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Increased body weight and hyperlipidemia caused by antipsychotics may be associated with improved antipsychotic efficacy in schizophrenia. If this association has a causal interrelationship via a genuine pathophysiological mechanism, then body weight loss in antipsychotic-treated patients would be accompanied by worsened psychopathology. This could have clinical implications.To explore whether the decreased body weight in these patients is associated with a worsened psychopathology.In our previously published study, a 16 week treatment period with add-on orlistat (but not placebo) resulted in body weight loss in male (but not female) clozapine- or olanzapine-treated overweight or obese patients. In the current study, we investigated whether body weight loss in those male patients could worsen psychosis. Changes in the Positive and Negative Syndrome Scale (PANSS) scores within groups and body weight changes and lipid profiles over the treatment period were analysed by the paired samples t-test. Between-group comparisons were analysed by the independent samples t-test.Over the treatment period body weight decreased by 2.56 ± 3.25 kg from initial 106.02 ± 12.61 kg (p = 0.04) for the orlistat group, with no statistically significant changes for the placebo group. Lipid levels did not change in either group. The orlistat-induced weight decrease was not associated with worsening in the PANSS scores.Weight loss was not associated with a worsening of psychosis. The interrelationship between the antipsychotic-induced weigh gain and improved schizophrenia psychopathology observed in earlier studies appears to be indirect. Orlistat treatment in our study did not worsen psychopathology in this population.

Clinical studies investigating adolescents' adherence to medicinal and non-pharmacological treatment in hospitalized psychiatric populations are few. In our study of 13-17 year old adolescents admitted to psychiatric inpatient care, the patients' adherence to treatment in general, and to medicinal and non-pharmacological treatment individually, was examined, with special focus on family and clinical factors. Data on adherence was collected from patients' hospital records. A step-wise logistic regression analysis was used to find the significant predictors of adherence to treatment. Good family or social network relational functioning and use of special services at school were positively related to adherence in adolescents. Involuntary treatment and self-mutilative behavior were related to non-adherence to treatment. The results indicate the importance of addressing adherence to treatment in adolescent psychiatric inpatients. More studies with larger samples are needed to investigate this area further.

Background Deviant birth measure is a risk factor for later somatic illness but also for later psychiatric disorders of the offspring. Only a few studies have examined the association of birth measures to later psychiatric disorders among adolescents. Studies on sex differences in these associations are scarce as well. Methods The cases consisted of 508 adolescents (208 boys and 300 girls) aged 12–17 years, who were admitted to inpatient psychiatric hospitalization between 2001 and 2006. In addition, 478 healthy controls were derived from the Northern Finnish Birth Cohort 1986, born in approximately the same period and same area as the cases. Data of birth measures were collected from the National Birth Register for cases and from antenatal clinics for controls. Both cases and controls were interviewed using the Schedule for Affective Disorder and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) to assess psychiatric disorders. Results The adolescent patients were statistically significantly shorter and had higher ponderal index at birth compared to healthy controls. In addition, the age of the mothers at adolescent’s birth was significantly younger in the patients than the controls. After controlling for various covariates, a 2.4-fold increased likelihood for internalizing disorders was seen among male adolescents with high ponderal index. Conclusions The association of birth measures to psychiatric disorders was confirmed in our study, particularly among male adolescents suffering from internalizing disorders. Further studies in larger adolescent samples are needed to confirm our findings and clear up the association of high ponderal index to specific psychiatric disorders.

Patients with neurological diseases often suffer from sleep disturbances. Insomnia among adult brain tumor patients has usually been studied as part of quality-of-life studies, or some case reports on insomnia in these patients have been described. The authors aimed to study insomnia in a prospective study setting among patients with primary brain tumors and evaluate whether insomnia is related to tumor laterality. Entire study population consisted of 70 patients with a solitary primary supratentorial brain tumor treated surgically at the Clinic for Neurosurgery, Oulu University Hospital. The overall functional state of the patients was assessed by the Karnofsky Performance Scale, depression was measured by Beck Depression Inventory, and insomnia by Nottingham Health Profile. Repeated measurements were assessed before tumor operation as well as 3 months and one year after surgery. Prevalence of insomnia among patients with a primary brain tumor waiting for surgery was higher compared to general population, but level of insomnia significantly decreased as soon as 3 months after tumor operation. Patients with a bilateral primary brain tumor had significantly more often insomnia without comorbid depression compared to patients with a left or right tumor for up to one year after operation. The authors suggest that insomnia among patients with a bilateral brain tumor may not be associated with depression but have other biological background.

We investigated the relationship between sibling characteristics (birth order, number of siblings and birth interval) and early onset psychosis among adolescent psychiatric inpatients and their mentally healthy controls. A short birth interval of 1-2 years to the nearest sibling was more common among adolescents with schizophrenia and schizophrenia spectrum psychoses and differed significantly from healthy controls (p = 0.037). A large family (at least 6 children in family) was more common among adolescents with psychosis NOS than among healthy controls (p = 0.035). The birth order among young adolescents with any subtype of psychosis did not differ from healthy controls. Sibling characteristics may be contributing factors in the multifactorial aetiology of schizophrenia and other psychotic disorders. Further studies are required to determine whether sibling characteristics reflect other unknown environmental factors.

Constipation is a common and potentially fatal side effect of clozapine treatment. Another important side effect of clozapine may also be significant weight gain. Orlistat is a weight-control medication that is known to induce loose stools as a common side effect. This study aimed to explore whether orlistat used to control clozapine-induced weight gain can simultaneously tackle clozapine-related constipation. In this 16-week randomized-controlled study, clozapine-treated patients received add-on orlistat (n=30) or add-on placebo (n=24). Colonic function was measured using the Bristol Stool Form Scale. There was a significant (P=0.039) difference in the prevalence of constipation in favor of orlistat over placebo in completers (n=40) at the endpoint. A decrease in the prevalence of constipation within the orlistat group (P=0.035) was observed (vs. no statistically significant changes in the placebo group). In clozapine-treated patients, orlistat may be beneficial not only for weight control but also as a laxative. As no established treatments for clozapine-induced constipation exist, orlistat can be considered for this population, although more studies are required.

We examined whether the use of health care and special school services, prior to admission for psychiatric inpatient treatment, differed between adolescents from child welfare units and those living at their parental home. 208 boys and 300 girls aged 12-17 years were admitted for psychiatric hospital between 2001 and 2006. Child welfare adolescents had used more health services/treatments prior to psychiatric hospital admission than adolescents living with their biological family. The best discriminating factors between study groups for both genders, were previous psychiatric hospitalizations, unemployed parents, use of special school services and self-perceived serious anxiety/tension or trouble controlling violent behavior. Repeated school grades and previous use of psychotropic medications were discriminating factors only in girls. Adolescents in child welfare deserve adequate mental health evaluations at an early stage, with referral to appropriate adolescent psychiatric services if required. Appropriate service provision and properly planned treatments may reduce the amount of intensive and sometimes unnecessary psychiatric inpatient treatments.

Objective The aim of this study was to investigate whether unhealthy weight control behaviors, fear of becoming obese, binge eating, impulsivity, and body mass index are associated with suicide ideation, repetitive self-mutilative behavior (SMB), suicide attempts, or both suicide attempts and SMB among female adolescent psychiatric inpatients. Methods Data were drawn from a clinical inpatient cohort of female adolescents (N = 300, aged 12-17 years) consecutively admitted for psychiatric hospitalization between April 2001 and March 2006. Information on adolescents' suicidal behavior, psychiatric Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) , diagnoses and weight control behaviors was obtained using the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL). Results Even after adjustment with DSM-IV , affective, anxiety and eating disorders self-induced vomiting was significantly associated with SMB and suicide attempts with SMB. Impulsivity was related to suicide attempts with SMB. Excessive exercising was a significant finding only in those girls who had attempted suicide. Girls who had attempted suicide were more often overweight compared with girls without suicidal behavior. Conclusion Unhealthy weight control behaviors among adolescent girls were found to be strongly associated with suicidal behavior. Girls with a history of both suicide attempts and SMB seem to be the most disturbed group, with multiple weight loss methods and impulsivity. Girls who are overweight or exercise excessively may represent risk groups for attempted suicide.

Background: Season of birth is associated with several psychiatric disorders and suicidal behavior. We explored the association between the season of birth and suicide among schizophrenic and psychotic suicide victims. Methods: The study sample consisted of all suicides in the province of Oulu in Northern Finland from 1989 to 2010. Causes of death were extracted from death certificates, and psychiatric diagnoses associated with the hospital treatments were obtained from the Finnish Hospital Discharge Register. The seasons were defined as follows: winter (from November to January), spring (from February to April), summer (from May to July), and autumn (from August to October). Suicide victims (n = 1,902) were categorized as having either schizophrenia (n = 228) or psychosis other than schizophrenia (n = 240). Suicide victims without any hospital-treated mental disorder (n = 1,434) were used as a comparison group. Results: The distribution of births among suicide victims with schizophrenia differed statistically significantly from that observed in the general population, with a peak in summer (OR 1.2, 95% CI 1.0-1.5). Conclusions: Birth during summer may predispose schizophrenic persons to suicide. The putative roles of serotonin, dopamine, and vitamin D status in the season of birth of psychotic suicide victims are discussed.

The association of traumatic brain injuries (TBI) with criminality, substance-related disorders and conduct disorders has mainly been studied in adult populations. In our study we examine the association in an adolescent population. We used a population-based clinical sample of 508 psychiatric inpatient adolescents from Northern Finland. The prevalences of TBI and criminality were 26 (5.1%) and 85 (16.7%), respectively. The information on TBI was acquired from the Finnish Hospital Discharge Register and on criminality from the Legal Register Center. DSM-IV diagnoses were obtained by interviewing the subjects using the semi-structured Schedule for Affective Disorder and Schizophrenia for School-Age Children, Present and Lifetime (K-SADS-PL). Adolescents with TBI had significantly more often committed crimes compared to adolescents without TBI (53.8% vs. 14.7%, respectively). Prevalences of both violent crimes (42.9% vs. 9.1%) and non-violent crimes (29.4% vs. 6.8%) were also higher in the TBI group. TBI during childhood and adolescence increased the risk of any criminality 6.8-fold (95% 3.0-15.2), conduct disorder 5.7-fold (95% 2.1-15.4) and concomitant criminality and conduct disorder 18.7-fold (95% 4.3-80.1). Our results suggest that clinicians working with mentally ill adolescents who have experienced head injuries should be aware of the increased risk for delinquency and violent tendencies occurring later in the adolescents' lives.

Recent case reports of insulin suicides have raised the need to study in detail the suicides among diabetes patients.The data consisted of 2489 suicides (2030 men, 459 women) in Northern Finland during 1988 to 2010. The suicide victims with hospital-treated type 1 (n=27) or type 2 diabetes (n=51) were compared with those without diabetes (n=2411).Of all suicide victims, 3.1% had diabetes (34.6% type 1 and 65.4% type 2 diabetes). 24.0% of victims with type 2 diabetes were under the influence of alcohol when they died from suicide, while the proportion was 44.4% in type 1 diabetes and 46.6% in victims without diabetes (P=0.007). Compared to those with type 2 diabetes or without diabetes, victims with type 1 diabetes had suffered more commonly from depression (44.4%, 23.5%, 19.9%, respectively) (P=0.006) and chosen self-poisoning as suicide method (48.1%, 31.4%, and 18.0%) (P0.001). In victims with type 1 diabetes insulin as a suicide method covered half of the self-poisoning cases, while the proportion in type 2 diabetes was 13%.We suggest that physicians who treat diabetes patients should evaluate co-occurring depression and substance abuse, both of which are major risk factors of suicide.

The present study examines the association of adverse childhood experiences (ACEs) to suicidal behavior and mortality in 508 Finnish adolescents (aged 12-17 years) who required acute psychiatric hospitalization between April 2001 and March 2006. The Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL) and the European Addiction Severity Index (EuropASI) were used to obtain information about ACEs, adolescents' suicidal behavior and psychiatric diagnoses. The cases of death were obtained from Statistics Finland. The results of our study indicated that, among girls, exposure to sexual abuse statistically significantly increased the risk of non-suicidal self-injury (NSSI) (OR, 1.8; 95 % CI, 1.0-3.2) and suicide attempts (OR, 2.3; 95 % CI, 1.0-4.5). The cumulative number of ACEs was also associated with an increased risk of NSSI (OR, 1.2; 95 % CI, 1.0- 1.4) and suicide attempts (OR, 1.2; 95 % CI, 1.0-1.4) in girls. Among all deceased adolescents, ACEs were most notable among those who had died due to accidents and injuries. Gender differences in the types of ACEs were noted and discussed.

The influence of family structure on criminality in adolescents is well acknowledged in population based studies of delinquents, but not regarding adolescent psychiatric inpatients. The association of family structure to criminality was examined among 508 adolescents receiving psychiatric inpatient treatment between 2001 and 2006. Family structure and DSM-IV based psychiatric diagnoses were based on the K-SADS-PL-interview and criminality on criminal records provided by the Finnish Legal Register Centre. After adjusting for socio-demographic, clinical and family factors, the adolescents from single parent families, child welfare placements and those not living with their biological parents showed an increased risk of committing crimes at an earlier age than adolescents from two parent families. Lack of a safe and stable family environment has important implications for adolescents with severe mental disorder. When these adolescents are discharged from hospital, special attention should be focused on organizing stable and long term psychosocial support which compensates for the lack of stable family environment and seeks to prevent future adversities.

Background: Exposure to obstetric complications is known to be associated with subsequent development of psychiatric disorders. However, earlier findings are mainly based on adult populations having a long follow-up time for onset of psychiatric illness. We examined whether the association of obstetric complications with severe mental disorders is already seen in a population of underage adolescents admitted to psychiatric inpatient care. Method: The study population was a clinical sample of adolescents (n = 508) aged 12–17 years admitted to psychiatric hospital. DSM-IV diagnoses of the psychiatric disorders of the adolescents as well as information on obstetric (i.e., pregnancy, delivery and perinatal) complications and substance use during pregnancy reported by the mothers of the adolescents were based on the semi-structured Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime. Results: A total of 96 (19%) adolescents had been exposed to obstetric complications. The prevalence of pregnancy, delivery or perinatal complications reported by the mothers of the offspring was 55 (57%), 57 (59%) and 13 (14%), respectively. Among adolescents with conduct disorder, exposure to delivery complications was more common among males compared to females (16 vs. 5%, p = 0.006); this was particularly true for section delivery (7 vs. 1%, p = 0.023). A trend towards a significant gender difference was also found among adolescents with anxiety disorder (21 vs. 8%, p = 0.085). Conclusions: Boys seem to be more vulnerable to the exposure of delivery complications than girls. Exposure to obstetric complication may be associated with development of subsequent psychiatric disorder; particularly conduct disorder of adolescent boys.

Depression is found to be present in up to 44% of brain tumor patients during their illness process. Anxiety as a comorbid psychiatric disorder with depression has formerly been studied, but phobia or obsessive-compulsive symptoms among brain tumor patients have not yet been noticed. By using a clinical prospective database of primary brain tumor patients (n=77) we studied the level of depression, anxiety, obsessionality (traits and symptoms) and phobic anxiety symptoms. Psychiatric symptoms were assessed before tumor operation as well as at three months and at one year after operation. The presence of comorbid anxiety, obsessionality and phobic anxiety symptoms was assessed before operation and at follow-ups in depressed and non-depressed patients, separately. Before tumor operation 16% of the patients had depression according to Beck Depression Inventory (BDI), while 10% had depression at three months and 15% at one year after operation. The depressed patients had statistically significantly higher anxiety scores and phobic scores at all three measurement points compared to corresponding scores among non-depressed brain tumor patients. The mean obsessionality scores among depressed brain tumor patients were significantly higher when measured before operation and at one year after the operation compared to non-depressed patients. To our knowledge, this is the first study so far in which comorbidity of psychiatric symptoms has been shown among depressive brain tumor patients. Concurrent comorbid conditions have been shown to be associated with increased severity, morbidity and chronicity of depression. It is recommended that treatment of depressive patients complicated with comorbid psychiatric disorders be planned by psychiatric units.

BackgroundAnxiety frequently accompanies low-grade inflammation-associated conditions like depression, insulin resistance, coronary heart disease and metabolic syndrome. The association between anxiety and low-grade inflammation is, unlike between depression and low-grade inflammation, a very sparsely studied area in general populations. The aim of the present study was to investigate whether anxiety symptoms as well as comorbid anxiety and depressive symptoms are associated with low-grade inflammation at population level.MethodsThe general population-based Northern Finland 1966 Birth Cohort was followed until age 31 (n= 2688 males and 2837 females), when the highly sensitive CRP concentrations were measured. Anxiety and depressive symptoms were defined by Hopkins Symptom Checklist-25 (HSCL-25).ResultsAfter adjusting for confounders, logistic regression analyses showed that anxiety symptoms alone increased the probability for elevated hs-CRP levels (> 3.0 mg/L) in males over two-fold (2.19 CI 95% 1.08–4.46), while comorbid anxiety and depressive symptoms caused a 1.7-fold (1.76 CI 95% 1.13–2.74) increase in the probability for elevated hs-CRP levels (1.0–3.0 mg/L).ConclusionsOur results support the hypothesis that anxiety as well as comorbid anxiety and depression can be associated with an increased risk for low-grade inflammation in males at population level.

International audience; Our aim was to investigate the relationship between the number of Conduct Disorder (CD) symptoms and specific DSM-IV symptom subscales (i.e., aggression towards people and animals, destruction of property, deceitfulness or theft, and serious violations of rules) and nicotine dependence (ND) among adolescent psychiatric inpatients in Finland. A total of 171 adolescents with CD (99 boys and 72 girls; age 12-17 years) were admitted to inpatient psychiatric hospitalization between April 2001 and March 2006. Information on their psychiatric DSM-IV diagnoses was obtained using the Schedule for Affective Disorder and Schizophrenia for School-Age Children (K-SADS-PL). The level of ND was assessed with the modified Fagerström Tolerance Questionnaire (mFTQ). The total number of CD symptoms correlated with the level of ND among both the boys (adj. = 0.31, = 0.002) and the girls (adj. = 0.324, = 0.006). For the boys, the number of conduct symptoms correlated with the level of ND on all subscales except for aggression, while the only statistically significant correlation for the girls was found with the deceitfulness or theft subscale. A comorbid substance use disorder was statistically significant and associated with a high level of ND among the boys (

Study Design. A population-based study of suicides and linkage with national hospital discharge registers.Objective. To investigate the prevalence of hospital-treated musculoskeletal diseases, particularly back pain, among suicide victims, to compare suicide characteristics between victims with and without musculoskeletal diseases, to analyse co-morbidity between musculoskeletal diseases and psychiatric disorders, and to evaluate whether specific drugs have a role in suicides by poisoning.Summary of background data. Depression, other psychiatric disorders and suicidal behavior are common comorbid conditions in patients with diseases of the musculoskeletal system.Methods. The data consisted of 2,310 suicides (1,885 males, 425 females) committed in the province of Oulu in Northern Finland during 1988-2007. The information on hospital-treated musculoskeletal diseases was extracted from the Finnish Hospital Discharge Registers. The suicide victims with a diagnosis of back pain including sciatica (BP, n = 133) and victims with musculoskeletal diseases other than back pain (MSD, n = 357) were compared to those of having no history of musculoskeletal diseases (reference group, n = 1,820). The data on suicides were based on death-certificates based from official medico-legal investigations.Results. A total of 490 (21.3%) of suicide victims had a history of hospital-treated musculoskeletal diseases. The age death of the victims with BP was about 11 years higher compared to the reference group. After adjusting for age, non-violent suicide methods and use of analgesics in poisoning suicides in both genders, and hospital-treated depression/ substance-related disorders in males were also more common in the BP and MSD groups. Females with BP had been more often under the influence of alcohol when committing suicide compared the other groups.Conclusions. Victims with a history of hospital-treated musculoskeletal diseases committed suicide at older age. However, the older person is, the more chance there is to have a treatment for some musculoskeletal diseases at some point of life. Use of analgesics as a potential suicide method should be kept in mind when treating patients with musculoskeletal system diseases. Language: en

Background: There are only a few recent studies on secular trends in child and adolescent suicides. We examine here trends in rates and methods of suicide among young people in Finland, where suicide rates at these ages are among the highest in the world. Methods: The data, obtained from Statistics Finland, consisted of all suicides (n = 901) committed by persons under 18 years of age over the period 1969-2008. Gender‐specific trends were analysed separately for the years 1969-1989 and 1990-2008 using 3‐year moving averages. Trends in methods of suicide were examined from 1975 to 2008 in five‐year periods. Results: The male‐to‐female ratio in youth suicides was 3.6:1. The male rates increased in 1969-1989, while the rates among females were inconsistent. After 1990, the rates decreased for males but turned to an increase among females. Shooting was the most common suicide method among males throughout the period, while hanging exceeded poisoning as the most common method among females after 1990. All violent suicides decreased for males and increased for females in 1990-2008. Conclusions: The increase in violent, i.e., more lethal, suicide methods among young females is alarming, as females are known to have higher rates of attempted suicide than males. Alcohol consumption, rates and treatment of depression and violent behaviour among adolescents are discussed as approaches towards explaining this phenomenon.

Background and objectiveOnly a few studies have examined the putative association between substance use and bullying others, and to our knowledge none of the previous studies have investigated substance abuse among victims or those who are both bullies and victims. The aim of our study was to investigate substance use among all of these three bullying subgroups and to examine the putative association between substance use and bullying behaviour.MethodsThe study sample consisted of 508 Finnish adolescents (age 12–17) admitted to psychiatric inpatient care between April 2001 and March 2006. We used the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL) to obtain DSM-IV psychiatric diagnoses, information about bullying behaviour and substance abuse of the adolescents. The level of nicotine dependence (ND) was assessed by using the modified Fagerström Tolerance Questionnaire (mFTQ).ResultsOur study showed that both among boys and girls, regular daily smoking and alcohol use among boys were statistically significantly associated with bullying behaviour. Further, among girls, but not among boys, there was also an association between bullying behaviour and more severe substance use, such as ND, use of cannabis and hard drugs.ConclusionSince an association between bullying and severe substance use was found in this study, our novel finding needs replication in adolescent general population samples.

Objective To explore long-term effects of orlistat in adult clozapine- or olanzapine-treated patients with DSM-IV-diagnosed schizophrenia and overweight or obesity who tolerate orlistat. Method Orlistat or placebo was added to clozapine or olanzapine in stable doses in a 16-week randomized controlled trial. Open-label orlistat was added to the antipsychotics during a 16-week extension phase for those completing the double-blind phase. No low-calorie diet or participation in behavioral programs was required. Body weight (primary outcome) and some metabolic parameters were measured prospectively. Analyses were performed for those completing both phases (ie, population differing from that reported earlier). The study was conducted from 2004 through 2005. Results During the open-label phase, the 44 patients experienced mean ± SD body weight loss of -1.29 ± 3.04 kg, P = .007. During both phases, men (but not women) showed a weight loss of -2.39 ± 5.45 kg, P = .023. Some subgroups showed desirable changes in several metabolic parameters. Prolonged (32 weeks) orlistat treatment yielded no additional benefits as compared to short (16 weeks) treatment. Conclusions In clozapine- or olanzapine-treated overweight or obese patients able to take orlistat on a long-term basis, the drug, with no concomitant hypocaloric diet or behavioral interventions, caused moderate weight loss only in men. However, some metabolic benefits may be achieved independently of weight changes. In patients who do not respond to orlistat within the first 16 weeks, continuation treatment may provide no additional benefits. Trial registration controlled-trials.com Identifier: ISRCTN65731856.

Advanced paternal age is a risk factor for adverse health outcomes in the offspring. In a population-based birth cohort from Finland, 10,965 singleton offspring born in 1966 and alive at age 1 were followed to age 39. Hazard ratios were calculated, adjusting for maternal age, gender, paternal social class, and maternal parity. In females but not in males, increasing paternal age was associated with a linear increased risk of suicide (hazard ratio [HR] = 1.13, 95% confidence interval [CI] = 1.04-1.24, p0.01) and all-causes mortality (HR = 1.06, 95% CI = 1.01-1.10, p = 0.02). Increasing maternal age was associated with a significantly decreased risk of suicide (HR = 0.93, 95% CI = 0.86-1.00, p = 0.04) and all-causes mortality (HR = 0.96, 95% CI = 0.93-1, p = 0.02) in the entire cohort. For paternal age/=30, the population attributable risk percentage was 13.7% for all deaths and 7.5% for suicides. Parental age at birth may affect suicide and all-causes mortality risk in the offspring in the general population. The causal pathways and specific disorders associated with this increased mortality are largely unknown.

The aim of this study was to investigate the association between family size and psychiatric disorders of underage adolescent psychiatric inpatients. The study sample consisted of 508 adolescents (age 12–17) admitted to psychiatric impatient care between April 2001 and March 2006. Diagnostic and Statistical Manual of Mental Disorders, fourth edition-based psychiatric diagnoses and variables measuring family size were obtained from the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL). The family size of the general Finnish population was used as a reference population. There was a significant difference between the family size of the inpatient adolescents and the general population: 17.0% of adolescents came from large families (with 6 or more children) while the percentage in the general population was 3.3. A girl from a large family had an about 4-fold risk of psychosis other than schizophrenia. However, large family size was not associated with a risk for schizophrenia. Large family size was overrepresented among underage adolescents admitted for psychiatric hospitalization in Northern Finland.

A season of birth effect in addictive disorders has scarcely been studied. As smoking is known to be a highly addictive behavior, we examined whether there exists an association between season of birth and smoking habits among the general population in the Northern Finland 1966 Birth Cohort (NFBC, n = 8,319). The birth month of each cohort member was categorized into one of the four seasons: spring (March-May), summer (June-August), autumn (September-November), or winter (December-February). Smoking habits of the cohort members were assessed by a postal questionnaire at the age of 31 yrs. Those who reported that they regularly smoked 11 or more cigarettes/day were regarded as heavy smokers. The association between season of birth and smoking was assessed with a logistic regression analysis: first, after controlling for early pregnancy-related and perinatal characteristics (Model 1) and second, after controlling for cohort members' hospital-treated psychiatric disorders, suicide attempts, adult educational level, and marital status (Model 2). Compared to males born in winter, the likelihood for heavy daily smoking was significantly increased, up to 1.3-fold, among males born in the autumn in both logistic regression models. However, among females the likelihood for heavy smoking was statistically significantly elevated among those born during any season other than winter. Season of birth may modify the development of dopaminergic or other neurotransmitter systems divergently among males and females. Altered expression of dopaminergic genes due to environmental climatic factors could explain the association between season of birth and heavy smoking.

OBJECTIVE: We studied the prevalence of hospital-treated Parkinson's disease (PD) among suicide victims and the profile of these persons, taking into account suicide attempts, timing of depression and comorbid somatic diseases. METHODS: The database of this study consisted of suicide victims aged 50 years of age or older (n = 555) during a fourteen-year period in the province of Oulu in Northern Finland. RESULTS: Hospital-treated Parkinson's disease occurred in 1.6% of the subjects, indicating a rather low prevalence of suicide in this group of patients. The persons with PD had attempted suicide earlier in 44% of the cases, while the corresponding percentage for other victims in older age was 9.9% (p = 0.009 Fischer exact test). CONCLUSIONS: Based on the case characteristics of our study the profile of PD person who completed suicide was as follows: male subject with recently diagnosed disease, living in rural area, having multiple physical illnesses, and having attempted suicide earlier. Psychiatric consultation is thus highly recommended for the PD patients with this disease profile. Language: en

OBJECTIVE: There are no studies investigating the degree of nicotine dependence (ND) and suicidality among underage adolescents. Our aim was to investigate the relationship between ND and various forms of suicidal behavior among adolescent psychiatric inpatients in Finland. METHODS: Data were collected from 508 patients (age, 12-17 years) admitted to inpatient psychiatric hospitalization between April 2001 and March 2006. The level of ND was assessed by the modified Fagerstrom Tolerance Questionnaire. Information on adolescents' suicide attempts and self-mutilation as well as psychiatric Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses was obtained by using the Schedule for Affective Disorder and Schizophrenia for School-Age Children. RESULTS: After adjusting for adolescents' age and psychiatric diagnoses, a more than 4-fold risk for suicide attempts (odds ratio [OR], 4.7; 95% confidence interval [CI], 1.3-17.2) and self-mutilative behavior (OR, 4.5; 95% CI, 1.6-13.3) was found among female adolescents with a high level of ND compared to nonsmoking adolescent females. In addition, the risk for suicide attempts was only increased by a high level of ND, whereas the risk for self-mutilation was increased among females with mild ND as well. Among males, the level of ND was not associated with suicide attempts or self-mutilative behavior. CONCLUSIONS: The level of ND should be taken into account when evaluating adolescent suicidality. Further sex-specific studies with accurate measurements of nicotine and its metabolites in relation to various suicidal and self-destructive behaviors are needed. Language: en

Purpose We sought to investigate the relationship between regular daily smoking in adolescence and in adulthood, the onset age of suicidal behavior, and the repetitiveness of suicide attempts by the age of 31 years. Methods Data from the Northern Finland 1966 Birth Cohort (NFBC 1966, n = 7995) were linked with the National Finnish Hospital Discharge registers (FHDR). Smoking habits of the cohort members were assessed at the ages of 14 and 31 years. Results After adjusting for hospital-treated psychiatric disorders and several sociodemographic characteristics, women with prolonged smoking from 14 to 31 years especially were at increased hazard (adjusted hazard ratio, 6.67; 95% confidence interval, 3.06–14.52) for having their first suicide attempt at younger age compared with infrequent smokers/nonsmokers. Smoking habits were not associated with the repetitiveness of suicide attempts in either gender. Conclusion This study confirms the association between smoking and suicidality. Further studies are needed to investigate the neurobiological basis of this association.

Suicide rate among schizophrenia patients may vary for several reasons, one of the most important being the time point of the suicide during the illness process. However, prospective studies on suicide risk in population-based cohort of individuals with new-onset schizophrenia have been lacking.The data were collected for 10,934 individuals alive in Finland at the age of 16 from the genetically homogenous, population-based Northern Finland 1966 Birth Cohort ascertained already during mid-pregnancy. The Finnish Hospital Discharge Register was used until the end of 1997 (age 31) to identify cases with mental disorder. Case records were scrutinized and diagnoses were re-checked for DSM-III-R criteria. One hundred subjects met the DSM-III-R criteria for schizophrenia. Deaths by the end of year 2005 (age 39) were ascertained from death certificates.Suicides (n = 7) accounted for 50% of all the deaths at age from 16 to 39. Seven (7.0%) subjects with schizophrenia had committed suicide; suicide rate being 2.9% (1/35) for women and 9.2% (6/65) for men. Furthermore, 71% of suicides in schizophrenia occurred during the first 3 years after onset of illness.The suicide rate for patients with new-onset schizophrenia followed until the age of 39 was high and accounted for half of the deaths. Great majority of the suicides took place during the first years of the illness.

This study investigated whether adolescent's family type was associated with regular smoking or the use of illicit substances (cannabis or hard drugs) among underage adolescent psychiatric in-patients. The sample consisted of 471 adolescents aged 12-17 years admitted to psychiatric hospital between April 2001 and March 2006 at Oulu University Hospital, Finland. The information on family factors and substance use was based on the Schedule for Affective Disorder and Schizophrenia for School-Age Children, Present and Lifetime interview and the European modification of the Addiction Severity Index questionnaire. Compared to adolescent boys from two-parent families, those from child welfare placement were more likely to regularly use both cannabis (odds ratio [OR]=4.4; 95%confidence interval [CI]=1.4-13.7; P=.012) and hard drugs (OR=8.4; 95% CI=1.7-42.1; P=.01).Among girls, no association was found between family type and the use of illicit substances. Two-parent or foster family units may protect adolescents from involvement with illicit substances. In clinical adolescent psychiatric practice more attention should be paid to family interventions and parental support.

We examined an association between a history of hospital-treated depression and physical diseases in 1877 suicide victims from Northern Finland. Information on physical diseases and depression of victims was extracted from the Finnish Hospital Discharge Registers. Of suicide victims, 31% of female and 16% of male victims had a lifetime history of depression. When compared with victims without any lifetime hospital-treated physical illnesses, a history of depression was shown to associate with the diseases of the nervous, circulatory, respiratory, and musculoskeletal systems in the group of symptoms and signs, injuries and poisonings, and infectious diseases among male victims. Respectively, in female victims, an increased prevalence of depression was seen in endocrine, nutritional and metabolic diseases, diseases of the nervous, circulatory, genitourinary, skin and subcutaneous tissue, and musculoskeletal systems, and with injuries and poisonings, pregnancy-related problems and infectious diseases. This study is the first to evaluate comorbidity between physical illnesses and depression over the lifetime in suicide victims; earlier studies reported findings in living patients from epidemiological or clinical populations. Since depression can affect quality of life in severely ill patients, targeting depression in patients with chronic illness may assist in decreasing suicide rates.

Information on parricidal offenders is mainly derived from selective samples of hospitalized patients. According to literature, a substantial proportion of parricidal offenders suffers from major mental disorders and is found to be not guilty by reason of insanity. The aim of this study was to examine and compare diagnoses and criminal responsibilities of matricidal and patricidal offenders in detail using a comprehensive national data set. Forensic psychiatric examination statements of 86 matricidal and 106 patricidal male offenders evaluated in a forensic psychiatric examination during 1973–2004 in Finland were reviewed retrospectively. Matricidal offenders suffered more commonly from a psychotic disorder than did patricidal offenders, whereas a greater proportion of patricidal offenders had a personality disorder. Among schizophrenic offenders the paranoid subtype was more common in the group of matricidal offenders than in the group of patricidal offenders. Of personality disorders, borderline personality disorder was more frequently found among patricidal offenders than among matricidal offenders. Matricidal offenders were more commonly found not guilty by reason of insanity than patricidal offenders. For matricidal offences the most common motive was a mental disorder, whereas patricidal offences were most often motivated by a long-term conflict. In addition, patricidal acts were more likely to be preceded by threat by the victim than matricidal acts. This study supports the hypothesis that matricidal offenders suffer from psychotic disorders more often than patricidal offenders, even though both groups seem to be characterized by a high level of psychopathology. Rarely reported in the literature, personality disorders show up frequently among parricidal offenders, particularly among patricidal offenders. Recognition and treatment of mental disorders underlying parricidal acts may prevent these offences, at least in some cases.

ObjectiveThe association between cigarette smoking and psychiatric disorders is well established for adult populations. However, only limited number of studies has investigated whether the young onset age of daily smoking (DS) among adolescents is associated with psychiatric morbidity and vice versa.MethodsData from 508 adolescents admitted to psychiatric hospitalization were collected. Cox proportional hazard model were used to compare the initiation of DS between adolescents with and without substance use (SUD), and other psychiatric disorders.ResultsRates of DS were high in each diagnostic category. Boys started smoking at younger age (mean 12.4 years) than girls (13.0 years). Both boys and girls diagnosed with conduct or oppositional defiant disorders (COD) and also girls with SUD started daily smoking earlier as compared to those of same gender without these disorders.COD were found to be primary to the initiation of DS among boys. SUD, psychotic, and depressive disorders (DEP) were found to be secondary to DS among both genders.ConclusionsDS in adolescence is related with later SUD. COD are associated with subsequent initiation of DS among boys. The temporal gap between smoking initiation and COD is shorter among girls. Gender difference plays a role in association of DS and DEP. Initiation of DS at very early age should alert health care professionals of development of later psychopathology, especially SUD.

OBJECTIVE: Elderly people commit suicide more often than people under the age of 65. An elevated risk is also attached to depression and other axis I psychiatric disorders. However, little is known about the preferred suicide method, effect of primary psychiatric diagnosis, and length of time between discharge from psychiatric hospitalization and suicide. The lack of information is most apparent in the oldest old (individuals over 75 years). METHODS: On the basis of forensic examinations, data on suicide rates were separately examined for the 50-64, 65-74 and over 75 year-olds (Total n = 564) with regard to suicide method, history of psychiatric hospitalization and primary diagnoses gathered from the Finnish Hospital Discharge Register. Study population consisted of all suicides committed between 1988 and 2003 in the province of Oulu in Northern Finland. RESULTS: Of the oldest old, females had more frequent hospitalizations than males in connection with psychiatric disorders (61% vs 23%), of which depression was the most common (39% vs 14%). In this age group, 42% committed suicide within 3 months after being discharged from hospital and 83% used a violent method. Both elderly males and females were less often under the influence of alcohol, but used more often violent methods than middle-aged persons. CONCLUSIONS: Suicide rates within the first 3 months following discharge from hospital in the 65-74 and the over 75 year olds were substantial and should influence post-hospitalization treatment strategies. To reduce the risk of suicides in elderly patients discharged from hospital, close post-hospitalization supervision combined with proper psychoactive medication and psychotherapy, are possible interventions. Language: en

The present study investigated the comorbidity of alcohol and drug dependence with psychiatric disorders by gender in a clinical sample of 300 girls and 208 boys (age 12–17) admitted to psychiatric inpatient hospitalization between April 2001 and March 2006. Information on alcohol and drug dependence, psychiatric diagnoses and age at onset of these disorders was obtained from the Schedule for Affective Disorders and Schizophrenia for School Aged Children – Present and Lifetime. The results of logistic regression models revealed that behavioral disorders were associated with alcohol dependence among girls (odds ratio [OR] 7.1) and boys (OR 4.6). In addition, behavioral disorders were associated with drug dependence, the ORs being 18.4 in girls and 9.1 in boys. Although depressive disorders were associated with both alcohol (OR 3.1) and drug dependence (OR 3.8) among boys, no corresponding association was seen in girls. Our results suggest that physicians treating substance-dependent adolescents should focus not only on behavioral disorders, but also on the screening and treatment of underlying depressive disorders, especially among substance-dependent boys.

Patients with epilepsy are known to have comorbid affective disorders and a higher risk for suicide compared with the general population. Epilepsy, depression, and suicidal behavior have been shown to have common pathogenic mechanisms in their etiology. We evaluated the association between epilepsy, suicidal behavior, and depression by using the comprehensive database of all suicides (n = 1877) committed in northern Finland during the years 1988–2002 with information on all hospital-treated somatic and psychiatric disorders. Hospital-treated epilepsy occurred in 1.3% of the victims. Compared with other suicide victims, those with epilepsy were more often female, were older, and had significantly more often suffered from depression. Epilepsy was first diagnosed 8.8 (3.9–11.6) years before suicide, and depression, about 1 year after epilepsy diagnosis. Interictal depression among patients with chronic epilepsy is often classified as atypical or chronic depression, or it can mimic a dysthymic disorder. Therefore, diagnosis and treatment of depression among patients with epilepsy constitute a great challenge in clinical practice.

Objective To investigate whether sleep disturbances are associated with C-reactive protein (CRP) levels at the population level. Elevated CRP levels have been found to accompany sleep disturbances, but evidence so far comes only from limited clinical and experimental studies; epidemiological studies are lacking. Methods We utilized the Northern Finland 1966 Birth Cohort, whose participants have been followed up to the age of 31 years. The hs-enzyme immunoassay method was used to measure highly sensitive-CRP (hs-CRP) concentrations (4011 participants). Self-reported sleep disturbances were ranked from 1 (no problem) to 5 (severe disturbances). Results Multivariate analyses, after adjusting for confounders, revealed that hs-CRP levels in men in the sleep disturbance category "moderate, considerable and severe" (i.e., self-reported sleep disturbances rated 3, 4, or 5), were >18% (18.2%, 95% Confidence Interval 3.0% to 36.3%) higher than those in men with "no" sleep disturbance. In women, hs-CRP levels did not significantly differ between different sleep disturbance categories. Conclusions Our results support the hypothesis that moderate-to-severe sleep disturbances in men are associated with slightly increased CRP levels at the epidemiological level. Further investigations are called for to see whether our results can be replicated in other databases.

PurposeTo investigate the relationship between heavy daily smoking and suicidality among adolescent psychiatric inpatients in Finland.MethodsData were collected from 411 patients (age 12–17 years) admitted to inpatient psychiatric hospitalization between April 2001 and July 2005. The number of daily cigarettes (>15) and the time of first cigarette after waking up (within 30 min) were used as indicators of heavy daily smoking.ResultsAfter adjusting for psychiatric diagnoses an over twofold risk for suicide attempts was found among adolescents who smoked over 15 cigarettes a day. Additionally, if an adolescent also smoked the first cigarette immediately after waking up the risk was over threefold. Suicidal ideation was not associated with smoking behaviour.Discussion and conclusionsAmong adolescents with severe psychiatric illnesses, heavy daily smoking may increase the risk of suicidal behaviour independently of current psychiatric diagnosis. The degree of nicotine dependence of an adolescent should therefore be carefully assessed as part of psychiatric evaluation.

Synaptic actions of gamma-amino butyric acid (GABA) have been implicated in many facets of ethanol's effects and risk for alcoholism. We examined whether variation in glutamate decarboxylase-2 (GAD2), a gene encoding for a major enzyme in the synthesis of GABA, contributes to risk of alcohol dependence (AD). We screened GAD2 for sequence variants using dHPLC in a population of 96 individuals. Several single nucleotide polymorphisms (SNPs), including four rare non-synonymous polymorphisms, were identified. Thirteen SNPs located in the GAD2 gene were genotyped in a sample of 113 Russian males with AD and 100 Russian male controls. These analyses revealed a modest association between the functional GAD2 -243 A > G SNP (rs2236418) and AD (allele P = 0.038, genotype P = 0.008). An additional sample of 138 Russian males with AD were genotyped for the GAD2 -243 A > G. These analyses supported an association of this polymorphism with AD (combined sample allele P = 0.038, genotype P = 0.0009). We extended these findings to additional populations: a sample of 538 college students assessed using the AUDIT and a sample of European-American (EA) AD subjects (n = 235) and controls (n = 310). Analyses in these populations did not support a role for GAD2 in alcoholism. In summary, the results of an extensive search for an association of GAD2 with AD suggest that variation in GAD2 is not a major risk factor for AD in EAs. The functional promoter GAD2 -243 A > G variant may influence risk for AD in some populations, or its role may be limited to susceptibility to severe AD.

Background To investigate whether depressive episodes (previous, current single, and recurrent) are associated in both genders with highly sensitive C-reactive protein (hs-CRP) levels, earlier recommended for risk assessment of cardiovascular disease. The impact of the severity of current single and recurrent depressive episodes on this putative association was also investigated. Methods The genetically homogeneous Northern Finland 1966 Birth Cohort was followed until age 31, when, in a cross-sectional setting (n = 5269), the highly sensitive enzyme immunoassay (hs-EIA) method was used to measure CRP concentration. Depressive episodes were defined through mailed questionnaires, including Hopkins Symptom Checklist-25 (HSCL-25) and information on self-reported, doctor-diagnosed depression. Results After adjusting for confounders, logistic regression analyses showed that in male subjects, elevated hs-CRP levels (≥1.0 mg/L) increased the probability for severe current and recurrent depressive episodes 1.7-fold and 3.1-fold, respectively. Correspondingly, an hs-CRP level of >3.0 mg/L increased the probability for recurrent depression up to 4.1-fold. In female subjects, no statistically significant associations were found. Conclusions Our results support the hypothesis that an activation of systemic inflammatory processes may contribute to the pathophysiology of severe depression in men. Further investigations are needed regarding the impact of our findings on diagnostic/treatment strategies concerning severe and, especially recurrent, depression in men.

The purpose of this research was to evaluate the level of nicotine dependence (ND) and to examine its association to psychiatric disorders in a representative clinical sample of adolescent psychiatric inpatients. The modified Fagerstrom Tolerance Questionnaire (mFTQ) was used to assess the level of ND. Psychiatric DSM-IV diagnoses were obtained by using the Schedule for affective disorder and schizophrenia for school-age children (K-SADS-PL). Of the total of 342 inpatients in the study sample, 259 (75.7%) reported to be current smokers. A sum score 6 or higher in the mFTQ, indicating a high level of ND, was found in 37.9% of all smokers. An increased likelihood for high level of ND was associated with substance related disorders (OR 5.1, 95% CI 2.8-9.3), conduct disorder and oppositional defiant disorders (OR 2.4, 95% CI 1.4-4.4). The usefulness of mFTQ in measuring ND among adolescent inpatients is apparent. Therefore, it can be recommended to be used as a routine screening instrument for ND among adolescents hospitalized due to psychiatric disorders.

To assess the long-term survival of brain tumor patients, and in particular to evaluate the relation of quality of life (QOL) to survival among low-grade glioma patients. The postoperative survival of 101 brain tumor patients was followed from surgery (1990–1992) until the end of the year 2003. Depression was evaluated by the Beck Depression Inventory (BDI) and QOL with Sintonen’s 15D scale before operation and at one year as well as at five years after operation. The mean survival times in years (SD) were significantly related to tumor malignancy, being the shortest, 1.9 (0.6), for patients with high-grade gliomas, while patients with low-grade gliomas or a benign brain tumor had mean survival times of 9.1 (1.0) and 11.6 (0.5), respectively. At all follow-ups, depressed low-grade glioma patients had a significantly shorter survival time, 3.3–5.8 years, compared to non-depressed low-grade glioma patients, 10.0–11.7 years. A decreased level of QOL in low-grade glioma patients was significantly related to the shorter survival. The results suggest that depression and decreased QOL among low-grade glioma patients is related to shorter survival at long-term follow-up. Decreased QOL may serve as an indicator for poor prognosis in low-grade glioma patients.

The association between insulin resistance (IR) and depression is a subject of growing research interest, especially as previous population-based studies have presented conflicting findings. The present study extends our understanding about the putative impact of the severity of depressive symptoms on this association and it provides further epidemiological evidence in support of earlier findings, suggesting that the association between IR and depression is present already in young adult males. To determine the impact of the severity of depressive symptoms on the putative association between IR and depression in young adult males, we were given access to the Northern Finland 1966 Birth Cohort database. During the 31-year follow-up survey of this genetically homogeneous birth cohort, IR was assessed by 'Qualitative Insulin Sensitivity Check Index' (QUICKI), and severity of depressive symptoms by 'Hopkins' Symptom Checklist-25' (HSCL-25). This study involved 2,609 male cohort members with complete variable information. In men, the means of the QUICKI-values decreased (i.e., IR increased) in line with the increased severity of depressive symptoms as assessed by HSCL-25 subgroups (analysis of covariance P-value for trend, P=0.003). In multivariate generalized logistic regression analyses, after adjusting for confounders, IR was positively associated with current severe depressive symptoms, the odds ratio (OR) being over threefold (adjusted OR 3.15, 95% confidence interval 1.48-6.68) and the value of OR increased in parallel with a tighter definition of IR (P-value for trend=0.007). The results indicate that in young males, a positive association exists specifically with severe depressive symptoms.

Objective. –We studied the relationship between depressive symptoms and quality of life (QOL) as well as functional status in primary brain tumor patients at recurrent measurements. Differences in QOL between depressive and non-depressive samples by gender were controlled for tumor characteristics and patients' psychosocial factors.Materials and methods. –The data consisted of 77 patients with a primary brain tumor, 30 males and 47 females. Depression of the patients was assessed by Beck Depression Inventory (BDI) and Crown-Crisp Experiential Index (CCEI), functional status by Karnofsky Performance scale (KPS) and QOL by Sintonen's 15D before tumor operation as well as at 3 months and at 1 year from surgical operation of the tumor.Results.The level of QOL in females was lower compared to that of males. Depression was the main predictor for worse QOL in the patients at all measurements. Depressive patients with a benign brain tumor had significantly worse QOL versus non-depressive ones.Discussion and conclusion. –Decreased QOL was strongly related to depression, especially among patients with a benign brain tumor. Further studies are needed to find whether sufficient depression therapy improves the QOL of patients.

OBJECTIVE: The aim was to investigate the impact of familial risk factors on the development of violent behaviour and conduct disorder (CD) by gender in a sample of adolescent psychiatric patients. METHODS: The study sample consisted of 278 adolescents (age 12-17) consecutively admitted to psychiatric inpatient care between April 2001 and January 2004. DSMIV psychiatric diagnoses were obtained from the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime (K-SADS-PL). RESULTS: Logistic regression analyses revealed that girls who had been physically abused at home had a 4.2-fold risk of having conduct disorder with violent behaviour (95% CI 1.4-12.2) compared to those not exposed to domestic violence. A broken primary family also increased the risk for having both violent CD (OR 7.8 95 % CI 1.7-36.4) and non-violent CD (OR 7.0 95% CI 1.5-33.5) among girls. Among boys, no statistically significant association was found between any familial risk factors and later CD. CONCLUSIONS: The results suggest that being physically abused by parents may influence the development of conduct disorder including violent behaviour among girls. This emphasizes the importance of early recognition of domestic violence. In girls, the absence of primary family seems to associate strongly with the development of CD, and should be taken into consideration by physicians and other professionals working with young people.