Educational Impairment in Social Anxiety Disorder and Post-Traumatic Stress Disorder

Tant la Fòbia social (FS) com el Trastorn d’estrès posttraumàtic (TEPT) s’han associat al baix rendiment acadèmic, però els estudis previs presentaven importants limitacions metodològiques. Per a realitzar recerca epidemiològica, és útil utilitzar els registres administratius i de salut poblacionals, com els disponibles a Suècia. Per tal de desenvolupar estudis amb garanties, és important que els codis diagnòstics que contenen aquests registres siguen vàlids i fiables. Aquesta tesi per compendi d’articles té com a primer objectiu validar el codi diagnòstic de l’FS (el codi diagnòstic del TEPT ja ha sigut prèviament validat) per a després explorar, per mitjà dels registres poblacionals suecs, l’associació entre l’FS i el TEPT i els indicadors objectius del rendiment acadèmic al llarg de tot el cicle escolar. Mètodes A l’estudi I, el codi diagnòstic de l’FS de la CIM-10 (F40.1) va ser validat per mitjà de la revisió d’històries clíniques i es calcularen el valor predictiu positiu (PPV) i la concordança entre jutges. Els estudis II i III exploraren les associacions entre l’FS i el TEPT i el rendiment acadèmic (respectivament) mitjançant dos estudis observacionals de cohorts poblacionals incloent tots els individus suecs nascuts entre 1973 i 1997, amb informació acadèmica fins a finals de 2013. Els nivells educatius estudiats van ser la idoneïtat per a accedir a l’educació secundària no obligatòria, la finalització de l’educació secundària superior, la iniciació d’estudis universitaris, la finalització d’un grau universitari i la finalització d’estudis de postgrau. S’analitzaren les dades mitjançant models de regressió logística. També es va estudiar la implicació de les comorbiditats psiquiàtriques en l’associació. Es va dur a terme una comparació entre germans, que permetia controlar els factors familiars compartits. A l’estudi III es van ajustar les anàlisis per la capacitat cognitiva dels individus en una submostra d’homes que havien realitzat el servei militar. Resultats El 81% de les històries clíniques revisades per a validar el codi d’FS van ser considerats vertaders positius (PPV = 0,81) i la concordança entre jutges va ser substancial (κ=0.72). Els estudis epidemiològics que examinaren les associacions entre l’FS i el TEPT amb el rendiment acadèmic incloïen cohorts amb 2,238,837 i 2,244,193 persones nascudes a Suècia, respectivament. Les persones diagnosticades amb FS tenien menys probabilitat d’aprovar totes les assignatures en l’últim any d’educació obligatòria (OR ajustada [aOR] amb rang de 0,19 a 0,44) i tenien menys probabilitat de ser idònies per a cursar un programa d’educació secundària superior vocacional (aOR=0.31) o acadèmic (aOR=0.52), menys probabilitat d’acabar l’educació secundària superior (aOR=0.19), menys probabilitat d’iniciar estudis universitaris (aOR=0.47), d’obtenir un grau universitari (aOR=0.35), i d’acabar un post-grau (aOR=0.58), comparat amb persones no exposades als trastorns. De manera similar, un diagnòstic de TEPT es va associar amb una menor probabilitat de completar tots i cadascun dels nivells educatius estudiats, incloent un 82% menys de probabilitat d’acabar l’educació obligatòria (aOR=0.18), un 87% menys de probabilitat d’acabar l’educació secundària superior (aOR=0.13), un 68% menys de probabilitat d’obtenir un grau universitari (aOR=0.32), i un 73% menys de probabilitat d’obtenir un grau universitari (aOR=0.27). En ambdós estudis epidemiològics, els resultats es van mantenir malgrat excloure les comorbiditats psiquiàtriques. A la comparació entre germans els resultats van romandre significatius però es van atenuar fins a quasi la meitat (rang d’aOR de 0,22 a 0,53) indicant que una part de les associacions observades podria explicar-se pels factors familiars. A l’estudi III, la capacitat cognitiva no va interferir en l’associació. Conclusió El codi diagnòstic de l’FS en el registre nacional de pacients de Suècia és vàlid i fiable. Les persones amb FS o TEPT tenen un risc substancialment més gran de disminució del rendiment acadèmic en tots els nivells educatius al llarg de la vida, independentment de factors de confusió com la comorbiditat psiquiàtrica, la capacitat cognitiva general o els factors familiars. Una detecció i intervenció precoç en aquests trastorns psiquiàtrics tenint present esta associació és necessària per a reduir la interferència funcional de les persones que conviuen amb un trastorn psiquiàtric.Psychiatric disorders have generally been linked to academic underachievement, but previous studies focusing on the association of social anxiety disorder (SAD) and post-traumatic stress disorder (PTSD) and educational outcomes had methodological limitations. Population-based administrative and health registers are often used for research purposes. In this sense, it is important that the diagnostic codes included in these registers are valid and reliable in order to conduct good quality epidemiological studies. This thesis aimed to validate the diagnostic code for SAD – the diagnostic code for PTSD had been previously validated – and, subsequently, explore the association between SAD and PTSD with objective indicators of educational attainment across the lifespan by using the Swedish population-based registers. Methods The ICD-10 code for SAD (F40.1) was validated using chart review methods. Positive predictive values (PPV) and agreement between two raters (using Cohen’s kappa) were calculated. Associations between SAD and PTSD and educational outcomes were studied by means of two population-based birth cohort studies of all Swedish individuals born between 1973 and 1997 and followed up until 2013. The exposed individuals were those with registered diagnosis of SAD or PTSD in the National Patient Register. The educational outcomes under study were: eligibility to access upper secondary school, finish upper secondary education, start a university degree, obtain a university degree, and finish postgraduate education. Logistic regression models, adjusted by relevant covariates, tested the association between SAD or PTSD and the educational outcomes.The role of psychiatric comorbidities was also studied. Sibling analyses controlled for familial factors shared by full siblings. Results A total of 81% of the reviewed files to validate the code of SAD were considered to be 'true positive' cases (PPV=0.81). Inter-rater agreement regarding the presence or absence of SAD was substantial (κ=0.72). The register-based studies examining the association between SAD and PTSD with educational achievement included cohorts of 2,238,837 and 2,244,193 Swedish-born individuals, respectively. Individuals diagnosed with SAD were less likely to pass all subjects in the last year of compulsory education and less likely to be eligible for a vocational (adjusted odds ratio [aOR]=0.31) or an academic program (aOR=0.52) in upper secondary education, finish upper secondary education (aOR=0.19), start a university degree (aOR=0.47), obtain a university degree (aOR=0.35), and finish postgraduate education (aOR=0.58), compared to unexposed individuals. Similarly, a diagnosis of PTSD was associated with lower odds of achieving each of the assessed educational milestones during the study period, including 82% lower odds of finishing compulsory education (aOR=0.18), 87% lower odds of finishing upper secondary education (aOR=0.13), 68% lower odds of starting a university degree (aOR=0.32), and 73% lower odds of obtaining a university degree (aOR=0.27). In both epidemiological studies, the results remained largely unchanged when psychiatric comorbidities were taken into account. The sibling analyses showed still statistically significant but attenuated estimates, indicating that part of the observed associations could be explained by factors shared by siblings. Conclusion The diagnostic code for SAD in the Swedish National Patient Register is valid and reliable. Individuals with SAD or PTSD, as recorded in this register, are consistently less likely to achieve all educational milestones across the lifespan, over and above a number of confounders such as psychiatric comorbidities and familial factors. Early detection and intervention in these psychiatric disorders is warranted in order to alleviate the long-term adverse effect on academic performance

Insight, sintomatología y funcionamiento neurocognitivo en pacientes con psicosis

Introducción: Se estudia la relación entre insight, sintomatología y funcionamiento cognitivo en una muestra de pacientes con trastornos psicóticos. Materiales y métodos: Se evaluaron 55 pacientes ingresados en una unidad de hospitalización psiquiátrica con diagnóstico de psicosis no afectiva. La evaluación se llevó a cabo con las siguientes escalas: para evaluar el insight clínico, se utilizó la Scale to Assess Unawareness of Mental Disorder (SUMD); para evaluar el insight cognitivo, la Escala de Insight Cognitivo de Beck (la EICB); para evaluar la clínica psicótica, la Positive and Negative Syndrome Scale (PANSS); y la sintomatología depresiva se evaluó con el Beck Depression Inventory (BDI). Las funciones ejecutivas neurocognitivas se valoraron con el Wisconsin Card Sorting Test (WCST) y el deterioro cognitivo con el Screen for Cognitive Impairment in Psychiatry (SCIP). Resultados: Un menor insight clínico se relaciona con una mayor presencia de síntomas psicóticos positivos y una menor presencia de síntomas negativos y depresivos. No se observó relación entre insight y funciones ejecutivas, pero sí con el deterioro cognitivo. Conclusiones: Un menor insight en pacientes con trastorno psicótico se relaciona con la presencia de más sintomatología psicótica positiva y menor sintomatología psicótica negativa y depresiva. El insight clínico aumenta cuanto mayor deterioro cognitivo se aprecia

Insight, sintomatología y funcionamiento neurocognitivo en pacientes con psicosis

Introducción: Se estudia la relación entre insight, sintomatología y funcionamiento cognitivo en una muestra de pacientes con trastornos psicóticos. Materiales y métodos: Se evaluaron 55 pacientes ingresados en una unidad de hospitalización psiquiátrica con diagnóstico de psicosis no afectiva. La evaluación se llevó a cabo con las siguientes escalas: para evaluar el insight clínico, se utilizó la Scale to Assess Unawareness of Mental Disorder (SUMD); para evaluar el insight cognitivo, la Escala de Insight Cognitivo de Beck (la EICB); para evaluar la clínica psicótica, la Positive and Negative Syndrome Scale (PANSS); y la sintomatología depresiva se evaluó con el Beck Depression Inventory (BDI). Las funciones ejecutivas neurocognitivas se valoraron con el Wisconsin Card Sorting Test (WCST) y el deterioro cognitivo con el Screen for Cognitive Impairment in Psychiatry (SCIP). Resultados: Un menor insight clínico se relaciona con una mayor presencia de síntomas psicóticos positivos y una menor presencia de síntomas negativos y depresivos. No se observó relación entre insight y funciones ejecutivas, pero sí con el deterioro cognitivo. Conclusiones: Un menor insight en pacientes con trastorno psicótico se relaciona con la presencia de más sintomatología psicótica positiva y menor sintomatología psicótica negativa y depresiva. El insight clínico aumenta cuanto mayor deterioro cognitivo se aprecia

Insight, symptomatology, and neurocognitive functioning in patients with psychosis

Introducción: Se estudia la relación entre insight, sintomatología y funcionamiento cognitivo en una muestra de pacientes con trastornos psicóticos. Materiales y métodos: Se evaluaron 55 pacientes ingresados en una unidad de hospitalización psiquiátrica con diagnóstico de psicosis no afectiva. La evaluación se llevó a cabo con las siguientes escalas: para evaluar el insight clínico, se utilizó la Scale to Assess Unawareness of Mental Disorder (SUMD); para evaluar el insight cognitivo, la Escala de Insight Cognitivo de Beck (la EICB); para evaluar la clínica psicótica, la Positive and Negative Syndrome Scale (PANSS); y la sintomatología depresiva se evaluó con el Beck Depression Inventory (BDI). Las funciones ejecutivas neurocognitivas se valoraron con el Wisconsin Card Sorting Test (WCST) y el deterioro cognitivo con el Screen for Cognitive Impairment in Psychiatry (SCIP). Resultados: Un menor insight clínico se relaciona con una mayor presencia de síntomas psicóticos positivos y una menor presencia de síntomas negativos y depresivos. No se observó relación entre insight y funciones ejecutivas, pero sí con el deterioro cognitivo. Conclusiones: Un menor insight en pacientes con trastorno psicótico se relaciona con la presencia de más sintomatología psicótica positiva y menor sintomatología psicótica negativa y depresiva. El insight clínico aumenta cuanto mayor deterioro cognitivo se aprecia

Validity and reliability of social anxiety disorder diagnoses in the Swedish National Patient Register

BACKGROUND: Population-based administrative registers are often used for research purposes. However, their potential usefulness depends on the validity of the registered information. This study assessed the validity of the recorded codes for social anxiety disorder (SAD) in the Swedish National Patient Register (NPR). METHODS: The personal identification numbers of 300 randomly selected individuals with a diagnosis of SAD (also known as social phobia) recorded in the NPR were obtained from the Swedish National Board of Health and Welfare. The medical files of these individuals were then requested from clinics nationally. A total of 117 files were received and two independent raters reviewed each file to assess the presence or absence of SAD, according to the definition of the International Classification of Diseases, Tenth Edition (ICD-10) and the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). When disagreements between the two raters were found, a third rater reviewed the file to establish a best estimate diagnosis. Positive predictive values (PPV) and agreement between the two initial raters (using Cohen’s kappa) were calculated. Additionally, raters completed the Clinical Global Impression – Severity (CGI-S) and the Global Assessment of Functioning (GAF) rating scales for each file. Inter-rater agreement for the CGI-S and the GAF was assessed using intraclass correlation coefficients (ICC). RESULTS: After exclusion of files not comprising sufficient information, 95 files were included in the analyses. Of these, 77 files (81.05%) were considered to be ‘true positive’ cases. This resulted in a PPV of 0.81 (95% confidence interval, 0.72-0.88). Inter-rater agreement regarding the presence or absence of SAD was substantial (κ=0.72). CGI-S and GAF scores indicated that patients were in the moderate range of severity and functional impairment. Inter-rater agreement for the CGI-S and the GAF was moderate to good (ICC=0.72 and ICC=0.82, respectively). CONCLUSIONS: The ICD-10 codes for SAD in the Swedish NPR are generally valid and reliable, but we recommend sensitivity analyses in future register-based studies to minimise the impact of potential diagnostic misclassification. Most patients were moderately severe and impaired, suggesting that results from register-based studies of SAD may be generalizable

Assessment of Posttraumatic Stress Disorder and Educational Achievement in Sweden

Importance Posttraumatic stress disorder (PTSD) has been associated with impaired educational performance. Previous studies on the disorder could not control for important measured and unmeasured confounders. Objective To prospectively investigate the association between PTSD and objective indicators of educational attainment across the life span, controlling for familial factors shared by full siblings, psychiatric comorbidity, and general cognitive ability. Design, Setting, and Participants This population-based cohort study included 2 244 193 individuals born in Sweden between January 1, 1973, and December 31, 1997, who were followed-up until December 31, 2013. Clusters of full siblings were used to account for familial factors. Data analyses were conducted between December 2018 and May 2020. Exposure International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses of PTSD in the Swedish National Patient Register. Main Outcomes and Measures Eligibility to access upper secondary education after finishing compulsory education, finishing upper secondary education, starting a university degree, and finishing a university degree. Results Of the final cohort of 2 244 193 individuals (1 151 414 [51.3%] men) included in the analysis, 1 425 326 were assessed for finishing compulsory education (919 with PTSD), 2 001 944 for finishing upper secondary education (2013 with PTSD), and 1 796 407 and 1 356 741 for starting and finishing a university degree (2243 and 2254 with PTSD, respectively). Posttraumatic stress disorder was associated with lower odds of achieving each of the educational milestones during the study period, including 82% lower odds of finishing compulsory education (adjusted odds ratio [aOR], 0.18; 95% CI, 0.15-0.20), 87% lower odds of finishing upper secondary education (aOR, 0.13; 95% CI, 0.12-0.14), 68% lower odds of starting a university degree (aOR, 0.32; 95% CI, 0.28-0.35), and 73% lower odds of finishing a university degree (aOR, 0.27; 95% CI, 0.23-0.31). Estimates in the sibling comparison were attenuated (aOR range, 0.22-0.53) but remained statistically significant. Overall, excluding psychiatric comorbidities and adjusting for the successful completion of the previous milestone and general cognitive ability did not statistically significantly alter the magnitude of the associations. Conclusions and Relevance Posttraumatic stress disorder was associated with educational impairment across the life span, and the associations were not entirely explained by shared familial factors, psychiatric comorbidity, or general cognitive ability. This finding highlights the importance of implementing early trauma-informed interventions in schools and universities to minimize the long-term socioeconomic consequences of academic failure in individuals with PTSD

A Cluster-Randomized Trial of Hydroxychloroquine as Prevention of Covid-19 Transmission and Disease

Background Current strategies for preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections are limited to non-pharmacological interventions. Hydroxychloroquine (HCQ) has been proposed as a postexposure therapy to prevent Coronavirus disease 2019 (Covid-19) but definitive evidence is lacking. Methods We conducted an open-label, cluster-randomized trial including asymptomatic contacts exposed to a PCR-positive Covid-19 case in Catalonia, Spain. Clusters were randomized to receive no specific therapy (control arm) or HCQ 800mg once, followed by 400mg daily for 6 days (intervention arm). The primary outcome was PCR-confirmed symptomatic Covid-19 within 14 days. The secondary outcome was SARS-CoV-2 infection, either symptomatically compatible or a PCR-positive result regardless of symptoms. Adverse events (AEs) were assessed up to 28 days. Results The analysis included 2,314 healthy contacts of 672 Covid-19 index cases identified between Mar 17 and Apr 28, 2020. A total of 1,198 were randomly allocated to usual care and 1,116 to HCQ therapy. There was no significant difference in the primary outcome of PCR-confirmed, symptomatic Covid-19 disease (6.2% usual care vs. 5.7% HCQ; risk ratio 0.89 [95% confidence interval 0.54-1.46]), nor evidence of beneficial effects on prevention of SARS-CoV-2 transmission (17.8% usual care vs. 18.7% HCQ). The incidence of AEs was higher in the intervention arm than in the control arm (5.9% usual care vs 51.6% HCQ), but no treatment-related serious AEs were reported. Conclusions Postexposure therapy with HCQ did not prevent SARS-CoV-2 disease and infection in healthy individuals exposed to a PCR-positive case. Our findings do not support HCQ as postexposure prophylaxis for Covid-19.This study was mainly supported by the crowdfunding campaign JoEmCorono (https://www.yomecorono.com/) with the contribution of over 72,000 citizens and corporations. The study also received financial support from Laboratorios Rubió, Gebro Pharma, Zurich Seguros, SYNLAB Barcelona, and Generalitat de Catalunya. Laboratorios Rubió also contributed to the study with the required doses of hydroxychloroquine (Dolquine®).N