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Aims: To explore the association between a depression diagnosis in young adulthood and risk of marginalisation at age 29 years, among those who had completed upper secondary school and those who had not completed at age 21. Methods: In a longitudinal cohort study based on nationwide registers we followed 111,558 people from age 22–29 years. Outcomes were risk of marginalisation and educational achievement at age 29. Exposure was a diagnosed depression at ages 22–26 years. Comorbid mental and somatic health conditions, gender and country of origin were covariates. Relative risks were estimated with Poisson regression models, stratified by educational level at age 21. Results: For people who had not completed upper secondary school at age 21 years, a depression diagnosis at age 22–26 increased the risk of low income (relative risk = 1.33; 95% confidence interval = 1.25–1.40), prolonged unemployment benefit (1.46; 1.38–1.55) and social security benefit (1.56; 1.41–1.74) at age 29 compared with those with no depression. Among those who had completed upper secondary school at age 21 years, depression increased the risk of low income (1.71; 1.60–1.83), prolonged unemployment benefit (2.17; 2.03–2.31), social security benefit (3.62; 2.91–4.51) and disability pension (4.43; 3.26–6.01) compared with those with no depression. Mental comorbidity had a significant impact on risk of marginalisation in both groups. Conclusions: Depression in one’s mid-20s significantly increases the risk of marginalisation at age 29 years, and comorbid mental health conditions reinforce this association. Functional ability should be given priority in depression care in early adulthood to counteract marginalisation.

Depression är en växande folkhälsosjukdom och anses vara den globalt ledande orsaken till funktionsnedsättning. Internetbaserad kognitiv beteendeterapi (IKBT) för depression har visat sig vara en effektiv behandling. Behandlingsformatet kan tillhandahållas på varierande sätt, exempelvis utifrån vem som väljer behandlingsprogram och grad av behandlarstöd. Lägre grad av stöd är exempelvis mindre resurskrävande och kan därmed bidra till en ökning av tillgången på psykologisk behandling. Samtidigt kräver det ett mer kognitivt och beteendemässigt engagemang av patienten. Till följd av detta är det intressant att undersöka för vilka patienter som en friare behandlingsform är mest fördelaktigt. I den aktuella studien undersöks således två oberoende behandlingsvariabler, typ av individualiserat behandlingsprogram och typ av stöd. Dessa undersöks med en faktoriell design (2x2) på en IKBT-behandling för vuxna (N = 172) med depression. Syftet med studien är att undersöka huruvida grad av self-efficacy och behandlingstrovärdighet/utfallsförväntan korrelerar med depressiva symtom samt om initial grad av self-efficacy och behandlingsförväntan/utfallsförväntan kan predicera den eventuella symtomförändring som uppnåtts efter behandlingens slut. Med syftet att generera kunskap om vilka som drar nytta av ett friare, och mer kostnadseffektivt, behandlingsformat undersöks dessutom om grad av self-efficacy korrelerar med behandlingsutfall specifikt för deltagare i behandlingsgruppen med egenvalda moduler och stöd vid behov. Huruvida skillnader mellan behandlingsgrupperna föreligger undersöktes även vad gällande förändring i upplevd self-efficacy. Sammanfattningsvis visar resultatet att grad av self-efficacy ökar (d = 0.46) under behandlingen och att förändringen i self-efficacy korrelerar med förändringen i depressiva symtom. Ett samband mellan behandlingstrovärdighet/utfallsförväntan och behandlingsutfall påvisades dessutom. Initial grad av upplevd self-efficacy predicerar inte behandlingsutfallet totalt, men högre grad av upplevd self-efficacy vid ett friare behandlingsformat visades ha ett samband med lägre förändring i depressionssymtom (ηp2= .030). Denna studie belyser därmed vikten av att ta hänsyn till både self-efficacy och behandlingstrovärdighet/utfallsförväntan vid IKBT-behandling för depression, vilka båda visats ha ett samband med behandlingsutfallet.

Previous findings on peripartum anxiety are inconsistent in respect to the prevalence and course of peripartum anxiety with comorbidity of depression. Our aim was threefold: (1) to examine the course of elevated anxiety during pregnancy, immediately after childbirth, and six weeks postpartum; (2) to establish comorbidity of postpartum anxiety and postpartum depression (PPD); and (3) to examine predictors of anxiety 6 weeks postpartum. A sample of women (N=272) who were below the cut-off score for clinical depression during pregnancy were assessed in the third trimester of pregnancy, then 2 days and 6 weeks postpartum. Questionnaires on anxiety, pregnancy specific distress, stress, coping styles, social support, and depression were administered at each assessment. Obstetric data were collected from the participants’ medical records. The estimated rate of high anxiety was 35% during pregnancy, 17% immediately after childbirth, and 20% six weeks postpartum, showing a decrease in anxiety levels after childbirth. Comorbidity of anxiety and PPD was 75%. Trait anxiety and early postpartum state anxiety are significant predictors of postpartum anxiety. Anxiety is a common peripartum psychological disturbance. Anxiety symptoms overlap with PPD, but not completely, indicating that screening for postpartum mental difficulties should include both depression and anxiety., Prethodna istraživanja o peripartalnoj anksioznosti nisu dosljedna s obzirom na učestalost, tijek anksioznosti i komorbiditet s depresijom. Cilj ovoga istraživanja bio je: 1) ispitati tijek povišene anksioznosti u trudnoći, neposredno nakon porođaja i 6 tjedana nakon porođaja; 2) utvrditi komorbiditet anksioznosti i poslijeporođajne depresije (PD); 3) ispitati prediktore anksioznosti 6 tjedana nakon porođaja. Uzorak žena (N=272) s rezultatom nižim od kritičnog za kliničku depresiju u trudnoći praćen je u trećem tromjesečju trudnoće te 2 dana i 6 tjedana nakon porođaja. U svakoj točki mjerenja primijenjeni su upitnici anksioznosti, stresa, stresa specifičnog za trudnoću, načina suočavanja, socijalne potpore i depresivnosti. Opstetrički podaci prikupljeni su iz medicinske dokumentacije. Utvrđena je učestalost povišene anksioznosti od 35% u trudnoći, 17% neposredno nakon porođaja i 20% šest tjedana nakon porođaja, pri čemu je utvrđeno smanjenje razine anksioznosti nakon porođaja. Komorbiditet anksioznosti i PD-a je bio 75%. Anksioznost kao osobina i anksioznost kao stanje neposredno nakon porođaja značajni su prediktori anksioznosti šest tjedana nakon porođaja. Anksioznost je česta psihološka smetnja u peripartalnom razdoblju. Anksiozni simptomi se preklapaju s PD-om, ali ne u potpunosti, što upućuje na to da trijaža za poslijeporođajne mentalne teškoće mora uključivati i depresiju i anksioznost.

Previous findings on peripartum anxiety are inconsistent in respect to the prevalence and course of peripartum anxiety with comorbidity of depression. Our aim was threefold: (1) to examine the course of elevated anxiety during pregnancy, immediately after childbirth, and six weeks postpartum; (2) to establish comorbidity of postpartum anxiety and postpartum depression (PPD); and (3) to examine predictors of anxiety 6 weeks postpartum. A sample of women (N=272) who were below the cut-off score for clinical depression during pregnancy were assessed in the third trimester of pregnancy, then 2 days and 6 weeks postpartum. Questionnaires on anxiety, pregnancy specific distress, stress, coping styles, social support, and depression were administered at each assessment. Obstetric data were collected from the participants’ medical records. The estimated rate of high anxiety was 35% during pregnancy, 17% immediately after childbirth, and 20% six weeks postpartum, showing a decrease in anxiety levels after childbirth. Comorbidity of anxiety and PPD was 75%. Trait anxiety and early postpartum state anxiety are significant predictors of postpartum anxiety. Anxiety is a common peripartum psychological disturbance. Anxiety symptoms overlap with PPD, but not completely, indicating that screening for postpartum mental difficulties should include both depression and anxiety. Prethodna istraživanja o peripartalnoj anksioznosti nisu dosljedna s obzirom na učestalost, tijek anksioznosti i komorbiditet s depresijom. Cilj ovoga istraživanja bio je: 1) ispitati tijek povišene anksioznosti u trudnoći, neposredno nakon porođaja i 6 tjedana nakon porođaja; 2) utvrditi komorbiditet anksioznosti i poslijeporođajne depresije (PD); 3) ispitati prediktore anksioznosti 6 tjedana nakon porođaja. Uzorak žena (N=272) s rezultatom nižim od kritičnog za kliničku depresiju u trudnoći praćen je u trećem tromjesečju trudnoće te 2 dana i 6 tjedana nakon porođaja. U svakoj točki mjerenja primijenjeni su upitnici anksioznosti, stresa, stresa specifičnog za trudnoću, načina suočavanja, socijalne potpore i depresivnosti. Opstetrički podaci prikupljeni su iz medicinske dokumentacije. Utvrđena je učestalost povišene anksioznosti od 35% u trudnoći, 17% neposredno nakon porođaja i 20% šest tjedana nakon porođaja, pri čemu je utvrđeno smanjenje razine anksioznosti nakon porođaja. Komorbiditet anksioznosti i PD-a je bio 75%. Anksioznost kao osobina i anksioznost kao stanje neposredno nakon porođaja značajni su prediktori anksioznosti šest tjedana nakon porođaja. Anksioznost je česta psihološka smetnja u peripartalnom razdoblju. Anksiozni simptomi se preklapaju s PD-om, ali ne u potpunosti, što upućuje na to da trijaža za poslijeporođajne mentalne teškoće mora uključivati i depresiju i anksioznost.

UVOD: Moždani udar spada u grupu masovnih nezaraznih bolesti, koje se smatraju najčešćim oboljenjima savremenog čoveka. On predstavlja jedan od najčešćih uzroka mortaliteta i invaliditeta u savremenom svetu. Među brojnim pratećim komplikacijama moždanog udara, navode se psihički poremećaji: depresija, anksioznost i psihotični poremećaji. Utvrđivanje povezanosti moždanog udara sa psihičkim poremećajima, kao i mehanizma njihovog nastanka predstavlja značajan doprinos boljem razumevanju ovog veoma čestog oboljenja, a njihov rani tretman omogućio bi brži i potpuniji oporavak nakon moždanog udara. CILJ: Utvrditi karakteristike psihičkog funkcionisanja osoba nakon ishemičnog moždanog udara, utvrditi uticaj lokalizacije lezije na nastanak određenih psihičkih poremećaja nakon moždanog udara, utvrditi uticaj vaskularnog statusa na nastanak psihičkih poremećaja, te utvrditi korelaciju između psihičkih komplikacija moždanog udara i brzine i stepena oporavka opšte životne aktivnosti. MATERIJAL I METODE: Istraživanje je izvedeno kao prospektivna studija, obuhvatilo je 101 pacijenta oba pola obolelih od moždanog udara, koji su hospitalno lečeni na Klinici za neurologiju u Novom Sadu. Svim pacijentima je uzeta anamneza o toku bolesti, faktorima rizika za moždani udar, kao i laboratorijska dijagnostika. Svim pacijentima načinjena je kompjuterizovana tomografija (CT) mozga (ili magnetna rezonanca - MRI mozga), ultrazvučni pregled karotidnih arterija, vertebrobazilarnih i krvnih sudova Willisovog poligona. Stepen neurološkog deficita i praćenje funkcionalnog oporavka u akutnoj fazi i nakon 3 meseca vršeno je primenom Skale Moždanog Udara Nacionalnog Instituta za Zdravlje (NIHSS), Rankinove skale i Bartelovog indeksa. Svim pacijentima je načinjena eksploracija psihičkog statusa u akutnoj fazi bolesti primenom Bekove Skale Depresije 2 (BDI-2), Skale procene anksioznosti kao stanja i odlike (STAI), Skale pozitivnih i negativnih sindroma (PANSS) i Kornelovog regrutnog indeksa (CSI). Kontrolno testiranje gore navedenim testovima obavljeno je nakon 3 meseca. Od statističkih metoda korišćena je deskriptivna statistika: tabelarni prikazi učestalosti i procentualna izraženost kod neparametrijski (nominalno ili ordinarno) organizovanih varijabli. Za ukršten prikaz dve varijable korišćene su tabele kontingencije. Takođe su korišćene mere centralne tendencije (aritmetička sredina) i mere disperzije (standardna devijacija) kod parametrijski korektno uređenih varijabli. Pored toga, korišćen je Hi-kvadrat test za utvrđivanje razlika između grupa za varijable nominalnog nivoa merenja, Kramerovo V za utvrđivanje povezanosti između nominalnog nivoa merenja, Pirsonov koeficijent korelacije r, za utvrđivanje povezanosti između varijabli intervalnog nivoa merenja, te analiza varijanse (ANOVA) za utvrđivanje značajnosti razlika između aritmetičkih sredina više grupa. REZULTATI: U ispitivanje je uključen 101 pacijent, 65.3% muškog pola, 34.7% ženskog pola. Prosečna starost bila je 60.69 godina (medijana=62.00, standardna devijacija =10.828, statistička greška=1.077). 38.6% je imalo lokalizaciju u desnoj hemisferi velikog mozga, 34.7% u levoj hemisferi, 4% u cerebelumu, 11.9% u moždanom stablu, dok je 10.9% imalo višestruku lokalizaciju infarkta. 39.6% je imalo teritorijalni infarkt, a 59.4% lakunarni infarkt. Distribucija faktora rizika za moždani udar bila je uobičajena za podneblje na kojem je vršeno istraživanje. 26.7% je imalo uredan nalaz na karotidnim krvnim sudovima, 26.7% je imalo difuznu ateromatozu, 27.7% je imalo stenozu ACI 70%. U odnosu na nalaz u VB slivu, 52.5% je imalo uredan nalaz, a 47.5% patološki nalaz (stenozu i difuznu ateromatozu). 54.5% pacijenata je imalo uredan nalaz na arterijama Willisovog poligona, a 45.5% je imalo patološki nalaz (stenozu i difuznu ateromatozu). 5.9% je imalo depresivni poremećaj, 29.7% anksiozni poremećaj, 9.9% neurotski poremećaj i 2% psihotični poremećaj. U odnosu na pol, depresivni poremećaj javlja kod 3% muškaraca i 11.4% žena, anksiozni kod 25.8% muškaraca i 37.1% žena, neurotski kod 7.6% muškaraca i 14.3% žena i psihotični kod 3% muškaraca, dok kod žena nije zabeležen. U odnosu na životno doba, kod mlađih od 45 godina depresija nije bila prisutna, anksioznih je bilo 30%, 10% psihotičnih, dok neurotičnih nije bilo. U grupi 46-65 godina depresivnih je bilo 6.9%, anksioznih 22.4%, neurotičnih 12.1%, a psihotičnih 1.7%. U grupi starijih od 65 godina, depresivnih je bilo 6.1%, anksioznih 42.4%, neurotičnih 9.1%, dok psihotičnih nije bilo. Distribucija odgfovora dobijenih na BDI-2 skali ukazivala je na veću učestalost depresivnog poremećaja kod lezija u levoj hemisferi velikog mozga. Distribucija odgovora dobijenih primenom STAI ukazivala je na veću učestalost anksioznog poremećaja kod lezija desne hemisfere. Distribucija odgovora dobijenih primenom CSI ukazivala je na veću učestalost neurotskog poremećaja kod višestrukih lezija. Distribucija odgovora dobijenih primenom PANSS ukazivala je na veću učestalost psihotičnog poremećaja kod lezija desne hemisfere. Upoređivanje lezije na karotidama i psihičkih poremećaja pokazalo je na progresivni porast učestalosti psihičkih poremećaja sa težinom lezije na karotidnim krvnim sudovima, kao i na potpuno odsustvo psihičkih poremećaja kod osoba koje su imale uredan nalaz na karotidama. Praćenje uticaja psihičkih poremećaja (sumarno i pojedinačno) na funkcionalni oporavak pacijenata nakon moždanog udara, nije pokazalo statistički značajan uticaj. Zabeleženo je statistički značajno udruženo pojavljivanje depresivnog i anksioznog, depresivnog i neurotskog i anksioznog i neurotskog poremećaja, bez značajne interakcije navedenih poremećaja sa psihotičnim poremećajem. ZAKLJUČAK: Kod pacijenata sa ishemičnim moždanim udarom najveća je učestalost anksioznog poremećaja, zatim depresivnog poremećaja, a najređe se javlja psihotični poremećaj. Depresivni i anksiozni poremećaj značajno su češći kod žena, dok se psihotični poremećaji isključivo javljaju kod muškaraca. Depresivni poremećaj značajno se češće javlja u srednjem i starijem životnom dobu, anksiozni poremećaj se češće javlja u mlađem i srednjem životnom dobu, dok se psihotične manifestacije javljaju najčešće u srednjem životom dobu. Depresivni i anksiozni poremećaj jednako se često javljaju kod pacijenata sa teritorijalnim i lakunarnim infarktom, dok se psihotične manifestacije isključivo javljaju kod pacijenata sa teritorijalnim infarktom. Ne postoji značajna korelacija između prisustva faktora rizika za moždani udar i pojave psihičkih poremećaja, iako je upadljivo odsustvo psihičkih poremećaja kod pacijenata bez faktora rizika za moždani udar. Nakon 3 meseca od moždanog udara nije primećena značajnija regresija simptoma psihičkih poremećaja. Anksiozni poremećaj i psihotične manifestacije se statistički značajno češće javljaju kod infarkta u desnoj hemisferi, dok za depresivni poremećaj nije potvrđeno statistički značajno češće pojavljivanje kod infarkta u levoj hemisferi. Psihički poremećaji kod pacijenata sa moždanim udarom češće se javljaju kod pacijenata sa lezijama u karotidnom slivu, što se povećava sa težinom lezije i veličinom stenoze. Ne postoji statistički značajna korelacija između lezija krvnih sudova u vertebrobazilarnom slivu i Willisovom poligonu sa pojavom psihičkih poremećaja. Nije dokazan značajan uticaj psihičkih poremećaja na oporavak bolesnika nakon moždanog udara. Dokazan je visok stepen udruženog javljanja depresivnog i anksioznog poremećaja., INTRODUCTION: Stroke belongs to noninfectious diseases, which are considered the most common diseases of modern man. It is one of the most common causes of mortality and disability in the modern world. The many associated complications of stroke include mental disorders: depression, anxiety and psychotic disorders. Determining the relationship between stroke and mental disorders, as well as enlightening their underlying mechanism, represents a significant contribution to a better understanding of this very frequent disease, and an early treatment of these associated disorders should allow a faster and more complete recovery from stroke. OBJECTIVE: To determine characteristics of mental functioning after ischemic stroke, to determine the impact of lesion localization on development of certain mental disorders after stroke, to determine the impact of vascular status on development of mental disorders, and to determine the correlation between the associated mental disorders and the speed and degree of recovery of general life activities. MATERIALS AND METHODS: The research was conducted as a prospective study that included 101 ischemic stroke patients of both sexes, hospitalized at the Clinic of Neurology in Novi Sad. Data about the course of disease and stroke risk factors was collected and laboratory diagnostics was performed in all patients. All patients underwent brain computed tomography (CT) (or magnetic resonance imaging - MRI), and ultrasound examination of carotid and vertebrobasilar arteries and the circle of Willis. The degree of neurological deficit and functional recovery in the acute phase and at 3-month follow-up were assessed using the National Institute of Health Stroke Severity (NIHSS) scale, the Rankin scale, and the Barthel Index. All patients underwent psychological exploration of the mental status in the acute phase of stroke by using the Beck Depression Inventory 2 (BDI - 2), the State-Trait Anxiety Inventory (STAI), the Positive and Negative Syndrome Scale (PANSS), and the Cornell Services Index (CSI). Follow-up testing with the same tests was performed after 3 months. Statistical analysis included methods of descriptive statistics: tabular presentation of the frequency and percentages in case of nonparametric (nominal or ordinal) variables. Contingency tables were used to present relationships between two variables. In addition, measures of central tendency (arithmetic mean) and measures of dispersion (standard deviation) were used for parametric variables. The chisquared test was used to determine differences between groups for nominal measurement variables, Cramer’s V was used to examine association between nominal levels of measurement. Association between interval measurement variables was measured by the Pearson correlation coefficient (r), and significance of differences between arithmetic means of more groups was determined by the analysis of variance (ANOVA). RESULTS: The study included 101 patients, 65.3% male and 34.7% female. The average age of patients was 60.69 years (median=62.00, standard deviation=10.828, statistical error=1.077). Stroke localizations were as follows: the right cerebral hemisphere in 38.6%, the left hemisphere in 34.7%, the cerebellum in 4%, the brainstem in 11.9%, and 10.9% of patients had multiple localizations. In 39.6% of patients, stroke was territorial, and in 59.4% lacunar. The distribution of risk factors for stroke was typical for the study area. Normal carotid arteries were found in 26.7%, 26.7% had diffuse atheromatosis, 27.7% had 70% ACI stenosis. As regards VB circulation, 52.5% had normal findings and 47.5% had pathological findings (stenosis and diffuse atheromatosis). As regards the circle of Willis, 54.5% had normal findings and 45.5% had pathological findings (stenosis and diffuse atheromatosis). Regarding mental functioning, 5.9% had depressive disorder, 29.7% had anxiety disorder, 9.9% had neurotic disorder, and 2% had psychotic disorder. In relation to sex, mental disorders were present as follows: depressive disorder in 3% of men and 11.4% of women, anxiety disorder in 25.8% of men and 37.1% of women, neurotic disorder in 7.6% of men and 14.3% of women, and psychotic disorder in 3% of men and none of women. With respect to age, among patients under 45 years of, age none had depressive disorder, 30% had anxiety disorder, 10% had psychotic disorder, and none had neurotic disorder. In the group of patients aged 46-65 years, 6.9% had depressive disorder, 22.4% had anxiety disorder, 12.1% had neurotic disorder, and 1.7% had neurotic disorder. In the group above 65 years of age, 6.1% had depressive disorder, 42.4% had anxiety disorder, 9.1% had neurotic disorder, and none had psychotic disorder. The distribution of responses obtained on the BDI-2 showed a higher prevalence of depressive disorder in patients with lesions in the left cerebral hemisphere. The distribution of responses obtained on the STAI showed a higher prevalence of anxiety disorder in patients who had lesion of the right hemisphere. The distribution of responses obtained on the CSI showed a higher prevalence of neurotic disorder in those who had multiple lesions. The distribution of responses obtained by the PANSS indicated a higher prevalence of psychotic disorder in those with lesion of the right hemisphere. Comparison of carotid artery lesions and mental disorders showed a progressive increase in the prevalence of mental disorders with increasing severity of the lesions, as well as a complete absence of mental disorders in people who had normal findings on carotids. The follow-up results showed that mental disorders (generally and individually) did not have a statistically significant effect on functional recovery of stroke patients. There were statistically significant comorbidities of depressive disorder and anxiety disorder, depressive disorder and neurotic disorder, and anxiety disorder and neurotic disorder, and no significant interactions of any of these disorders with psychotic disorder. CONCLUSION: In patients with ischemic stroke, anxiety disorder has the highest prevalence, followed by depressive disorder, whereas psychosis is the rarest. Depressive and anxiety disorders are significantly more common in women, while psychotic disorder occurs exclusively in men. Depressive disorder is significantly more common in the middle and old ages, anxiety disorder is more frequent in the younger and middle ages, while psychotic manifestations occur most often in the middle age of life. Depressive and anxiety disorders are similarly prevalent in patients with territorial and lacunar strokes, while psychotic manifestations occur exclusively in patients with territorial stroke. There is no significant correlation between the presence of stroke risk factors and mental disorders, although there is an evident absence of mental disorders in patients without stroke risk factors. Three months after stroke, no significant regression of the symptoms of mental disorders was observed. Anxiety disorder and psychotic manifestations are significantly more common in right hemispheric stroke, while as regards depressive disorder, there is no statistically significant association with left-hemispheric stroke. Mental disorders in stroke patients are more common in those with carotid lesions and increase in severity with increasing severity of lesion and degree of stenosis. There are no statistically significant correlations between lesions in the vertebrobasilar circulation or the circle of Willis and development of mental disorders. No significant impact of mental disorders on recovery from stroke was found. A high prevalence of comorbid depressive and anxiety disorders was proven/confirmed.

Uvod - Etiologija sindroma gornjeg otvora grudnog koša (thoracic outlet syndrome- TOS) je udruženost više faktora koji su posledica narušavanja anatomsko-topografskih odnosa u nivou gornjeg otvora grudnog koša: kostoklavikularnog prostora, prednjeg skalenskog otvora, kao i same mehanike rebarnih zglobova i hrskavica, koji dovode do suženja prostora kroz koje prolaze neurovaskularne strukture, njihove kompresije, a samim tim i iritacije neurovaskularnih struktura. Sindrom gornjeg otvora grudnog koša je kompleks simptoma uzrokovanih kompresijom brahijalnog spleta, vene subklavije, arterije subklavije i simpatičkih vlakana, koji karakterišu bol, parestezije, mišićna slabost i osećaj nelagodnosti u ruci/rukama koji se pojačava podizanjem ruke/ruku ili prekomernim pokretima glave i vrata, te dovode do smanjenja funkcionalne sposobnosti ruke/ruku i poteškoća u obavljanju svakodnevnih aktivnosti. Pored toga imaju često izraženu tahikardiju, osećaj stezanja u grudima, glavobolju, vrtoglavicu, zujanje u ušima. Navedene tegobe su izraženije ponekad noću i dovode do poremećaja spavanja (problemi usnivanja, hrkanje, kašljanje, osećaj toplo/hladno, apnea, poremećaj dnevno/noćnog ritma- hronotipizacija, itd). Kao posledica lošeg spavanja moguća je pojava depresivnih simptoma. U raspoloživoj literaturi, spavanje i kvalitet spavanja se uglavnom posmatraju kroz prizmu drugih bolesti i stanja. Materijal i metode - Istraživanjem je obuhvaćeno ukupno 181 (sto osam deset jedna) osoba. Od tog broja 53 muškarca i 128 žena. Test grupu sačinjavalo je 82 ispitanika sa dijagnostikovanim TOS, a 99 zdravih osoba/osoba oba pola koji nemaju simptomatologiju TOS, je predstavljalo kontrolnu grupu. Grupe su bile ujednačene po polu i starosti (od 18 do 65). Tokom studije ispitanici su podvrgnuti kliničkom pregledu – fizikalnom i neurološkom pregledu. Pregled je podrazumevao pregled posture obolelog (posmatranje mišića regije vrata, ramena i ruku- trofika, tonus, konzistencija, mobilnost i kontraktilnost), posmatranje promena na koži (sa posebnim osvrtom na promene boje kože, trofičkih promena kože i noktiju i temperature kože ruku - šaka), testiranje refleksa, ispitivanje senzibiliteta u regijama inervacije odgovarajućih spinalnih korenova brahijalnog spleta. Takođe vršena je analiza stanja uhranjenosti (telesna visina, telesna masa, indeks telesne mase) i izvođenje provokativnih testova (Adson manevar, Rus test, Halsted test, Elvi test i Kostoklavikularni test). Kao deo ispitivanja obavljeno je i radiološko snimanje vratne kičme kao i pregled oscilografom. Ispitanici su imali za zadatak da ispune sledeće upitnike: Upitnik o nesposobnosti ruke, ramena i šake (DASH), Pitsburški indeks kvaliteta spavanja (PSQI), Upitnik o hronotipizaciji (MEQ), Bekov upitnik o depresiji (BDI II). Na kraju ispitanici su davali odgovore na pitanja iz vodiča za istraživača sastavljenog sa ciljem evaluacije različitih aspekata spavanja. Rezultati - Rezultati su pokazali da su upotrebljene skale dale zadovoljavajuću pouzdanost. Pokazalo se da osobe sa dijagnozom TOS pored bogate simptomatologije imaju još i probleme sa spavanjem. Analizom rezultata došlo se do zaključka da osobe sa dijagnozom TOS su starije, imaju više problema sa spavanjem i veću nesposobnost ruke, ramena i šake. Nije se pokazala razlika u hronotipizaciji kod osoba sa TOS u odnosu na kontrolnu grupu. Takođe može se zaključiti da osobe koje imaju izraženu nesposobnost ruku, ramena i šake imaju značajno veću šansu da imaju sindrom gornjeg otvora grudnog koša. Ove osobe pri tom imaju i veću šansu da razviju depresiju i poremećaj spavanja, te se zaključuje da ova dva parametra svoj uticaj na TOS ostvaruju preko problema sa funkcionisanjem ruke, ramena i šake. Dobar prediktor za postavljanje dijagnoze TOS može biti testiranje osoba DASH skalom. Zaključak - Rezultati studije mogu biti putokaz daljim istraživanjima, koja bi otvorila vrata formiranju protokola i opservaciji kvaliteta života osoba sa sindroma gornjeg otvora grudnog koša, sa posebnim osvrtom na poremećaje spavanja., Etiology of thoracic outlet syndrome (TOS) is an association of several factors which are the result of disruption in the anatomical-topographical relations, in the level of superior thoracic aperture: costoclavicular space, anterior scalene aperture, as well as the mechanics of rib joints and cartilage, causing narrowing of space through which the neurovascular structures pass, their compression, and thus the irritation of neurovascular structures. Thoracic outlet syndrome is a complex of symptoms caused by the compression of the brachial plexus, subclavian vein, subclavian artery and sympathetic fibres, which is characterized by pain, parasthesias, muscle weakness and a feeling of discomfort in the arm / arms, which increases with raising the arm/arms or by excessive head and neck movements leading to a reduction of functional capabilities of the hands / arms and difficulties in everyday activities. In addition, patients often have expressed tachycardia, feeling of tightness in the chest, headache, dizziness, tinnitus. These problems are more pronounced at night and sometimes lead to sleep disorders (difficulty in falling asleep, snoring, coughing, feeling hot/cold, apnea, day/night rhythm disorder - Morningness/Eveningness disorder, etc.). As a result of poor sleeping depressive symptoms may occur. In the available bibliography, sleep and quality of sleep are mainly viewed through other diseases and conditions. The study included a total number of 181 (one hundred eighty one) people. Out of that 53 men and 128 women. The test group consisted of 82 patients diagnosed with TOS, and 99 healthy persons of both genders who had no symptoms of TOS, and constitute the control group. Groups were equalled by gender and age (18 to 65). Throughout the study subjects underwent clinical examination - both physical and neurological. This included an assessment of posture of the patient (observation of muscles in region of the neck, shoulders and arms - trophic, muscle tone, consistency, mobility and contractility), observation of changes on the skin (with a special emphasis on skin colour changes, trophic changes of the skin, nails and skin temperature of arms - hands), reflex testing, sensitivity testing in regions of innervations which correspond to spinal roots of the brachial plexus. Moreover, an analysis was conducted on the body composition analysis (body height, body weight, body mass index) as well as provocative tests (Adson manoeuvre, the Roos test, Halstead test, Elvy test and Costoclavicular test). Radiology scan of the cervical spine as well as oscillograph testing was conducted as a part of the test. The subjects were asked to fulfil the following questionnaires: Questionnaire on Disabilities of the Arm, Shoulder and Hand (DASH), Pittsburgh Sleep Quality Index (PSQI), The Morningness / Eveningness Questionnaire (MEQ), Beck Questionnaire on Depression (BDI II). Finally the subjects answered questions that researcher had drawn up in order to evaluate different aspects of sleep. The results showed that the scales used were reliable. It proved that persons diagnosed with TOS in addition to numerous symptoms also had problems with sleep. By analyzing the results it was concluded that people diagnosed with TOS are older, have more problems with sleep and greater disability of arms, shoulders and hands. There was no difference in Morningness/Eveningness type in patients with TOS in comparison to the control group. It can also be concluded that people who have pronounced disability of arms, shoulders and hands have a significantly greater chance of having thoracic outlet syndrome. These persons are more likely to develop depression and sleep disorders therefore those two entities impact TOS through the problems with the functioning of the arms, shoulders and hands. A good predictor in diagnosis of TOS may be testing people with DASH scale. The study findings can serve as a guideline for further research, opening the door into forming protocols and observation of the quality of life of people with the thoracic outlet syndrome, with special emphasis on sleep disorders.

Cilj ovog istraživanja je utvrditi specifičnosti depresije u ranoj, srednjoj i kasnoj adolescenciji, učestalost depresije po dobi adolescenata te raspodjelu depresije po spolu. Također je cilj prikazati komorbiditetna stanja koja su najčešća u adolescenciji, analizirati njihovu pojavnost s obzirom na tri faze adolescencije. U istraživanje su uključeni adolescenti s dijagnozom depresije koji su posjećivali ambulantu za dječju i adolescentnu psihijatriju. Podaci potrebni za istraživanje prikupljeni su iz medicinske dokumentacije Poliklinike za rehabilitaciju osoba sa smetnjama u razvoju u Splitu. Podaci su uneseni i analitički obrađeni u programu Microsoft Office Excel 2010. Ovim istraživanjem analizirano je 105 pacijenata s depresijom. Što se tiče raspodjele depresije prema spolu, nešto je učestalija kod ženske djece s 52%. U ranoj adolescenciji bilo je više depresivnih dječaka. Za razliku od rane, u srednjoj i kasnoj adolescenciji je depresija bila izraženija u adolescentica. Najveća učestalost depresije bila je u 17. godini. Što se tiče specifičnosti depresije u ranoj adolescenciji je najveća učestalost poremećaja ponašanja, tikova, te selektivnog mutizma. U srednjoj adolescenciji ponovno dominiraju poremećaji ponašanja a slijede ih psihotična depresija, školska fobija i mucanje. U kasnoj adolescenciji kao i u ranoj i srednjoj, najveća je učestalost poremećaja ponašanja nakon kojih slijedi školska fobija i psihotični oblici depresije. Najveću učestalost u komorbiditetu je imalo ovisničko ponašanje koje čini čak 34% ukupnog komorbiditeta. Na drugom mjestu je depresija povezana s organskim uzrocima koja čini 24% ukupnog komorbiditeta. 17 % ukupnog komorbiditeta otpada na opsesivno kompulzivni poremećaj. U ranoj adolescenciji dominira depresija povezana s organskim uzrocima, u srednjoj najviše je bilo opsesivno kompulzivnog ponašanja, a u kasnoj adolescenciji najviše adolescenata je pokazivalo ovisničko ponašanje. U ranoj i srednjoj adolescenciji ovisničko ponašanje je dominantno u muške djece i u tim slučajevima se radi o ovisnosti o kompjuterskim igricama za razliku od kasne adolescencije u kojoj dominira ovisničko ponašanje kod ženskih adolescenta i tim slučajevima se radi o ovisnosti o raznim drogama. Učestalost izolirane depresije je samo 27% u odnosu na depresiju s komorbiditetom koje čini 73%. Depresija mijenja obličje od rane do kasne adolescencije. Nešto je učestalija kod adolescentica te je u velikom broju slučajeva popraćena poremećajima ponašanja. Ovisničko ponašanje često prati depresiju te postoji razlika među spolovima u izboru ovisničkog ponašanja., The aim of this study was to determine the distinctiveness of depression in the three phases of adolescence, the frequency of depression according to the age of the adolescents and the distribution of depression by gender. Also our goal was to show the comorbid conditions that are most common in adolescence, analyze their appearance according to the three phases of adolescence. The study included adolescents that were diagnosed with depression and frequented the infirmary for child and adolescent psychiatry. The data was collected from the medical documentation of the Polyclinic for rehabilitation of persons with developmental difficulties in Split. The data was entered and analyzed analytically using Microsoft Office Excel 2010. We analyzed 105 patients with depression. Regarding the distribution by gender, depression was more often found with female adolescents (52%). In early adolescence depression was more often found with boys. In median and late adolescence, depression was more often found with female adolescents. We found that the biggest frequency of depression was with adolescents aged 17. Specifically, behavioral disorders, tics and selective mutism were the most frequent of disorders in early adolescence. Behavioral disorders, psychotic depression, school phobia and stutter were the dominant disorders in median adolescence. In late adolescence we most often found behavioral disorders followed by school phobia and psychotic depression. Regarding comorbidity, 34% of the complete comorbidity was made up of addictive behavior. The second most often disorder was the depression connected with organic diseases which made up 24% of the comorbidity. 17% of the comorbidity was made out of obsessive compulsive disorder. In early adolescence, depression connected with organic diseases was most common, in the median adolescence obsessive compulsive disorder was most common and in the late adolescence addictive behavior was most common. Addictive behavior in early and median adolescence was more often found with boys and it manifested itself as computer game addiction. In late adolescence it manifested itself as substance addiction and it was more often found with female adolescents. The frequency of isolated depression was 27% compared to the depression connected with comorbidity which made up 73% of the total ddepression. Depression changes its form from early to late adolescence. It’s somewhat more frequent with female adolescents and in most cases is followed by behavioral disorders. Addictive behavior often follows depression and we must not neglect the potential differences in the addictive behavior.

Komorbiditet u bolesnika s reumatoidnim artritisom (RA) otežava i/ili ograničava liječenje primarne bolesti te negativno utječe na cjelokupnu kvalitetu života bolesnika, kao i na ishode bolesti. Kardiovaskularni komorbiditet vodeći je uzrok povećanog mortaliteta u ovih bolesnika i do dva puta je veći u odnosu na opću populaciju. Povišenom mortalitetu pridonose i infekcije, plućna bolest i malignomi dok kroničan umor, depresija i osteoporoza pridonose smanjenoj kvaliteti života. Osim adekvatnog liječenja reumatoidnog artritisa (postizanje remisije ili najmanje niske aktivnosti bolesti) u svakodnevnom kliničkom radu potrebno je činiti i probir na komorbiditete koji su vrlo česti i s primarnom bolesti kompleksno uzročno-posljedično povezani. Takav pristup omogućuje bolju kvalitetu života i u konačnici ishod u bolesnika s reumatoidnim artritisom i komorbiditetom., Comorbidity in rheumatoid arthritis (RA) patients significantly impairs and limits management of primary disease, decreases general quality of life, and worsens outcomes. Cardiovascular comorbidity is the leading cause of excess mortality in RA patients, which is up to two times higher compared to the general population. Infections, pulmonary disease and malignant diseases also contribute to excess mortality, while fatigue, depression and osteoporosis are related to decreased quality of life. Adequate management of RA patients should therefore, besides tight control of disease activity, also include comorbidity screening and management. This approach should improve both RA and comorbidity related outcomes.

The aim of this study was to evaluate the prevalence of psychiatric comorbidities, depression and anxiety, among patients with epilepsy in the outpatient Clinic for Epilepsy, Clinical Centre of Montenegro. Patients aged 18 and above with a diagnosis of epilepsy for at least one year were consecutively enrolled during a six-month period. Patients anonymously filled out a questionnaire which included data on the gender, age, education, marital status and degree of seizure control. The Hamilton Depression Rating Scale (HAM-D) and Hamilton Anxiety Rating Scale (HAM-A) were used to evaluate the presence or absence of anxiety and depression. Total number of study patients was 70, including 52 patients with partial seizures and 18 patients with generalized tonic-clonic seizures. The mean patient age was 37}7.92 years. The prevalence of depression in our sample was 32.8%, whereas the prevalence of anxiety was 21.4%. Patients with partial seizures were more depressed, while those with idiopathic generalized seizures were more anxious (p, Cilj ovoga istraživanja bio je ispitati učestalost psihijatrijskih bolesti, depresije i anksioznosti, u bolesnika s epilepsijom u Dispanzeru za epilepsije Kliničkog centra Crne Gore. Bolesnici u dobi od 18 godina i više s dijagnozom epilepsije od najmanje jedne godine uključivani su u studiju kroz šest mjeseci. Bolesnici su ispunjavali upitnik koji je uključivao podatke o spolu, dobi, obrazovanju, bračnom stanju i stupnju kontrole napadaja. Ljestvice Hamilton Depression Rating Scale (HAM-D) i Hamilton Anxiety Rating Scale (HAM-A) su korištene za procjenu prisutnosti ili odsutnosti depresije i tjeskobe. Ukupno je bilo uključeno 70 bolesnika: 52 bolesnika s parcijalnim napadajima i 18 bolesnika s generaliziranim toničko-kloničkim napadajima. Prosječna dob bolesnika je bila 37}7,92 godine. Učestalost depresije u našem uzorku je bila 32,8%, dok je učestalost anksioznosti bila 21,4%. Bolesnici s parcijalnim napadajima su bili više depresivni u odnosu na bolesnike s idiopatskim generaliziranim napadajima, koji su bili anksiozniji (p

Insomni och depression är psykiatriska åkommor som idag drabbar många människor. Forskning har visat att det råder en stor samsjuklighet mellan diagnoserna där många drabbade lider av samtidig insomni och depression vilket utgör en stor belastning för den enskilde individen. Patienter rapporterar ofta en negativ påverkan på kognitiva funktioner, bland annat minnessvårigheter och problem med koncentration och uppmärksamhet. Inom forskningen råder det i dagsläget en osäkerhet kring vilka kognitiva nedsättningar som karakteriserar personer med dessa diagnoser och på vilka sätt de skiljer sig åt. Det finns också ett behov av att undersöka vilken roll kognitiv förmåga spelar för människors möjlighet att tillgodogöra sig psykologisk behandling. I föreliggande studie var syftet att undersöka dessa båda områden. Resultaten visade inte på några signifikanta skillnader mellan personer med insomni, personer med depression och personer med det komorbida tillståndet avseende kognitiva funktioner, när det mättes genom test av uppmärksamhet, arbetsminne och exekutiva funktioner. Däremot framkom vissa samband mellan arbetsminne och förbättring av upplevda sömnbesvär, liksom mellan förmåga till bibehållen uppmärksamhet och förbättring av depressionssymtom. Vidare forskning med större och jämnare urvalsgrupper behövs för att undersöka stabiliteten i dessa fynd.

The overarching goal of this thesis has been to enhance Internet-delivered psychological treatments for depression and its comorbidity. To this end, three randomized controlled trials (Study II, III and IV) with a total of 313 participants were conducted. A prevalence study (Study I) was also conducted to provide an up-to-date estimate of the prevalence of depression, anxiety disorders, and their comorbidity in the Swedish general population. Study I showed that more than every sixth individual in Sweden suffers from symptoms of depression and/or anxiety. Comorbidity between depression and anxiety was substantial and associated with higher symptom burden and lower health-related quality of life. Study II showed that a tailored Internet-based CBT protocol (ICBT) was effective in reducing symptoms of depression when compared to a control group. Among individuals with more severe depression and comorbidities, the tailored ICBT treatment worked better than standardized ICBT. Study III showed that a psychodynamic Internet-based psychotherapy was highly effective in the treatment of depression, when compared to a group who received psychoeducation and online support. In Study IV, an Internet-delivered affect-focused psychodynamic psychotherapy proved to have a large effect on depression and a moderately large effect on anxiety disorders. In conclusion, this thesis shows that in the context of treating depression and its comorbidity, Internet-delivered psychological treatments can be potentially enhanced by psychodynamic psychotherapy and by individualization. Det övergripande syftet med denna avhandling har varit att vidareutveckla internetbaserad psykologisk behandling för depression och dess komorbiditet. Tre randomiserade kontrollerade studier (Studie II, III och IV) med totalt 313 deltagare genomfördes i linje med detta syfte. En prevalensstudie (Studie I) genomfördes också för att tillhandahålla ett uppdaterat estimat av prevalensen av depression, ångest och deras komorbiditet i Sverige. Studie I visade att mer än var sjätte individ i Sverige lider av symptom på depression och/eller ångest. Det fanns påtaglig komorbiditet mellan depression och ångest, vilket var associerat med högre symptombörda och lägre livskvalitét. Studie II visade att en skräddarsydd internetbaserad KBT-behandling var effektiv för att reducera symptom på depression, i jämförelse med en kontrollgrupp. Bland individer med svårare depression och komorbiditet, fungerade den skräddarsydda interventionen bättre än en standardiserad. Studie III visade att psykodynamisk internetbehandling var effektiv vid behandling av depression, i jämförelse med en grupp som fick psykoedukation och stödsamtal online. I Studie IV visades att en affektfokuserad psykodynamisk internetbehandling hade stor effekt vad gällde att reducera symptom på depression, och medelstor effekt vad gällde att reducera symptom på ångest. Sammanfattningsvis visar denna avhandling att internetbaserad psykologisk behandling kan potentiellt vidareutvecklas av psykodynamisk psykoterapi och individanpassning, vid behandling av depression och dess komorbiditet.

The overarching goal of this thesis has been to enhance Internet-delivered psychological treatments for depression and its comorbidity. To this end, three randomized controlled trials (Study II, III and IV) with a total of 313 participants were conducted. A prevalence study (Study I) was also conducted to provide an up-to-date estimate of the prevalence of depression, anxiety disorders, and their comorbidity in the Swedish general population. Study I showed that more than every sixth individual in Sweden suffers from symptoms of depression and/or anxiety. Comorbidity between depression and anxiety was substantial and associated with higher symptom burden and lower health-related quality of life. Study II showed that a tailored Internet-based CBT protocol (ICBT) was effective in reducing symptoms of depression when compared to a control group. Among individuals with more severe depression and comorbidities, the tailored ICBT treatment worked better than standardized ICBT. Study III showed that a psychodynamic Internet-based psychotherapy was highly effective in the treatment of depression, when compared to a group who received psychoeducation and online support. In Study IV, an Internet-delivered affect-focused psychodynamic psychotherapy proved to have a large effect on depression and a moderately large effect on anxiety disorders. In conclusion, this thesis shows that in the context of treating depression and its comorbidity, Internet-delivered psychological treatments can be potentially enhanced by psychodynamic psychotherapy and by individualization. Det övergripande syftet med denna avhandling har varit att vidareutveckla internetbaserad psykologisk behandling för depression och dess komorbiditet. Tre randomiserade kontrollerade studier (Studie II, III och IV) med totalt 313 deltagare genomfördes i linje med detta syfte. En prevalensstudie (Studie I) genomfördes också för att tillhandahålla ett uppdaterat estimat av prevalensen av depression, ångest och deras komorbiditet i Sverige. Studie I visade att mer än var sjätte individ i Sverige lider av symptom på depression och/eller ångest. Det fanns påtaglig komorbiditet mellan depression och ångest, vilket var associerat med högre symptombörda och lägre livskvalitét. Studie II visade att en skräddarsydd internetbaserad KBT-behandling var effektiv för att reducera symptom på depression, i jämförelse med en kontrollgrupp. Bland individer med svårare depression och komorbiditet, fungerade den skräddarsydda interventionen bättre än en standardiserad. Studie III visade att psykodynamisk internetbehandling var effektiv vid behandling av depression, i jämförelse med en grupp som fick psykoedukation och stödsamtal online. I Studie IV visades att en affektfokuserad psykodynamisk internetbehandling hade stor effekt vad gällde att reducera symptom på depression, och medelstor effekt vad gällde att reducera symptom på ångest. Sammanfattningsvis visar denna avhandling att internetbaserad psykologisk behandling kan potentiellt vidareutvecklas av psykodynamisk psykoterapi och individanpassning, vid behandling av depression och dess komorbiditet.

Farmakoepidemiologi er læren om legemiddelbruk i samfunnet. Ved hjelp av statistikk kan vi se nærmere på hvordan legemidler brukes av befolkningen og om det finnes et mønster i denne bruken. Diabetes og depresjon er begge store sykdomsgrupper som rammer folk over hele verden. I senere tid har forskning vist en mulig sammenheng mellom disse. Denne oppgaven vil bruke farmakoepidemiologiske metoder og beskrive bruk av legemidler mot diabetes, bruk av legemidler mot depresjon, og sambruk av legemidler mot diabetes og depresjon i den norske befolkningen. I tillegg til å beskrive prevalens vil det presenteres odds ratio for å bruke antidepressiva hos personer som bruker legemidler mot diabetes, sammenlignet med den øvrige befolkning. Vi vil undersøke om risikoen er ulik mellom kvinner og menn, og hvordan den er i de ulikebehandlingsgruppene, og finne ut om behandlingsregime har betydning for en eventuell risiko. Til slutt vil vi å se om det har skjedd en endring i risiko fra 2004 til 2009. Datamateriale er hentet fra Det norske reseptregisteret, som får informasjon om alle ekspederinger av reseptpliktige legemidler fra alle apotek i Norge. Informasjon ble hentet ut for 2004 og 2009 om alle ekspederinger på legemiddelgruppene A10 (antidiabetika) og N06A (antidepressiva). Dataene fra reseptregisteret inneholder informasjon om brukernes kjønn og fødselsår. Tilsvarende informasjon om den øvrige befolkningen ble hentet fra Statistisk sentralbyrå. Prevalens og odds ratio ble regnet ut for undergrupper av behandlingsregimer, kjønn og alder. Vi fant en økning i prevalens av bruk av antidiabetika fra 23,9 (2004) til 32,8 (2009) per tusen innbyggere, mens prevalens i bruk av antidepressiva falt fra 55,9 (2004) til 53,6 (2009). Det var flest menn som brukte antidiabetika, mens det var dobbelt så mange kvinner som menn som brukte antidepressiva. Prevalens for sambruk av antidiabetika og antidepressiva gikk opp fra 2,9 i 2004 til 3,4 i 2009. Analysene for risiko viste at det er 2,4 ganger så stor sjanse for å brukte antidepressiva hvis man bruker antidiabetika enn den øvrige befolkningen. Risikoen var høyest blant de yngste aldersgruppene, høyere blant menn enn kvinner. Vi fant ingen endring i odds ratio fra 2004 til 2009, til tross for en økning i prevalens av sambruk av legemidler mot diabetes og depresjon. MATF-FARM FARM399

SAŽETAK Pozadina istraživanja: U svjetlu strukturiranja novih izdanja klasifikacija bolesti, propituju se kriteriji za neke kliničke entitete. Među njima je i trajna promjena osobnosti uslijed traume/DESNOS koji se definira kao psihološka posljedica psihotraumatizacije, a njegovo postojanje isključuje postojanje PTSP-a. Svakodnevna klinička praksa ovu stavku dovodi u pitanje. Cilj: Utvrditi moguću prisutnost Disorder of extreme stress not otherwise classified (DESNOS) kod veterana Domovinskog rata s borbom uzrokovanim posttraumatskim stresnim poremećajem (PTSP). Metode: Istraživanje je uključilo 355 ispitanika u četiri centra u Hrvatskoj. Primijenjeni su upitnici: Structured Interview for Disorder of Extreme Stress (SIDES- SR), te Međunarodni neuropsihijatrijski intervju (MINI), Upitnik za poremećaj osobnosti DIP-Q, upitnik o kvaliteti života MANSA, Upitnik traumatskih događanja – TAQ, Harvard Trauma Questionnaire (HTQ): Croatian Version te opći demografski upitnik. Rezultati: U ispitivanoj populaciji 43% veterana Domovinskog rata koji boluju od PTSP-a zadovoljavaju sve kriterije i za DESNOS. Na kliničkoj razini, ispitivani veterani zadovoljili su kriterije za sljedeće poremećaje osobnosti: paranoidni, shizotipni, granični, izbjegavajući i opsesivno kompulzivni. Ispitanici s izraženijim DESNOS-om imaju i izraženije simptome poremećaja osobnosti i to: granični, paranoidni, opsesivno-kompulzivni, izbjegavajući i shizotipni. A ispitanici koji u potpunosti zadovoljavaju kriterije za DESNOS, na kliničkoj razini zadovoljavaju, uz navedene poremećaje i shizoidni poremećaj osobnosti. Na izraženost poremećaja osobnosti najviše utječu posttraumatski simptomi, odnosno što su izraženiji posttraumatski simptomi to je više prisutno simptoma poremećaja osobnosti. Simptomi trajne promjene osobnosti su jače izraženi u osoba koje su bile više traumatizirane. Ispitanici, koji uz PTSP imaju i DESNOS dva puta češće imaju u komorbiditetu: depresiju i/ ili socijalnu fobiju. Dijagnoza trenutnog paničnog poremećaja kod osoba s DESNOS-om se javlja gotovo tri puta češće nego kod osoba koje imaju samo PTSP. Također, što je kod ispitanika veći broj komorbidnih poremećaja uz PTSP, veća je i izraženost trajnih promjena osobnosti uslijed traume. Manje zadovoljstva s kvalitetom života može se predvidjeti kod ispitanika s ranom traumatizacijom i s jače izraženim simptomima bilo PTSP-a bilo DESNOS-a. Zaključak: Suprotno kriterijima postavljenima u ICD-10, rezultati ovog istraživanja govore da se PTSD i DESNOS mogu javljati u komorbiditetu. Veći intenzitet simptoma te češći komorbiditet s drugim psihijatrijskim poremećajima posebice depresijom, paničnim poremećajem i socijalnom fobijom zahtjeva dodatne terapijske intervencije u procesu liječenja veterana s DESNOS-om. Background: In light of new editions of the DSM and ICD classifications of diseases being prepared, certain clinical entities are being reassessed. Among others, clinical entities under reexamination are Disorder of Extreme Stress Not Otherwise Specified (DESNOS) or Complex PTSD according to the classification of the American Psychiatric Association. The corresponding diagnostic entity of the ICD would be Enduring Personality Change After Catastrophic Experience, which, according to definitions, occurs as a psychological effect of psychotraumatization and excludes the presence of PTSD. Day-to-day clinical practice casts doubts as to the view that PTSD and DESNOS/EPCACE symptoms are mutually exclusive. Aim: To determine possible presence of Disorders of Extreme Stress Not Otherwise Specified (DESNOS) in Croatian war veterans who suffer from combat-related Posttraumatic Stress Disorder (PTSD). Methods: The research included 355 participants in four clinical centers in Croatia. It was based on the following instruments: Structured Interview for Disorder of Extreme Stress (SIDES-SR) and International Neuropsychiatric Interview (MINI), Questionnaire for personality disorders DIP-Q, Quality of Life questionaire (MANSA), Traumatic Antecedents Questionnaire TAQ, Harvard Trauma Questionnaire (HTQ): Croatian Version and General Demographic Questionnaire. Results: Forty three percent of veterans of the Homeland War in Croatia who suffer from PTSD met criteria for DESNOS. At the clinical level, tested veterans met the criteria for the following personality disorders: paranoid, schizotypal, borderline, and obsessive-compulsive and avoidant. Veterans with pronounced DESNOS have more often expressed symptoms of personality disorder as follows: borderline, paranoid, and obsessive-compulsive, avoidant and schizotypal. The veterans who fully meet the criteria for DESNOS, at the clinical level meet - with listed personality disorders - criteria for schizotypal personality disorder. Posttraumatic symptoms affect mostly the expressiveness of personality disorders. Enduring personality change symptoms are more pronounced in subjects who were more traumatized. Persons, who suffer from both, PTSD and DESNOS, twice more frequently suffer from comorbid depression with melancholic features or social phobia. DESNOS patients are almost three times more likely to have the diagnosis of current panic disorder. Furthermore, veterans who have more comorbid disorders with PTSD, have more pronaunced permanent changes in personality due to trauma. Less satisfaction with quality of life can be predicted in subjects with early trauma and more pronounced symptoms of PTSD or DESNOS. Conclusion: The research results demonstrate that PTSD and DESNOS can occur in comorbidity, which is in contrast with the ICD-10 criteria. A higher intensity of symptoms and a more frequent comorbidity with other psychiatric disorders, especially depression, panic disorder and social phobia require additional therapy interventions in treatment processes for DESNOS veterans.

Studien har syftat till att undersöka samband mellan samsjuklig psykologisk problematik och katastroftänkande hos ungdomar utifrån ett transdiagnostiskt perspektiv. Katastroftänkandets roll för förändring av social ångest och depressiva symtom undersöktes utifrån en studie av internetbaserad KBT-behandling mot social fobi (N=18). Resultatet indikerar att ungdomar med hög initial nivå av katastroftänkande har större reduktion av depressiva symtom än ungdomar med låg nivå av katastroftänkande. Detta talar för att hänsyn bör tas till grad av katastroftänkande vid utformning av behandling för personer med social fobi, särskilt vid samsjuklighet med depression. Kopplingen mellan katastroftänkande och samsjuklighet undersöktes utifrån en tvärsnittsstudie av gymnasieungdomar (N=713). Resultatet visar på en koppling mellan katastroftänkande och social rädsla, sömnproblematik och nedstämdhet., This study was aimed at examining the relationship between co-existing psychological problems and catastrophizing in adolescents from a transdiagnostic perspective. The role of catastrophizing for the change of social anxiety and depression was analyzed in an internet based CBT-treatment for social phobia (N=18). The results indicate that adolescents with high initial level of catastrophizing have a larger reduction of depression than adolescents with low initial level of catastrophizing. This suggests that catastrophizing should be considered when specifying treatment for social phobia, especially if it co-occurs with depression. The relationship between catastrophizing and comorbidity was analyzed in a cross-sectional study of adolescents (N=713). The result suggests that catastrophizing is associated with the level of social fear, sleep problems and depression.

Background. 50% of depressive disorders in primary health care are unrecognized. Depression is accompanied by comorbid diseases in 70%, and is the reason for poorer prognosis and poorer comorbidity outcomes. Aim. To investigate the prevalence of depression in family medicine registrars' surgeries, the connection with socioeconomic factors, and to identify the most frequent comorbid diseases. Subjects and Method. Cross-sectional research was provided in May 2006 in five family medicine registrars' surgeries from different parts of Croatia, and among 7228 patients in their care. Patients with diagnosis of depression according to ICD 10, code F32 – Depression and code F33 – Depression recurrences were identified. A questionnaire was constructed for this research and filled with data from medical records and data according to estimations of family physicians. Results. Depression was diagnosed in 179 (2.4%) patients, most of them – 77 (43%) were in the age group from 45 to 65 years of age, 2.5 times more frequent among women – 128 (71%). Most of the depressive patients were among the retired -107 (60%). The socioeconomic status in 130 (73%) depressive patients was estimated as under average. According to family physicians’ estimation 100 (56%) depressive patients had a good family relationship, and 158 (88%) of them had low job strain. 77 (43%) depressive patients were considered as "difficult" patients, and 46 (26%) depressive patients did not look depressed. In 26% of the depressive patients comorbid diseases were from the diagnostic group of diseases of the musculoskeletal system and connective tissue (M00-M99), in 23% diseases of the circulatory system (I00-I99), and in 15% diseases of the digestive system (K00-K99). There was a different distribution of comorbidity among age groups and gender. Conclusion. The prevalence of only 2.4% depressive patients had a very low recognition percentage and implicated better family medicine registrars' education of depression according to recommendations created in family medicine., Uvod. U primarnoj zdravstvenoj zaštiti nepoznato je 50 % depresivnih poremećeje. Depresija je u 70& slučajeva praćena nekom komorbiditetnom bolešću i razlog je lošijoj prognozi, kao i ishodu te bolesti. Cilj. Istražiti prevalenciju depresije u ambulantama liječnika specijalizanata obiteljske medicine, njezinu povezanost sa socioekonomskim čimbenicima, te utvrditi najčešće komorbiditetne bolesti. Ispitanici i metoda. Istraživanje je provedeno u svibnju 2006., u pet ambulanti liječnika specijalizanata obiteljske medicine iz različitih krajeva Hrvatske - među 7228 pacijenata u njihovoj skrbi. Izdvojeni su pacijenti s dijagnozom depresije prema MKB-10 pod šifrom F 32-Depressio, te šifrom F 33 - Depressio recurrens. Za ovo istraživanje sastavljeni upitnik ispunjen je podacima iz zdravstvenih kartona, te prema procjeni obiteljskih liječnika. Rezultati. Depresija je dijagnosticirana u 179 (2,4%) pacijenata, od kojih je većina -77 (43%) bilo u dobi od 45 do 65 godina, 2,5 puta je češća bila među ženama - 128 (71%). Većina depresivnih pacijenata su bili umirovljenici - 107 (60%). Ispod prosječnog socioekonomskog stanja je bilo 130 (73%) pacijenata. Prema procjeni obiteljskih liječnika 100 (56%) depresivnih pacijenata imalo je dobre obiteljske odnose, te 158 (88%) nije imalo probleme na poslu. "Teškim" pacijentima procijenjeno je 77 (43%) depresivnih pacijenata, a 46 (26%) depresivnih pacijenata nije izgledalo depresivno. Kod 26 % depresivnih pacijenata komorbiditetne bolesti su bile iz dijagnostičke skupine - bolesti mišićnokoštanog sustava (M00-M99), kod 23% bolesti krvožilnog sustava (I00-I99), te kod 15% depresivnih pacijenata bolesti probavnog sustava (K00-K99). Različita je bila raspodjela komorbiditetnih bolesti po dobi i spolu. Zaključak. Prevalencija od samo 2,4 % depresivnih pacijenata je veoma niska i zahtjeva bolju edukaciju specijalizanata obiteljske medicine o depresiji prema preporukama napravljenim u samoj obiteljskoj medicini.

Terapija depresija kod bolesnika s komorbiditetom zahtijeva umijeće terapijske prilagodbe njihovu sveukupnomu zdravstvenom stanju. Depresiju mogu pratiti svi drugi psihički i tjelesni poremećaji. Među psihičkim poremećajima najčešći su anksiozni poremećaji i bolesti ovisnosti. Najčešći tjelesni poremećaji koji prate depresiju jesu: kardiovaskularni (kronična bolest srca, infarkt srca), endokrini (hipotireoza, hipertireoza, Cushingov sindrom, dijabetes, seksualni poremećaji), bolni sindromi, iatrogena stanja te rak i terminalna stanja. Poseban terapijski problem predstavlja komorbiditet depresije s višestrukim tjelesnim poremećajima u starosti. Lijekovi prvog izbora u liječenju depresije praćene anksioznim poremećajima i bolestima ovisnosti jesu selektivni inhibitori ponovne pohrane serotonina (SIPPS-i). Kako SIPPS-i u početku liječenja mogu izazvati prolazno pogoršanje anksioznosti, preporučuje se liječenje početi nižim dozama antidepresiva, a po potrebi i anksioliticima. Pri liječenju depresija s tjelesnim komorbiditetom, izbor antidepresiva treba prilagoditi tjelesnomu stanju bolesnika. Rana dijagnoza depresije kod oboljelih od infarkta miokarda i pravodobni početak njezina liječenja selektivnim inhibitorima ponovne pohrane serotonina, može značajno produžiti život srčanog bolesnika i poboljšati njegovu kvalitetu. Kao lijek prvog izbora za depresiju s dijabetesom preporučuju se SIPPS-i. Kod kroničnih bolnih sindroma praćenih depresijom efikasni su triciklički antidepresivi, a u slučaju njihove nepodnošljivosti, preporučuju se dualni antidepresivi nove generacije. Premda ima dosta studija koje su potvrdile povoljan terapijski odgovor starih tjelesno zdravih depresivnih pacijenata na tricikličke antidepresive, treba ih davati s oprezom zbog niza nuspojava koje mogu biti neugodne kod te dobne skupine. Danas se selektivni inhibitori ponovne pohrane serotonina smatraju lijekovima prvog izbora i najčešće su upotrebljavana skupina antidepresiva kod starih. Ovisno o vrsti depresivnog i komorbidnog poremećaja, preporučuje se također psihoedukacija te primjena odgovarajuće kognitivno-bihevioralne terapije., The treatment of depression in comorbid patients requires therapeutic adaptation to their overall health condition. Depression can be accompanied by other mental and physical disorders. Anxiety disorders and addictions are the most common mental disorders. The most frequent somatic disorders accompanying depression are: cardiovascular (chronic heart disease, cardiac infarction); endocrine (hypothyreosis, hyperthyreosis, Cushing’s syndrome, diabetes mellitus, sexual disorders); painful syndromes; iatrogenic conditions; cancer and terminal conditions. The unique therapeutic problem in the elderly is the treatment of comorbidity of depression and multiple physical disorders. Selective serotonin reuptake inhibitors (SSRIs) represent the treatment of choice for depression accompanied by anxiety disorders and addictions. Since SSRIs can cause a transient deterioration of anxiety at the beginning of treatment, the treatment should be initiated with lower doses of antidepressants and, if necessary, anxyolitics. During the treatment of depression with physical comorbidity, the choice of antidepressants should be adjusted to the patient’s physical condition. In patients with myocardial infarction, the early diagnosis of depression and timely beginning of treatment with SSRIs could significantly prolong life and improve its quality. SSRIs are the first choice drugs in the treatment of depression with diabetes. Tricyclic antidepressants are efficient in the treatment of chronic painful syndromes accompanied by depression. However, in the case of intolerability, the new generation dual antidepressants are recommended. Although a sufficient number of trials confirmed a favorable therapeutic response to tricyclic antidepressants in physically healthy but depressive elderly patients, they should be given with caution due to numerous unpleasant side effects. Today, SSRIs are considered as the drugs of first choice, and they are the most frequently administered antidepressants in the elderly. Depending on a type of depressive and comorbid disorder, psychoeducation and appropriate cognitive-behavioral therapy are also recommended.