olanzapine, risperidone, quetiapine and clozapine can be used for bipolar disorders and schizophrenia. CONCLUSION: It is important that health professionals treating fertile women with a psychiatric disease discuss whether psychotropic drugs are needed during pregnancy and how it has to be administered.

Influence of birth cohort on age of onset cluster analysis in bipolar I disorder.

PURPOSE: Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database. METHODS: The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared. RESULTS: There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups. CONCLUSION: These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.

Interaction between serotonin transporter gene variants and life events predicts response to antidepressants in the GENDEP project.

There is substantial inter-individual variation in response to antidepressants, and genetic variation may, in part, explain these differences. For example, there is evidence to suggest that variation in the serotonin transporter gene (SLC6A4) predicts response to selective serotonin reuptake inhibitors (SSRIs). Environmental factors such as the occurrence of stressful life events before treatment may also be important. One prior report suggests that both factors interact in predicting response to antidepressants. GENDEP, a prospective part-randomized pharmacogenomics trial, collected longitudinal data on the outcome of 811 patients with major depression undergoing treatment with either an SSRI (escitalopram) or a tricyclic antidepressant (nortriptyline). Life events experienced over 6 months preceding treatment were measured using a List of Threatening Experiences Questionnaire, and several polymorphisms in the serotonin transporter gene (SLC6A4) have been genotyped including the serotonin transporter-linked polymorphic region (5-HTTLPR). Stressful life events were shown to predict a significantly better response to escitalopram but had no effect on response to nortriptyline. Variation in the 5-HTTLPR and another polymorphism in the gene, STin4, significantly modified these effects. Gene-environment interactions including life events may therefore be important not only in the aetiology of depression, but also in predicting response to antidepressant medication.

Veterinary practice management: teaching needs as viewed by consultants and teachers.

A study was conducted to assess veterinary practice management (VPM) educational and research needs from the perspective of consultants and teachers. An online focus group discussion was designed, involving two separate groups (consultants and teachers). One week was allocated to each group, with five to eight questions posed per day. Pseudonyms were used to provide confidentiality. Teachers were selected by inviting the primary VPM course coordinator at each AAVMC school. Consultants required at least two recommendations and were selected in a stratified, non-random manner to achieve both geographic and disciplinary diversity. Participation was stronger within the consultant group: 98 pages of data were generated by the consultants and 35 pages by teachers. Participants agreed that the sub-optimal economic conditions that characterize the veterinary profession are reflective of relatively low-level management skills. This situation establishes the need to strengthen VPM educational and research programs. Many specific suggestions were provided. It was recommended that a cooperative effort between academia and the private sector be employed. However, participants recognized that successful DVM education programs in VPM will be difficult to achieve and sustain without strong support from college administrators and faculties.

Determinants of acceptance of a community-based program for the prevention of falls and fractures among the elderly.

BACKGROUND: Low-energy fractures among the elderly may be prevented by measures aimed at reducing the risk of falling or increasing the strength of the skeleton. Acceptance of these interventions in the target population is necessary for their success. METHODS: The total elderly population in a Danish municipality 7,543 community-dwelling persons aged 66+ years, were offered participation in one of three intervention programs: 2,550 persons were offered a home safety inspection, evaluation of prescribed medicine, and identification of possible health and food problems (Program I); 2,445 persons were offered 1000 mg of elemental calcium and 400 IU (10 microg) of vitamin D(3) per day in combination with evaluation of prescribed medicine (Program II); and 2,548 persons were offered a combination of the two programs (Program III). Acceptance was defined as willingness to receive an introductory visit by a nurse. RESULTS: Acceptance of Program I was 50%; of Program II, 56% (P < 0.00005 as contrasted with Program I); and of Program III, 46% (P < 0.005). Acceptance was associated with gender (females, 53%; males, 47%) and did not change from ages 66 to 84 but decreased significantly after the age of 85. Widows aged 66-84 had the highest acceptance (57%) and never married males aged 66-84 the lowest (30%). An important determinant, however, was the individual social service center that communicated the specific program. Acceptance varied from 39 to 66% between the social centers. CONCLUSIONS: Acceptance of a fall and fracture prevention program varies with intervention type; with gender, age, and social status of the target population; and with the motivation and attitude of the health workers involved in the implementation of the program.

Sauvé-Kapandji operation for disorders of the distal radioulnar joint after Colles' fracture. Good results in 12 patients followed for 1.5-4 years.

Controversies continue concerning the treatment of the posttraumatic caput ulna syndrome. We have treated 12 patients, mean age 42 (23-77) years, with arthrodesis ad modum Sauvé-Kapandji of the distal articulation between the radius and ulna, combined with resection of the ulnar neck. Before the operation, all patients had persistent ulnar wrist pain and restricted pronation-supination movement. At follow-up, after a mean of 2 (1.5-4) years, 8 patients had an excellent outcome, 3 a good, and 1 patient had a fair outcome. 10 patients had no wrist pain. The average grip-score improved from 53% preoperatively to 76% at the follow-up.

[The value of X-ray examinations for elective arthroscopy]. / Vaerdien af røntgenundersøgelse før elektiv artroskopi.

In 1990 elective arthroscopy was performed on 327 knees at this department. In all cases X-ray pictures were taken preoperatively. The arthroscopic findings were registered consecutively in a predesigned form. The radiographs were evaluated by an experienced specialist at the radiography department. In 35 cases the X-ray diagnosis was arthrosis, 25 of these cases were confirmed by arthroscopy. Osteochondritis dissecans was found in 10 cases by arthroscopy, four of these were found by X-ray examination. Free bodies were found in six cases at arthroscopy, only three were detected by X-ray examination. As a consequence we find that routine X-ray examination before elective knee arthroscopy is unnecessary provided that clinical signs of conditions expected to be seen by X-ray are absent.

[Selective screening for non-insulin-dependent diabetes mellitus. A study among 35-69 year-old patients at risk in general practice in Kolding]. / Selektiv screening for ikkeinsulinkraevende diabetes mellitus. Undersøgelse blandt 35-69-årige risikopatienter i almen praksis i Kolding.

In order to identify previously undiagnosed cases of non-insulin dependent diabetes (NIDDM) in general practice, we measured non-fasting blood-glucose in all risk patients (n = 1,790) between 35-69 years old belonging to 29 general practices in Kolding. Patients at risk for NIDDM were defined as those suffering from one or more of the following: overweight, arterial hypertension, coronary heart disease, hyperlipidaemia, stroke, gout, cataract, Dupuytren's contracture, peripheral atherosclerosis or recurrent urinary- or skin-infections. A positive result, defined as a non-fasting blood-glucose of > or = 8.0 mmol/l using the same stix-lot-nr. on Refloflux S machines, was found in 86 individuals. These were then followed up with two fasting blood-glucose measurements carried out in a central laboratory, whereby 34 patients with NIDDM were identified. The newly-diagnosed NIDDM patients mostly suffered from diseases related to the insulin resistance syndrome, and we thus recommend measurement of non-fasting blood-glucose as a screening procedure in such patients. When carrying out measurements in general practice, it is important to know the precision and accuracy of the apparatus used.

Hepatic changes produced by 30-day administration of a novel aminocyclitol antibiotic, trospectomycin sulfate, to laboratory animals.

The studies described here were done to characterize the hepatic response to a new aminocyclitol antibiotic, trospectomycin sulfate, administered intravenously (beagle dog) or subcutaneously (Sprague-Dawley rat) at a variety of dose levels, to investigate reversibility of observed changes, and to document any untoward effects of subchronic trospectomycin sulfate administration. Both species showed significant elevations in serum levels of alanine and aspartate transaminases in higher dose groups. In the dog only, a transient neuromuscular blockade was also observed within higher dose groups. No other functional, morphological, or serum chemical changes were observed. Examination of liver by electron microscopy revealed the presence of cytoplasmic lamellar inclusion bodies, concentrated in the bile canalicular region of the hepatocytes. Occurrence of the lamellar bodies and coincident transaminase increases were found to be reversible upon discontinuance of treatment (studied in the dog). Electron microscopy of acid phosphatase cytochemistry in the rat indicated that most, but not all, of the lamellar bodies contained this enzyme. This observation suggests that they may be derived from the lysosome, or once formed become lysosomal.

Reversible, hepatic, lysosomal phospholipidosis in rat induced by subchronic daily administration of trospectomycin sulfate.

Trospectomycin sulfate is an experimental aminocyclitol antibiotic which has been shown previously to induce the formation of cytoplasmic lamellar bodies in rat and dog liver in subchronic experiments. The effect of repeated daily administration of trospectomycin sulfate on hepatic phospholipid levels and activities of marker enzymes for subcellular organelles was examined. Rats were treated for 30 or 90 days with 0, 50, or 250 mg/kg/day of trospectomycin sulfate prior to being killed, and another group was dosed for 90 days and then allowed to recover for 79 days prior to sacrifice. Transmission electron microscopy showed the presence of lamellar bodies in hepatocytes in both 50 and 250 mg/kg groups at 90 days but no other apparent changes in cellular morphology. Total phospholipids were increased significantly (1.6-fold) only at 90 days (P less than 0.01) and only in the 250 mg/kg group. Phosphatidylcholine, phosphatidylinositol, and two acidic lysosomal phospholipids, bis(monoacylglycero)phosphate and acylphosphatidylglycerol, accounted for 42, 35, and 21% of the increase in total phospholipids. Changes in the activities of marker enzymes were generally confined to the 250 mg/kg group at 90 days, with the largest and most significant increases being in the lysosomal enzymes acid phosphatase and hexosaminidase (P less than 0.01). Levels of all phospholipids and marker enzymes, with the exception of succinate dehydrogenase, were not significantly different from controls 79 days after cessation of dosing, and lamellar bodies had disappeared. We conclude that repeated trospectomycin sulfate treatment in rat induces a reversible, dose- and time-dependent lysosomal phospholipidosis in liver which is characterized by an increase in lysosomal enzymes and selected anionic phospholipids.

Differential effects of cefmetazole sodium on the reproductive system of infant and pubertal male rats.

The effects of cefmetazole (CMZ), a cephem antibiotic which contains the N-methyltetrazolethiol (NMTT) side-chain moiety, were compared in infant (6-42 days of age) and pubertal (6-10 weeks of age) male Sprague-Dawley rats. High doses of either CMZ or free NMTT caused reductions in testicular weight and delayed maturation of spermatogenic germ cells in the testes of infant rats, implicating NMTT as the active component in causing these effects. Pubertal rats expressed neither of these effects, even when treated with doses of CMZ far in excess of those used in infant rats. The effects of CMZ and NMTT on testicular weights and histologic features of testes of rats treated as infants were mainly reversed when these animals were examined 35 and 70 days after cessation of treatment. All reproductive functional parameters were normal in mating studies using male rats which had been treated with CMZ or NMTT as infants and allowed to recover. Because of the species differences in rates of sexual maturation and the greater rate at which rats metabolize CMZ to NMTT, the relevance to humans of the testicular effects of CMZ in infant rats is unknown.