<b>VLBW adolescents</b> We found that the VLBW adolescents had specific emotional and cognitive traits. Some of them fit with psychiatric concepts and others do not. They had an increased risk of developing psychiatric symptoms and disorders compared with controls, especially attention deficit, anxiety and relational problems affecting their social skills and overall functioning. Academic achievement was reduced. The attention problems were widespread, but only a minority fulfilled the diagnostic criteria of Attentiondeficit/ hyperactivity disorder. Increased prevalence of anxiety symptoms and disorders may be due to a number of factors, comprising both biological/neuroendocrine and psychosocial mechanisms. The peer problems and deficits in social skills may indicate specific difficulties in relating and adjusting to others, with deficits in comprehending the subtle cues of social relations. The implication of thought problems reported by teachers is unclear. Adolescents with birth weight ≤ 1000 g showed a tendency towards more psychiatric disorders than those with birth weight between 1000 and 1500 g. The lack of gender differences demonstrates that prematurity exceeds the usual effect of gender regarding vulnerability for developing psychiatric symptoms. We found that the VLBW adolescents perceived self-esteem and quality of life as others did at the age of 14. However, parents reported functional disadvantages and reduced quality of life measures for their adolescents. The parents worried more for their children’s functioning and well-being, especially if the child had a psychiatric disorder or cerebral palsy. Still, being born VLBW did not influence the warmth in the parent-child relationship, nor did the parents have more mental health problems. As the association between VLBW and psychiatric problems could not be explained by SES or the parents’ mental health, a biological cause-effect relationship seems plausible. The frequency of cerebral MRI abnormalities was higher in the VLBW group than in the control group. Furthermore, ADHD symptoms were associated with white matter reduction and thinning of the corpus callosum, while other psychiatric symptoms were not associated with MRI abnormalities. These results support the hypothesis of a specific (“pure”) type of ADHD with a dominant neurological aetiology, while interacting psychosocial experiences play a minor part. Our study indicates that being born VLBW involves a biological vulnerability with increased risk of psychiatric symptoms. <b>SGA adolescents</b> Although every fifth SGA adolescent had psychiatric symptoms, assessed by interview, the prevalence of symptoms and disorders did not differ significantly from controls. Yet, screening questionnaires displayed more behavioural problems, lowered social competence and a tendency towards attention deficit/hyperactivity. Teachers reported withdrawal and thought problems, while academic performance did not differ from controls. Boys had more attention and externalizing problems than girls. Generally, on psychiatric measures, the term SGA group seemed to fall inbetween the VLBW and the control group, resembling the control group more than the VLBW group. The SGA adolescents and their parents reported self-esteem and quality of life as in the control group. Being born SGA at term did not influence the warmth in the parent-child relationship, and the parents did not have more mental health problems than others. The frequency of cerebral MRI abnormalities in the SGA group did not differ from the control group, and no associations were found between psychiatric symptoms and MRI abnormalities. / Paper V reprinted with kind permission of Elsevier, sciencedirect.com

Uppsatsen behandlar ämnet unga högpresterande flickor som mår psykiskt dåligt. Syftet med undersökningen var att ta reda på hur skolan kan upplevas för någon som är drabbad av detta samt att få konkreta exempel på hur arbetet kan se ut på en gymnasieskola gällande detta problem. Metoden som användes var kvalitativa intervjuer och litteraturstudie. Fem intervjuer och litteratur som behandlar ämnen som självmord, depression, ångest samt ätstörningar har varit grundläggande för undersökningen. Den viktigaste slutsatsen är att det krävs ett annorlunda angreppssätt från skolans håll om vi vill förändra utsikterna för högpresterande flickor med psykiska problem. Det krävs bl.a. att fler lärare tar sina elever på allvar, är uppmärksamma på hur de mår samt har större kunskap på detta område. / The subject of this essay is high achieving girls with mental disorders. The purpose with the investigation was to find out how these girls felt during their years in school and also to get concrete examples of how a school handles these problems. This study was based on qualitative interviews. Five interwieves and literature about suicide, depression and eating disorders have been the foundation of this study. The most important conclusion of this work is that it seems like a new agenda will be needed if we want to improve the circumstances for high achieving girls with mental disorders. Amongst the many things that can be done, all teachers need to get more aware of how their pupils feel and more knowledge in this area.

Aus der Einleitung: "The authors of the seven meta-structure papers in this issue have to be applauded for their inspiring attempt to suggest and elaborate a new meta-structure of mental disorders consisting of five ‘ clusters ’. At first sight this proposal seems to be considerably simpler than the current diagnostic classifications structure used by DSM-IV-TR (17 categories ; APA, 2000) and, in some parts, more convergent with the ICD-10 (10 categories ; WHO, 1993). Against the background of dissatisfaction expressed with the current diagnostic classification structure for mental disorders and its principles, the authors provide a selective critical review of relevant research. In particular, evidence is examined to address the question of whether current individual mental disorders differ sufficiently from each other and whether the current more fine-graded distinction of specific mental disorders and their grouping in 10 major classes according to ICD-10 and 17 in DSM-IV-TR is justified. To help answer this question, a prioricriteria were chosen in the form of a wide range of ‘validators ’ grouped into so-called ‘causal’ risk factors (i.e. shared genetic risk factors, familiality, shared environmental risks, shared neural substrates, shared biomarkers, shared temperamental antecedents) and factors thought to be more likely to reflect the clinical picture itself (shared abnormalities of cognitive and emotional processing, symptom similarity, rates of co-morbidity, course, treatment response). The results of this impressive exploration are interpreted to suggest a substantial reduction of the current major classes to five clusters and a fairly large residual category of disorders not yet assigned. Particularly noteworthy examples for classificatory changes associated with the proposed meta-structure involve: the suggestion to group anxiety, somatoform and depressive disorders together under the term ‘emotional disorders ’ ; the allocation of bipolar disorders to the ‘psychotic cluster ’ ; and the formation of a broad externalizing cluster that comprises substance use disorders, some of the personality disorders and impulse control disorders. [...]"

This special issue was prepared within the framework of the European College of Neuropsychopharmacology (ECNP) Task Force on “Size and Burden of Mental Disorders in Europe”. The core aim of the Task Force was to describe the prevalence and the burden of treated and untreated mental disorders in all European member states and to highlight needs for further research. Ten state-of-theart epidemiological papers summarize the outcome of this project, making an attempt to provide for the first time ever prevalence estimates for a wide range of mental disorders, as well as for dementia and Parkinson’s disease in 28 European countries. These data also provide input for the European Brain Council (EBC, http://www.ebc-eurobrain. net) Initiative “Cost of Disorders of the Brain in Europe” aiming at estimating the cost of major classes of mental, neurological and neurosurgical disorders and conditions in Europe.

Background: Although positive effects of physical activity on mental health indicators have been reported, the relationship between physical activity and the development of specific mental disorders is unclear. Method: A cross-sectional (12-month) and prospective-longitudinal epidemiological study over 4 years in a community cohort of 2548 individuals, aged 14–24 years at outset of the study. Physical activity and mental disorders were assessed by the DSM-IV Composite International Diagnostic Interview (CIDI) with an embedded physical activity module. Multiple logistic regression analyses controlling for age, gender and educational status were used to determine the cross-sectional and prospective associations of mental disorders and physical activity. Results: Cross-sectionally, regular physical activity was associated with a decreased prevalence of any and co-morbid mental disorder, due to lower rates of substance use disorders, anxiety disorders and dysthymia. Prospectively, subjects with regular physical activity had a substantially lower overall incidence of any and co-morbid mental disorder, and also a lower incidence of anxiety, somatoform and dysthymic disorder. By contrast, the incidence of bipolar disorder was increased among those with regular physical activity at baseline. In terms of the population attributable fraction (PAF), the potential for preventive effects of physical activity was considerably higher for men than for women. Conclusions: Regular physical activity is associated with a substantially reduced risk for some, but not all, mental disorders and also seems to reduce the degree of co-morbidity. Further examination of the evidently complex mechanisms and pathways underlying these associations might reveal promising new research targets and procedures for targeted prevention.

In this thesis I investigate how the Canadian criminal justice system handles persons with mental disorders who come into conflict with the law. Through an in-depth examination of the Kitchener Mental Health Court this research explores the legal concept of diversion. Diversion is a voluntary option for individuals accused of minor offences. Its main objective is to function as a positive intervention. Offenders who participate in diversionary programs avoid a criminal record but are still held accountable for their criminal behavior. Diversion programs lessen the burden on the criminal justice system by decreasing the volume of caseloads in the courts via diverting individuals away from incarceration through alternative measures. The goal of this study is to uncover the processes involved in diverting offenders away from incarceration and into appropriate mental health treatment. Two theoretical frameworks applicable to mental health courts include the medical model and therapeutic jurisprudence. The thesis explores the philosophies of mental health courts, the principles of sentencing, and the role of community support agencies in the location and provision of mental health treatment. This research includes a six-month observational study of the Kitchener Mental Health Court setting and five in-depth interviews with the Crown prosecutor, defense attorney, Canadian Mental Health Association Court Coordinator, Salvation Army representative, and a mother of one of the accused. The findings from this research suggest that mental health courts strongly adhere to the treatment ideology contained in the medical model and therapeutic jurisprudence. The Kitchener Mental Health Court demonstrates this through its empathetic, treatment-oriented approach towards offenders, language, and commitment to locate appropriate health care. This research also reveals the crucial role community support agencies play in directing individuals towards the necessary health care. But most especially, the evidence points to the role community support agencies play as key facilitators in the legal processes of mental health courts.

In this thesis I investigate how the Canadian criminal justice system handles persons with mental disorders who come into conflict with the law. Through an in-depth examination of the Kitchener Mental Health Court this research explores the legal concept of diversion. Diversion is a voluntary option for individuals accused of minor offences. Its main objective is to function as a positive intervention. Offenders who participate in diversionary programs avoid a criminal record but are still held accountable for their criminal behavior. Diversion programs lessen the burden on the criminal justice system by decreasing the volume of caseloads in the courts via diverting individuals away from incarceration through alternative measures. The goal of this study is to uncover the processes involved in diverting offenders away from incarceration and into appropriate mental health treatment. Two theoretical frameworks applicable to mental health courts include the medical model and therapeutic jurisprudence. The thesis explores the philosophies of mental health courts, the principles of sentencing, and the role of community support agencies in the location and provision of mental health treatment. This research includes a six-month observational study of the Kitchener Mental Health Court setting and five in-depth interviews with the Crown prosecutor, defense attorney, Canadian Mental Health Association Court Coordinator, Salvation Army representative, and a mother of one of the accused. The findings from this research suggest that mental health courts strongly adhere to the treatment ideology contained in the medical model and therapeutic jurisprudence. The Kitchener Mental Health Court demonstrates this through its empathetic, treatment-oriented approach towards offenders, language, and commitment to locate appropriate health care. This research also reveals the crucial role community support agencies play in directing individuals towards the necessary health care. But most especially, the evidence points to the role community support agencies play as key facilitators in the legal processes of mental health courts.

Converging research on the diagnostic criteria for personality disorders (PDs) reveals that most criteria have different psychometric properties. This finding is inconsistent with the DSM-IV-TR PD diagnostic system, which weights each criterion equally. The purpose of the current study was to examine the potential effects of using equal weights for differentially-functioning criteria. Using data from over 2,100 outpatients, response patterns to the diagnostic criteria for nine PDs were analyzed and scored within an item response theory (IRT) framework. Results indicated that combinations that included the same number of endorsed criteria (the same "raw score") yielded differing estimates of PD traits, depending on which criteria were met. Moreover, trait estimates from subthreshold criteria combinations often overlapped with diagnostic combinations (i.e., at threshold or higher), indicating that there were subthreshold combinations of criteria that indicated as much or more PD traits than some combinations at the diagnostic threshold. These results suggest that counting the number of criteria an individual meets provides only a coarse estimation of their PD trait level. Suggestions for the improved measurement of polythetically-defined mental disorders are discussed.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2009. / Härtill 4 uppsatser.

Section A is a systematic review of the literature surrounding school-based interventions to address the stigma faced by people diagnosed with mental health problems. It asks the question of what the role of these interventions currently and potentially is and what is important for their efficacy. It begins by acknowledging the problem that stigma and discrimination presents, identifying what leads to and perpetuates this stigma. It then presents key theoretical and empirical contributions to our understanding of stigma and also to our understanding of how learning develops and attitudes form. The review goes on to look at what has been done in schools to date and highlights ‘active ingredients’ in these programmes, discussing the extent to which the current picture addresses theoretical and empirical contributions. Suggestions for further research are provided. Section B provides the findings of a grounded theory study investigating how primary school teachers communicate with children about mental health problems. Individual semi-structured interviews were carried out with fifteen teachers in three state schools. A model of communication is presented, which explains why discussions about mental health problems are absent from the primary school classroom. There appear to be a number of reasons for this. Teachers have fears about the implications of talking about mental health problems with children. These are connected to their beliefs and fears regarding those with mental health problems, their beliefs about mental health problems in relation to children and its place in the classroom, and about their professional roles. Relating to theory, teachers perceive themselves as part of a homogenous ‘in-group’ as distinct from a homogenous ‘out-group’ with mental health problems. Fears, beliefs and ingroup perceptions lead teachers to ‘play safe’ and avoid conversations about mental health problems in the classroom. This absence of discussion may reinforce for children that mental health problems are taboo. Greater links are required between schools and mental health services, and clinical psychologists need to be proactive in influencing policymakers by promoting the argument that teaching on mental health problems has an important place within the British school curriculum. Section C is a critical appraisal of this research, including discussion of the experience of being a researcher throughout this process. Consideration is given to the skills developed, areas where they may need to be expanded upon, areas where things could have been done differently, as well as research and clinical implications of the findings.