A population-based study of the risk of schizophrenia and bipolar disorder associated with parent-child separation during development

Mapping review of register-based cohort studies of bipolar disorder

OBJECTIVES

Register-based cohorts allow us to better understand bipolar disorder over a life course. They are inclusive and their long-term data collection provides a longer scope than most clinical trials. This mapping review provides an overview of register-based cohort studies of bipolar disorder to inform researchers of the strengths and limitations to this body of research and identify gaps for future research.

METHODS

A systematic search was performed of Medline, EMBASE, and PsycINFO databases. Cohort studies were included if they focused on bipolar disorder and had a minimum of 1 year of longitudinal data. Studies needed to be from databases that monitor the whole state or national population. A descriptive analysis of the studies' populations and methodology provides an overview of this field of study and identifies evidence gaps.

RESULTS

A hundred and forty-six studies were included. The majority were from databases in Taiwan (n = 63), Denmark (n = 38), Sweden (n = 23), and Finland (n = 11). Forty-eight studies focused on aetiological questions. Sixty prognostic studies identified cohorts with bipolar disorder and described the impact of the illness by considering comorbidity, prescribing patterns, social functioning, and mortality. Thirty-six treatment studies focused on the efficacy and adverse effects of pharmaceuticals and ECT. No studies focused on psychological treatments.

CONCLUSION

Bipolar disorder research should include register-based cohorts with greater geopolitical and cultural diversity. Custodians of health registers should consider how non-pharmaceutical interventions such as psychotherapy are captured. Register-based cohorts investigating treatments of bipolar disorder should consider long-term social outcomes alongside the usual clinical outcomes.

The impact of comorbid premenstrual syndrome or premenstrual dysphoric disorder on the clinical characteristics of bipolar disorder among Han Chinese women

Bipolar disorder (BD) is commonly comorbid with premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). However, little is known about their relationship. This study aimed to assess the impact of comorbid PMS or PMDD on the clinical characteristics of BD. A cross-sectional study was conducted on 262 women with BD. PMS and PMDD were screened with the Premenstrual Symptoms Screening Tool (PSST). Symptomatic features were assessed with Hamilton Depression Scale (HAMD), Young Mania Rating Scale (YMRS), and atypical features by the depressive episode section of SCID-I/P. The rates of PMS and PMDD among BD were 57.6% and 20.6% according to PSST. No significant difference in the rates of PMS and PMDD was found between BD I, BD II, and BD-NOS. Compared to BD patients without PMS or PMDD, patients with comorbid BD and PMS or PMDD were younger, more educated, had a higher risk of OCD, had an earlier age of onset, scored higher on HAMD-17 and its sub-scale of anxiety/somatization, cognitive deficit, psychomotor retardation, and were more likely to have increased appetite and leaden paralysis. In addition, patients with comorbid BD and PMDD were less likely to experience traumatic life events, more likely to have family history of mental disorders and have inflammatory or autoimmune disease, scored higher on HMAD-17, particularly in its sub-scale of anxiety/somatization, cognitive deficit, psychomotor retardation, and sleep disturbance. Compared with BD without PMS or PMDD, BD with PMS or PMDD might be a specific subtype of BD characterized with earlier onset age, heavier genetic load, increased symptom severity, and atypical features.

Development and initial validation of a multivariable predictive Early Adversity Scale for Schizophrenia (EAS-Sz) using register data to quantify environmental risk for adult schizophrenia diagnosis after childhood exposure to adversity

BACKGROUND

Additional to a child's genetic inheritance, environmental exposures are associated with schizophrenia. Many are broadly described as childhood adversity; modelling the combined impact of these is complex. We aimed to develop and validate a scale on childhood adversity, independent of genetic and other environmental liabilities, for use in schizophrenia risk analysis models, using data from cross-linked electronic health and social services registers.

METHOD

A cohort of N = 428 970 Western Australian children born 1980-2001 was partitioned into three samples: scale development sample (N = 171 588), and two scale validation samples (each N = 128 691). Measures of adversity were defined before a child's 10th birthday from five domains: discontinuity in parenting, family functioning, family structure, area-level socioeconomic/demographic environment and family-level sociodemographic status. Using Cox proportional hazards modelling of follow-up time from 10th birthday to schizophrenia diagnosis or censorship, weighted combinations of measures were firstly developed into scales for each domain, then combined into a final global scale. Discrimination and calibration performance were validated using Harrell's C and graphical assessment respectively.

RESULTS

A weighted combination of 42 measures of childhood adversity was derived from the development sample. Independent application to identical measures in validation samples produced Harrell's Concordance statistics of 0.656 and 0.624. Average predicted time to diagnosis curves corresponded with 95% CI limits of observed Kaplan-Meier curves in five prognostic categories.

CONCLUSIONS

Our Early Adversity Scale for Schizophrenia (EAS-Sz), the first using routinely collected register data, predicts schizophrenia diagnosis above chance, and has potential to help untangle contributions of genetic and environmental liability to schizophrenia risk.

Cognitive and Behavioral Development of 9-Year-Old Children After Maternal Cancer During Pregnancy: A Prospective Multicenter Cohort Study

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.This multicenter cohort study reports on the long-term effects of prenatal exposure to maternal cancer and its treatment on cognitive and behavioral outcomes in 9-year-old children. In total, 151 children (mean age, 9.3 years; range, 7.8-10.6 years) were assessed using a neurocognitive test battery and parent-report behavioral questionnaires. During pregnancy, 109 children (72.2%) were exposed to chemotherapy (only or in combination with other treatment modalities), 18 (11.9%) to surgery only, 16 (10.6%) to radiotherapy, one to trastuzumab, and 16 (10.6%) were not exposed to oncologic treatment. Mean cognitive and behavioral outcomes were within normal ranges. Gestational age at birth showed a positive association with Full Scale Intelligence Quotient (FSIQ), with the average FSIQ score increasing by 1.6 points for each week increase in gestational age (95% CI, 0.7 to 2.5; P < .001). No difference in FSIQ was found between treatment types (F[4,140] = 0.45, P = .776). In children prenatally exposed to chemotherapy, no associations were found between FSIQ and chemotherapeutic agent, exposure level, or timing during pregnancy. These results indicate a reassuring follow-up during the critical maturational period of late childhood, when complex functions develop and rely on the integrity of early brain development. However, associations were observed with preterm birth, maternal death, and maternal education.

An Identity Process Theory Account of the Impact of Boarding School on Sense of Self and Mental Health: an Interpretative Phenomenological Analysis

Boarding schools exist to provide education for children, but this involves the child leaving the family home and residing in an educational institution. Identity Process Theory suggests that such a change in circumstances can threaten the child’s identity, which triggers coping strategies and impacts on the individual’s self-concept during both childhood and adulthood. This study undertook an Interpretative Phenomenological Analysis of semi-structured interviews conducted with five adults who boarded as children. The focus was on exploring participants’ beliefs in terms of how the boarding experience affected their sense of self. Emerging themes relate to the (i) coping strategies used by participants during childhood, such as amnesia, compartmentalising, compliance and acceptance, and (ii) long-term effects of boarding on identity, self-concept and intimate relationships. Findings also highlight the interplay of factors such as privilege and social class, which were reported as motives for participants’ parents choosing boarding for their children. The study raises important questions about the long-term health impacts of sending children away to board.

Age of onset by sex in schizophrenia: Proximal and distal characteristics

BACKGROUND

Earlier schizophrenia onset in men relative to women has been a consistent finding in the literature, but a nuanced understanding of underlying reasons remains elusive. Further consideration should be given to factors associated with sex differences in age of onset.

METHOD

Participants with schizophrenia were derived from the 2010 Australian Survey of High Impact Psychosis (n = 857). The SHIP survey constituted a representative, population-based study of almost 1.5 million Australian adults seen at various mental health services, and assessed personal health information, psychiatric comorbidities as well as psychosis illness and treatment. Hierarchical clustering was employed to identify age of onset by sex. Within-sex comparisons on distal and proximal factors affecting age of onset were conducted.

RESULTS

Using modal age, two and three clusters were respectively found in men (early versus late onset) and women (early versus mid versus late onset). Early onset groups in both sexes had an increased family history of psychosis compared to older onset, but other risk factors were not consistent across the sexes. Less premorbid impairment was noted in females with middle to later onset schizophrenia.

CONCLUSION

These findings further inform our understanding of the pathogenesis of schizophrenia. Added explorations of trends in older onset schizophrenia cohorts is especially important.

Childhood Separation From Parents and Self-Harm in Adolescence: A Cross-Sectional Study in Mainland China

As the prevalence of self-harm among adolescents in Chinese escalates, finding out the potential risk factors associated with self-harm behaviors has aroused much attention. This study aims to explore the association between parent-child separation and series of self-harm (SH) subtypes among Chinese adolescents. We survey a total of 4,928 middle school students aged from 12 to 18 years at school. Parent-child separation was investigated from four dimensions-occurrence of parental separation, separation status, age at first separation and duration of separation. Self-harm series are deemed as five subtypes-highly lethal self-harm, less lethal self-harm with visible tissue damage, self-harm without visible tissue damage, self-harmful behaviors with latent damage and psychological self-harm. Multivariate logistic regression is used to explore the associations between parent-child separation and different subtypes of self-harm among adolescents. Paternal separation is associated with each type of self-harm whilst maternal separation is not correlated with highly lethal self-harm. Except for highly lethal self-harm, the other four subtypes of self-harm demonstrate a relation with both length of paternal separation and maternal separation with aOR ranging from 1.02 to 1.06. Individuals who suffer parental separation prior to the age of three were at a higher risk for four types of less-lethal self-harm. The association of parent-child separation with self-harm deserves our attention, and future research is needed to identify the underlying mechanisms.

Impact of Family Separation on Subjective Time Pressure and Mental Health in Refugees from the Middle East and Africa Resettled in North Rhine-Westphalia, Germany: A Cross-Sectional Study

Little is known about social determinants among refugees resettled in Germany. This study aims to examine the impact of family separation on refugees' subjective time pressure and mental health. Data come from the FlueGe Health Study (n = 208), a cross-sectional study administered by Bielefeld University. We used logistic regression analysis to investigate the effect of family separation on (i) being time-stressed and (ii) having a high risk for adverse mental health, considering sociodemographic and postmigration factors. As a result, more than 30% of participants with a spouse or partner and about 18% with a child or children reported separation. Multiple logistic regression showed that family separation was not associated with being time-stressed, but separation from at least one child was associated with adverse mental health (OR = 3.53, 95% CI = [1.23, 10.11]). In conclusion, family separation primarily contributes to adverse mental health among refugees from the Middle East and Africa resettled in North Rhine-Westphalia, Germany. Therefore, policies and practices that facilitate family reunification can contribute significantly to the promotion of refugees' mental health and well-being.

The impact of study design on schizophrenia incidence estimates: A systematic review of Northern European studies 2008-2019

The best estimates of the incidence of schizophrenia range more than 25-fold from 3 to 80 per 100,000 person-years. To what extent do differences in study design explain this wide variation? We selected all studies published between 2008-2019 reporting the incidence of schizophrenia in general populations of Northern Europe. We identified 17 estimates covering 85 million person-years and more than 15,000 individual cases. The estimates ranged from 4-72 per 100,000 person-years (median 30; interquartile range 13-41). We classified the estimates in terms of three study design factors (coverage of services, time frame, and diagnostic quality) and two population factors (urbanicity and age). A meta-regression model of the three design factors, using the two population factors as covariates, explained 91% of between-study variation. Studies performed in general psychiatric services reported similar estimates [incidence rate ratio 1.12 (95% confidence interval 0.88 to 1.43)] to those performed in specialized services. But studies applying a cumulative time frame to diagnosis reported fourfold higher estimates [4.04 (3.14 to 5.2)] than those applying a first-contact time frame. And studies based on clinical diagnoses reported lower estimates [0.55 (0.43 to 0.72)] than those based on standardized research diagnoses. The three study design factors by themselves explained 67% of between-study variation. When comparing incidence rates from different populations, distorsions arising from differences in study design can eclipse differences caused by schizophrenia risk factors, such as gender, age or migrant status.

Impact of parent-child separation on children's social-emotional development: a cross-sectional study of left-behind children in poor rural areas of China

BACKGROUND

Parent-child separation is a considerable adversity for left-behind children (LBC), but there is little evidence on the association between detailed characteristics of parent-child separation and social-emotional development among LBC. This study examined the characteristics of parent-child separation and its impacts on developmental delay among under-3 LBC in poor rural China.

METHODS

We used data from 811 LBC surveyed in five poor counties in rural China in 2018. Detailed characteristics of their parental migration were recalled by their primary caregivers in face-to-face interviews. The children's social-emotional development was measured by using the Ages and Stages Questionnaire: Social-Emotional. Logistic regression was employed to examine the association of detailed characteristics of parent-child separation with early social-emotional problems after adjusting for the children's and primary caregivers' sociodemographic characteristics.

RESULTS

287 (35.4%) children were left behind by fathers and cared for by mothers (FM-MC), while 524 (64.6%) were left behind by both parents and cared for by grandparents (PM-GC). The rate of social-emotional problems among LBC was 36.8% (PM-GC vs FM-MC: 40.6% vs 29.5%; aOR 1.51, 95% CI: 1.06 to 2.16). For paternal migration, the medians of the child's age at the first migration and average duration per migration were 3 months (IQR: 1 to 9 months) and 4.48 months (IQR: 2.38 to 7.54 months), respectively. For maternal migration, the corresponding values were 9 months (IQR: 6 to 13 months) and 4.65 months (IQR: 2.71 to 7.62 months), respectively. On average, LBC had been separated from fathers for 72% of their life due to paternal migration and from mothers for 52% of their life due to maternal migration. No significant association was found between the detailed characteristics of paternal migration and social-emotional development among LBC, while social-emotional problems among LBC were significantly associated with the proportion of cumulative duration of maternal migration in the child's lifetime (aOR 2.83; 95% CI: 1.13 to 7.10).

CONCLUSIONS

LBC under 3 years had a high risk of social-emotional problems in poor rural China. Cumulative exposure to maternal migration may be detrimental to LBC's early social-emotional development. Programs are necessary to support these children as well as their families.

Robust data-driven identification of risk factors and their interactions: A simulation and a study of parental and demographic risk factors for schizophrenia

OBJECTIVES

Few interactions between risk factors for schizophrenia have been replicated, but fitting all such interactions is difficult due to high-dimensionality. Our aims are to examine significant main and interaction effects for schizophrenia and the performance of our approach using simulated data.

METHODS

We apply the machine learning technique elastic net to a high-dimensional logistic regression model to produce a sparse set of predictors, and then assess the significance of odds ratios (OR) with Bonferroni-corrected p-values and confidence intervals (CI). We introduce a simulation model that resembles a Finnish nested case-control study of schizophrenia which uses national registers to identify cases (n = 1,468) and controls (n = 2,975). The predictors include nine sociodemographic factors and all interactions (31 predictors).

RESULTS

In the simulation, interactions with OR = 3 and prevalence = 4% were identified with <5% false positive rate and ≥80% power. None of the studied interactions were significantly associated with schizophrenia, but main effects of parental psychosis (OR = 5.2, CI 2.9-9.7; p < .001), urbanicity (1.3, 1.1-1.7; p = .001), and paternal age ≥35 (1.3, 1.004-1.6; p = .04) were significant.

CONCLUSIONS

We have provided an analytic pipeline for data-driven identification of main and interaction effects in case-control data. We identified highly replicated main effects for schizophrenia, but no interactions.

Social vulnerability and COVID-19: A call to action for paediatric clinicians

The COVID-19 pandemic has had dramatic effects on the lives of children globally. However, socially vulnerable children have been particularly impacted. Certain populations have increased vulnerabilities, including children and youth experiencing homelessness. Increased infection risk due to congregant living and challenges with physical distancing are contributing factors. An urgent need exists for a wholistic approach to care with unique cross-sectoral partnerships across disciplines. A recognition of the unintended consequence of the COVID-19 pandemic on this population is urgently required by all those supporting children. Families should receive direct support in clinical settings to identify their social needs. Partnership with community agencies and advocacy for appropriate isolation facilities for patients experiencing homelessness are critical.

How parental migration affects early social-emotional development of left-behind children in rural China: a structural equation modeling analysis

OBJECTIVES

This study assessed the early social-emotional development of left-behind children (LBC) in rural China and determined the mediating factors linking parental migration to LBC's developmental outcome.

METHODS

We used cross-sectional data of 845 LBC under 3 years old from five counties in rural China in 2018. Social-emotional problems were assessed by the ages and stages questionnaires: social-emotional. Family structure, function, and child nurturing care practices were measured to explore their roles in potential pathways of parental migration affecting early social-emotional development.

RESULTS

36.4% of LBC were identified with social-emotional problems; the rate was higher among LBC with migrant parents than those with migrant fathers (39.9% vs. 30.5%, adjusted OR: 1.40 [95% CI 1.01, 1.93]). Results of structural equation modeling reveal that caregivers' low education and depressive symptoms, poor migrant-caregiver communication, family poverty, and no assistant caregiving weakened home parenting environment, and then contributed to LBC's social-emotional problems.

CONCLUSIONS

LBC in early childhood may be at a high risk of social-emotional problems, which are primarily caused by the transition of family structure and function and consequently weakened home environment.

Family structure and alcohol use disorder: a register-based cohort study among offspring with and without parental alcohol use disorder

AIMS

To assess whether parental alcohol use disorder (AUD) is associated with higher risks of living in a non-intact family and assess whether non-intact family structure is associated with higher risks of AUD in the offspring.

DESIGN

Prospective cohort study.

SETTING

Danish nation-wide registries.

PARTICIPANTS

A total of 9948 parental AUD offspring and 98 136 reference offspring from the Danish population.

MEASUREMENTS

Family structure assessed at birth and at each birthday until age 15 as intact or non-intact (with mother only, father only or neither parent); years lived in an intact family defined as total number of years lived with both parents from birth until the 15th birthday; AUD defined as registration in medical, treatment and cause of death registries. Data were analyzed by Cox regression.

FINDINGS

At birth, 30.9% [95% confidence interval (CI) = 29.1-32.6] of parental AUD offspring and 10.7% (95% CI = 10.3-11.0) of reference offspring lived in a non-intact family. At age 15, the numbers were 84.6% (95% CI = 83.9-85.3) and 38.4% (95% CI = 38.1-38.7). Parental AUD was associated with a higher risk of offspring AUD [hazard ratio (HR) = 1.88, 95% CI = 1.74-2.02]. Offspring were at lower risk of AUD if they lived 15 years in an intact family compared with offspring who never lived in an intact family (HR = 0.67, 95% CI = 0.52-0.87 for those with parental AUD, and HR = 0.53, 95% CI = 0.48-0.59 for those whose parents did not have AUD). Findings were inconclusive as to whether or not an association was present between family structure and AUD among offspring with parental AUD and reference offspring.

CONCLUSIONS

The prevalence of non-intact family structure appears to be higher in offspring of parents with alcohol use disorder (AUD) than among offspring from the general population. Parental AUD appears to be associated with increased risk of offspring AUD, and non-intact family structure appears to be associated with increased risk of offspring AUD regardless of parental AUD.

Childhood adversity and psychosis: a systematic review of bio-psycho-social mediators and moderators

The association between childhood adversity (CA) and psychosis has been extensively investigated in recent years. An increasing body of research has also focused on the mediating or moderating role of biological and psychological mechanisms, as well as other risk factors that might account for the link between CA and psychosis. We conducted a systematic search of the PsychINFO, Embase, Ovid, and Web of Science databases for original articles investigating the role of genetic vulnerabilities, environmental factors, psychological and psychopathological mechanisms in the association between CA and psychosis up to August 2019. We included studies with individuals at different stages of the psychosis continuum, from subclinical psychotic experiences to diagnosed disorders. From the 28 944 records identified, a total of 121 studies were included in this review. Only 26% of the studies identified met the criteria for methodological robustness. Overall, the current evidence suggests that CA may be associated with psychosis largely independently of genetic vulnerabilities. More consistent and robust evidence supports interaction between early and recent adversities, as well as the mediating role of attachment and mood symptoms, which is suggestive of an affective pathway between CA and psychosis across the continuum from subclinical experiences to diagnosable disorder. This review highlighted numerous methodological issues with the existing literature, including selection bias, heterogeneity of measurement instruments utilised, and lack of control for potential confounders. Future research should address these limitations to more accurately estimate mediation and moderation effects on the CA-psychosis association to inform the development of preventive interventions.

Long-term outcome of early-onset compared to adult-onset schizophrenia: A nationwide Danish register study

OBJECTIVE

Early-onset schizophrenia (EOS) may have worse outcomes than adult-onset schizophrenia (AOS), but data are scarce. We compared outcomes of EOS vs. AOS.

METHODS

Longitudinal, register-based study of patients diagnosed with schizophrenia in Denmark between 1996 and 2012, with follow-up until 12/2014. Co-primary outcomes were psychiatric inpatient days during the initial two years after schizophrenia diagnosis and mean number of annual inpatient days for the remaining follow-up.

RESULTS

Altogether, 16,337 patients with schizophrenia were included (EOS = 1223, AOS = 15,114, mean follow-up = 9.5 ± 5.0 years). EOS were hospitalized longer during the first two years than AOS (180.9 ± 171.0 vs 163.4 ± 183.1 days, p < 0.005; IRR = 1.27, 95% CI = 1.19-1.35, p < 0.001), but duration and annual rates thereafter did not differ (EOS = 26.8 ± 57.1 days, AOS = 26.6 ± 56.2 days, p = 0.95; IRR = 1.07, 95% CI = 0.94-1.23, p = 0.30). Fewer EOS patients were never psychiatrically hospitalized (EOS = 17.2%, AOS = 20.1%, p < 0.001), but with no difference in re-admissions in patients diagnosed during hospitalization (EOS = 77.1% vs AOS = 78.1%, p = 0.56). More EOS patients were admitted involuntarily (41% vs. 36%, p < 0.02). AOS patients had more often comorbid substance use disorders during follow-up than EOS (EOS = 21.7%, AOS = 34.2%, p < 0.001). Substance use disorders and out-of-home placement were significantly associated with more inpatient days during both short- and long-term follow-up.

CONCLUSION

Although EOS was associated with more inpatient days in the first two years after diagnosis, results do not seem to support a generally poorer long-term outcome of EOS compared to AOS. Longer initial hospitalization may be driven by different treatment patterns in child and adolescent vs. adult psychiatry. These data suggest that patient characteristics other than age of onset significantly affect outcomes.

Expression of Behavioral Phenotypes in Genetic and Environmental Mouse Models of Schizophrenia

Schizophrenia is a neuropsychiatric disorder characterized by multifactorial etiology involving complex interactions among genetic and environmental factors. "Multiple-hit" models of the disorder can explain its variable incidence and prevalence in related individuals. Hence, there is a dire need to understand these interactions in the emergence of schizophrenia. To test these factors in the emergence of schizophrenia-like behaviors, we employed a genetic mouse model of the disorder (harboring the DISC1 mutation) along with various environmental insults, such as early life stress (maternal separation of pups) and/or pharmacological interventions (ketamine injections). When assessed on a battery of behavioral tests, we found that environmental interventions affect the severity of behavioral phenotypes in terms of increased negative behavior, as shown by reduced mobility in the forced swim and tail suspension tests, and changes to positive and cognitive symptoms, such as increased locomotion and disrupted PPI along with reduced working memory, respectively. Among the various interventions, the genetic mutation had the most profound effect on behavioral aberrations, followed by an environmental intervention by ketamine injections and ketamine-injected animals that were maternally separated during early postnatal days. We conclude that although environmental factors increased the prevalence of aberrant behavioral phenotypes, genetic background is still the predominant influence on phenotypic alterations in these mouse models of schizophrenia.

Association Between Parental Income During Childhood and Risk of Schizophrenia Later in Life

IMPORTANCE

Evidence linking parental socioeconomic position and offspring's schizophrenia risk has been inconsistent, and how risk is associated with parental socioeconomic mobility has not been investigated.

OBJECTIVE

To elucidate the association between parental income level and income mobility during childhood and subsequent schizophrenia risk.

DESIGN, SETTING, AND PARTICIPANTS

National cohort study of all persons born in Denmark from January 1, 1980, to December 31, 2000, who were followed up from their 15th birthday until schizophrenia diagnosis, emigration, death, or December 31, 2016, whichever came first. Data analyses were from March 2018 to June 2019.

EXPOSURE

Parental income, measured at birth year and at child ages 5, 10, and 15 years.

MAIN OUTCOMES AND MEASURES

Hazard ratios (HRs) for schizophrenia were estimated using Cox proportional hazard regression. Cumulative incidence values (absolute risks) were also calculated.

RESULTS

The cohort included 1 051 033 participants, of whom 51.3% were male. Of the cohort members, 7544 (4124 [54.7%] male) were diagnosed with schizophrenia during 11.6 million person-years of follow-up. There was an inverse association between parental income level and subsequent schizophrenia risk, with children from lower income families having especially elevated risk. Estimates were attenuated, but risk gradients remained after adjustment for urbanization, parental mental disorders, parental educational levels, and number of changes in child-parent separation status. A dose-response association was observed with increasing amount of time spent in low-income conditions being linked with higher schizophrenia risk. Regardless of parental income level at birth, upward income mobility was associated with lower schizophrenia risk compared with downward mobility. For example, children who were born and remained in the lowest income quintile at age 15 years had a 4.12 (95% CI, 3.71-4.58) elevated risk compared with the reference group, those who were born in and remained in the most affluent quintile, but even a rise from the lowest income quintile at birth to second lowest at age 15 years appeared to lessen the risk elevation (HR, 2.80; 95% CI, 2.46-3.17). On the contrary, for those born in the most affluent quintile, downward income mobility between birth and age 15 years was associated with increased risks of developing schizophrenia.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that parental income level and income mobility during childhood may be linked with schizophrenia risk. Although both causation and selection mechanisms could be involved, enabling upward income mobility could influence schizophrenia incidence at the population level.

Working with Parents and Children Separated at the Border: Examining the Impact of the Zero Tolerance Policy and beyond

The crisis of family separation caused by Trump Administration's zero tolerance policy (ZTP) on the southern border has focused the nation's attention and provoked public uproar due to the violation of basic rights and the expected negative impact on children and parents. There is decades' worth of research documenting the damage of separating children from their parents in a wide diversity of circumstances and for a wide variety of reasons. There is also ample research evidence of the impact of any form of childhood trauma and consequent disruptions in development, cognitive impairments, and health problems through adulthood. However, there is no first-hand documentation published of how these children and families specifically experienced separation at the border and the effects it is having on them to date. The present article first provides an overview of the historical and socio-political context of family separation policies in the US, and a thorough description of how ZTP was implemented in actuality. Second, this article offers a review of the literature on the impact of family separation on children and parents in diverse contexts. Third, we describe direct clinical experiences with these children and parents receiving services at the Terra Firma program in the Bronx community in New York. Finally, this article delineates important recommendations for policy makers, service providers, and the community as a whole.

The association between low-grade inflammation and the clinical features of bipolar disorder in Han Chinese population

Variety of evidence suggests that low-grade inflammation may be involved in the pathophysiology of bipolar disorder (BD). However, the conclusion regarding the relationship between inflammation and BD has been inconsistent. In this study, we aimed to survey the prevalence of low-grade inflammation in a large Han Chinese population with BD and assess its impact on the clinical features of BD. 430 eligible cases were drawn from patients who were admitted or had ever been admitted for BD to the inpatient service of the psychiatric department of the Third Hospital of Sun Yat-sen University. Subjects with current active physical diseases or white blood count (WBC) >19.0 × 10⁹/L (2 times the upper reference) were excluded. Serum C-reactive protein (CRP) levels and WBC were measured with fast blood sample. Low-grade inflammation was defined as CRP>3 mg/L or WBC > 9.5 × 10⁹/L(the upper reference). Clinical features of BD were collected through semi-structural interview conducted by trained interviewers with background of psychiatric education. If defined as CRP>3 mg/L, the prevalence of low-grade inflammation among BD was 10.1% (41/404), it was positively associated with BMI (p = 0.012), comorbidity of glycolipid metabolic diseases(p = 0.018). After adjusting for BMI, it was found to be positively related to recent suicide attempt (p = 0.03), initiation with (hypo)manic episode(p = 0.047), leaden paralysis (p = 0.037) and family history of mental disorders(p = 0.012), while the association between comorbidity of glycolipid metabolic diseases and low-grade inflammation disappeared (p = 0.330). If defined as WBC > 9.5 × 10⁹/L, the prevalence of low-grade inflammation was 8.1% (33/409), it was positively associated with psychotic features (p = 0.011) and adverse life events before the onset of illness(p < 0.001), but was not significantly influenced by BMI (p = 0.077). A much lower prevalence of low-grade inflammation in BD is found among Han Chinese population than among western population. Low-grade inflammation of different definition impacts differentially on the clinical features of BD.

The Recovery House in Trieste: rational, participants, intervention as the “work”

Purpose

Too often people with complex mental health needs do not find their way out of the mental health system or find satisfactory solutions that enable them to live a full life. In 2015 the Mental Health Department (MHD) of Trieste established the Recovery House pilot project to address this concern. The paper aims to Investigate the project.

Design/methodology/approach

The Recovery House was co-created with and for people between 18 and 35 years old with diagnoses of psychosis and other complex mental health conditions. An integral part of the pilot was the organization of the “Recovery Community,” inspired by the Assembly model embraced by Franco Basaglia. The Recovery Community met regularly to both support and learn from the Recovery House and aimed to create a democratic and reflective space where power relationships, self-determination, responsibility and ownership by all the stakeholders, including family members, could be explored together.

Findings

Over a period of 31 months, four groups of people have successfully completed their residency at the Recovery House. In total, 89 percent of people who stayed at the Recovery House did so up to six months. After the period of staying at the Recovery House most of them moved to independent living or shared supported accommodation.

Originality/value

This initiative sheds light on the fact that democratic values, approaches and structures can improve both service functioning and the recovery outcomes for people with complex health needs. Further, the Recovery House has had a significant effect on the culture and practice of the MHD in adopting a comprehensive approach to emotional distress.

Childhood trauma in mood disorders: Neurobiological mechanisms and implications for treatment

A contemporary model for the pathogenesis of mood disorders (bipolar and depressive disorders) involves gene-environmental interaction, with genetic predisposition, epigenetic regulation, and environmental effects. Among multiple environmental factors, the experience of childhood trauma can be connected with the pathogenesis, course and the treatment of mood disorders. Patients with mood disorders have the greater frequency of childhood trauma compared with the general population, and adverse childhood experiences can exert a negative impact on their clinical course. In this article, the neurobiological mechanisms of childhood trauma are presented. The influence of negative childhood experiences on the central nervous system can result in many structural and functional changes of the brain, including such structures as hippocampus and amygdala, associated with the development of bipolar and depressive illnesses. Interaction of several genes with childhood trauma to produce pathological, clinical phenomena in adulthood has been demonstrated, the most important in this respect being the serotonin transporter gene and the FKBP5 gene playing an important role in the pathogenesis of mood disorders. Neurobiological effects can also involve epigenetic mechanisms such as DNA methylation which can exert an effect on brain function over long-term periods. Somatic effects of childhood trauma include disturbances of stress axis and immune-inflammatory mechanisms as well as metabolic dysregulation. Negative childhood experiences may also bear implications for the treatment of mood disorders. In the article, the impact of such experiences on the treatment of mood disorders will be discussed, especially in the context of treatment -resistance to antidepressants and mood-stabilizing drugs.

Experience of Child-Parent Separation and Later Risk of Violent Criminality

INTRODUCTION

Separation from a parent during childhood has been linked with heightened longer-term violence risk, but it remains unclear how this relationship varies by gender, separation subgroup, and age at separation. This phenomenon was investigated by examining a wide array of child-parent separation scenarios.

METHODS

National cohort study including individuals born in Denmark, 1971-1997 (N=1,346,772). Child-parent separation status was ascertained each year from birth to 15th birthday, using residential addresses from the Danish register. Members were followed up from their 15th birthday until the date of first violent offense conviction, or December 31, 2012. Incidence rate ratios were estimated using survival analyses techniques. Analyses were conducted during 2016-2017.

RESULTS

Separation from a parent during childhood was associated with elevated risk for subsequent violent offending versus those who lived continuously with both parents. These links were attenuated but persisted after adjustment for parental SES. Associations were stronger for paternal than for maternal separation at least up until mid-childhood and rose with the number of separations. Separation from a father for the first time at a younger age was associated with higher risks than if paternal separation first occurred at an older age, but there was little variation in risk associated with age at first maternal separation. Increasing risks were linked with rising age at first separation from both parents.

CONCLUSIONS

Violence prevention should include strategies to tackle a range of correlated familial adversities, with promoting a stable home environment being one salient aspect.

Parent-child separation: the relationship between separation and psychological adjustment among Chinese rural children

PURPOSE

The current study aimed to explore the characteristics of psychological adjustment among Chinese left-behind children (LBC) in rural areas, and to examine the association between separation duration from parent/parents (SDP) and children's psychological adjustment and the extent to which personality mediates this hypothesized link.

METHODS

We surveyed 534 rural children and adolescents aged 10-17 years at school (440 LBC and 94 non-LBC) in 2013, who were selected for participation using stratified cluster sampling from two counties in Chongqing, China. Measures used included socio-demographic variables, age at the commencement and end of the separation from parents, the revised Chinese Juvenile Eysenck Personality Questionnaire, and the Adolescent Psychological Adaptability Scale.

RESULTS

Most children (82.4%) had experienced separation from parents. t test results showed a marginally significant difference (p = .08) in psychological adjustment between LBC (mean = 64.44, SD = 8.62) and non-LBC (mean = 66.16, SD = 9.26). LBC's mean SDP was 5.64 years (SD = 3.90). Correlation analysis showed that children's SDP was negatively associated with psychological adjustment. Structural equation modeling showed that neuroticism, but not extraversion or psychoticism, fully mediated the link between children's SDP and psychological adjustment.

CONCLUSION

Personality (neuroticism) is one of the mediating pathways through which long-term SDP may predict poor psychological adjustment among children. Given the detrimental impact of long-term SDP, interventions should target the mediating pathway to buffer against the negative impact of parental separation on the affected rural children and to improve their mental health.

Childhood trauma and psychosis: Beyond the association

Childhood traumas have been extensively associated with the development of psychotic disorders. However, our understanding of processes underlying this relationship remains poor. In order to address this issue, we examined which specific aspects of childhood trauma are significantly associated with a first episode of psychosis. 109 patients with first episode of psychosis and 145 controls representative from general population were recruited in three centers in France. Child experiences of care and abuses allowed obtaining information about types of childhood trauma, age at first exposure, identity of perpetrator, and social support. Odds ratio were calculated for each of these aspects, adjusted for age, sex, and education. Sexual and physical abuses (OR=2.26 (1.19-4.32)), and separation from one or both parents (OR ranging from 1.94 to 3.17; all significant) are significantly associated with an increased risk to present a first episode of psychosis. Furthermore, separation from mother occurring before age of 4 (OR=5.96 (1.24-28.77)), and sexual and physical abuses perpetrated by someone other than parents (OR=4.61 (1.66-12.80)) were also associated with an increased risk of first episode of psychosis. Finally, social support was significantly associated with a decreased risk to develop psychotic disorders (OR ranging from 0.33 to 0.42; all significant). Together, these findings suggest that some but not all aspects of childhood trauma are related to a significant risk to develop a first episode of psychosis.

Risk of eating disorders in immigrant populations

OBJECTIVE

The risk of certain psychiatric disorders is elevated among immigrants. To date, no population studies on immigrant health have addressed eating disorders. We examined whether risk of eating disorders in first- and second-generation immigrants differs from native-born Danes and Swedes.

METHOD

All individuals born 1984-2002 (Danish cohort) and 1989-1999 (Swedish cohort) and residing in the respective country on their 10th birthday were included. They were followed up for the development of eating disorders based on out-patient and in-patient data.

RESULTS

The risks of all eating disorder types were lower among first-generation immigrants compared to the native populations: Incidence-rate ratio (95% confidence interval) was 0.39 (0.29, 0.51) for anorexia nervosa, 0.60 (0.42, 0.83) for bulimia nervosa, and 0.62 (0.47, 0.79) for other eating disorders in Denmark and 0.27 (0.21, 0.34) for anorexia nervosa, 0.30 (0.18, 0.51) for bulimia nervosa, and 0.39 (0.32, 0.47) for other eating disorders in Sweden. Likewise, second-generation immigrants by both parents were at lower risk, whereas those with only one foreign-born parent were not.

CONCLUSION

The decreased risk of eating disorders among immigrants is opposite to what has been observed for other psychiatric disorders, particularly schizophrenia. Possible explanations include buffering sociocultural factors and underdetection in health care.

Family structure and childhood mental disorders: new findings from Australia

PURPOSE

Many children now live in non-traditional families-including one-parent, blended, and step families. While a substantial body of international evidence indicates that these children display poorer cognitive and socio-emotional outcomes than children living in traditional families, research on childhood mental disorders is scarce. This report provides new evidence of the relationships between family structure and childhood mental disorders in an under-researched context, Australia.

METHODS

We use recent, nationally representative data on children aged 4-17 from Young Minds Matter, the second Australian Child and Adolescent Survey of Mental Health and Well-being (N = 6310). Mental disorders were assessed using the Diagnostic Interview Schedule for Children-Version IV and included social phobia, separation anxiety disorder, generalised anxiety disorder, obsessive-compulsive disorder, major depressive disorder, attention-deficit/hyperactivity disorder, and conduct disorder.

RESULTS

Compared to children living in original families, children in one-parent, blended, and step families experienced a higher prevalence of mental disorders. Amongst children whose parents separated, the time since separation was not statistically significantly related to the prevalence of mental disorders.

CONCLUSIONS

Although we are unable to assess causality, our findings highlight the strength of the association between family structure and child and adolescent mental health. They also stress the need for programs to support children, parents, and families in non-traditional family types to reduce mental health inequalities in childhood and later life.

Parental separation in childhood as a risk factor for depression in adulthood: a community-based study of adolescents screened for depression and followed up after 15 years

BACKGROUND

Earlier research has investigated the association between parental separation and long-term health outcomes among offspring, but few studies have assessed the potentially moderating role of mental health status in adolescence. The aim of this study was to analyze whether parental separation in childhood predicts depression in adulthood and whether the pattern differs between individuals with and without earlier depression.

METHODS

A community-based sample of individuals with adolescent depression in 1991-93 and matched non-depressed peers were followed up using a structured diagnostic interview after 15 years. The participation rate was 65% (depressed n = 227; non-depressed controls n = 155). Information on parental separation and conditions in childhood and adolescence was collected at baseline. The outcome was depression between the ages 19-31 years; information on depression was collected at the follow-up diagnostic interview. The statistical method used was binary logistic regression.

RESULTS

Our analyses showed that depressed adolescents with separated parents had an excess risk of recurrence of depression in adulthood, compared with depressed adolescents with non-separated parents. In addition, among adolescents with depression, parental separation was associated with an increased risk of a switch to bipolar disorder in adulthood. Among the matched non-depressed peers, no associations between parental separation and adult depression or bipolar disorder were found.

CONCLUSIONS

Parental separation may have long-lasting health consequences for vulnerable individuals who suffer from mental illness already in adolescence.

Neurocognitive performance, psychopathology and social functioning in individuals at high risk for schizophrenia or psychotic bipolar disorder

INTRODUCTION

Although cognitive deficits are consistent endophenotypes of schizophrenia and bipolar disorder, findings in psychotic bipolar disorder (BDP) are inconsistent. In this study we compared adult unaffected first-degree relatives of schizophrenia and BDP patients on cognition, psychopathology, social functioning and quality of life.

METHODS

Sixty-six unaffected first-degree relatives of schizophrenia patients (SUnR), 36 unaffected first-degree relatives of BDP patients (BDPUnR) and 102 controls participated in the study. Between-group differences were examined and Discriminant Function Analysis (DFA) predicted group membership.

RESULTS

Visual memory, control inhibition, working memory, cognitive flexibility and abstract reasoning were linearly impaired in the relatives' groups. Poorer verbal fluency and processing speed were evident only in the SUnR group. The SUnR group had higher depressive and somatization symptoms while the BDPUnR group had higher anxiety and lower social functioning compared with the controls. Individuals with superior cognition were more likely to be classified as controls; those with higher social functioning, prolonged processing speed and lower anxiety were more likely to be classified as SUnR.

LIMITATIONS

The relatives' sample is quite heterogeneous; the effects of genetic or environmental risk-factors were not examined.

CONCLUSIONS

Cognitive functions mediated by a fronto-parietal network, show linear impairments in unaffected relatives of BDP and schizophrenia patients; processing speed and verbal fluency impairments were evident only in schizophrenia relatives. Self-perceived symptomatology and social functioning also differ between schizophrenia and BDP relatives. The continuum seen in patients in several indices was also seen in the cognitive impairments in unaffected relatives of schizophrenia and BDP patients.

Self-harm risk between adolescence and midlife in people who experienced separation from one or both parents during childhood

BACKGROUND

Experience of child-parent separation predicts adverse outcomes in later life. We conducted a detailed epidemiological examination of this complex relationship by modelling an array of separation scenarios and trajectories and subsequent risk of self-harm.

METHODS

This cohort study examined persons born in Denmark during 1971-1997. We measured child-parent separations each year from birth to 15th birthday via complete residential address records in the Civil Registration System. Self-harm episodes between 15th birthday and early middle age were ascertained through linkage to psychiatric and general hospital registers. Incidence rate ratios (IRRs) from Poisson regression models were estimated against a reference category of individuals not separated from their parents.

RESULTS

All exposure models examined indicated an association with raised self-harm risk. For example, large elevations in risk were observed in relation to separation from both parents at 15th birthday (IRR 5.50, 95% CI 5.25-5.77), experiencing five or more changes in child-parent separation status (IRR 5.24, CI 4.88-5.63), and having a shorter duration of familial cohesion during upbringing. There was no significant evidence for varying strength of association according to child's gender.

LIMITATIONS

Measuring child-parent separation according to differential residential addresses took no account of the reason for or circumstances of these separations.

CONCLUSIONS

These novel findings suggest that self-harm prevention initiatives should be tailored toward exposed persons who remain psychologically distressed into adulthood. These high-risk subgroups include individuals with little experience of familial cohesion during their upbringing, those with the most complicated trajectories who lived through multiple child-parent separation transitions, and those separated from both parents during early adolescence.

Big data for bipolar disorder

The delivery of psychiatric care is changing with a new emphasis on integrated care, preventative measures, population health, and the biological basis of disease. Fundamental to this transformation are big data and advances in the ability to analyze these data. The impact of big data on the routine treatment of bipolar disorder today and in the near future is discussed, with examples that relate to health policy, the discovery of new associations, and the study of rare events. The primary sources of big data today are electronic medical records (EMR), claims, and registry data from providers and payers. In the near future, data created by patients from active monitoring, passive monitoring of Internet and smartphone activities, and from sensors may be integrated with the EMR. Diverse data sources from outside of medicine, such as government financial data, will be linked for research. Over the long term, genetic and imaging data will be integrated with the EMR, and there will be more emphasis on predictive models. Many technical challenges remain when analyzing big data that relates to size, heterogeneity, complexity, and unstructured text data in the EMR. Human judgement and subject matter expertise are critical parts of big data analysis, and the active participation of psychiatrists is needed throughout the analytical process.

Childhood adversities and psychosis: evidence, challenges, implications

There is a substantial body of research reporting evidence of associations between various forms of childhood adversity and psychosis, across the spectrum from experiences to disorder. This has been extended, more recently, to include studies of cumulative effects, of interactions with other factors, of specific effects, and of putative biological and psychological mechanisms. In this paper we evaluate this research and highlight the remaining methodological issues and gaps that temper, but do not dismiss, conclusions about the causal role of childhood adversity. We also consider the emerging work on cumulative, synergistic, and specific effects and on mechanisms; and discuss the broader implications of this line of research for our understanding of psychosis. We conclude that the current balance of evidence is that childhood adversities - particularly exposure to multiple adversities involving hostility and threat - do, in some people, contribute to the onset of psychotic experiences and psychotic disorders.