There is an increased risk for cardiovascular (CV) comorbidity among patients with rheumatoid arthritis (RA), with premature atherosclerosis, and a higher incidence of CV events, compared with the general population. Disease related factors add to the CV risk, and interact with the traditional CV risk factors. The underlying mechanism for this is not completely understood. In active RA there is a loss of muscle mass and an increase in body fat content. Production of cytokines, i.e., adipokines, in the adipose tissue could link the inflammation with the CV system. Control of the inflammation has been suggested to modify the CV risk in RA, and the recently introduced biological drugs, such as the tumor necrosis factor inhibitors (TNFi), have opened up new treatment opportunities. The aim of this thesis was to evaluate aspects of the interaction between inflammation and CV comorbidity in RA using biochemical and epidemiological methods. Methods In the first two studies, patients with established RA were examined for clinical disease activity, and blood samples were analysed for cytokines and adipokines using ELISAs and multiplex technology. In Study I (n RA=23) anthropometric measurements were assessed and in Study II (n RA=51) measurements of intima-media thickness (IMT), and endothelial function (FMD). From a subgroup of patients (Study II, n RA=13) samples of abdominal subcutaneous adipose tissue (SAT) were analysed for content of adipokines. In study III and IV associations between treatment with TNFi and acute coronary syndromes (ACS) were analysed using data from the Swedish Rheumatology Register; in Study III regarding early RA (n TNFi exposed=1,271, n bionaïve RA=4,729), and in Study IV comprising patients with RA of all stages (n TNFi exposed=7,213, n bionaïve RA=17,769) and with a matched general population comparator cohort (n=32,161). Associations between response to TNFi therapy and risk for ACS in the early RA cohort were evaluated in a nested case-control design (cases n=24, controls n=81). Results Serum levels of the cytokines/adipokines interleukin-1 receptor antagonist (IL-1Ra), IL-6, osteopontin, visfatin and TNF were increased in patients compared with controls (p≤0.001-0.036). The amount of TNF receptor II extracted from SAT was greater in patients (p=0.006). The serum (s-) levels of IL-1Ra correlated with s-leptin (r=0.71, p≤0.001) and s-haptoglobin in RA patients (r=0.56, p≤0.01). The result from a factor analysis indicated IL-1Ra to be associated with both adipose tissue and inflammation. Levels of s-visfatin (p=0.019) and s-IL-1Ra (p=0.023), respectively, were positively associated with IMT independently of inflammatory activity and CV risk factors. PAI-1 and MCP-1 extracted from SAT showed inverse associations with IMT. Patients with RA, whether exposed to TNFi or bio-naïve, had a doubled risk for ACS compared with the general population; HR 2.09 (95%CI 1.58-2.76) and 1.80 (1.49-2.17), respectively. No significant associations between risk for ACS and TNFi exposure were detected after adjustments; HR 0.80 (0.52-1.24) in early RA and HR 1.08 (0.82-1.41) in RA of any duration. Furthermore, no association between the risk for ACS and response to TNFi treatment in patients with early RA was observed, OR 1.5 (0.3-6.9). Conclusions The results indicate that cytokines/adipokines may have a role in the development of atherosclerosis in RA patients. A continuing increase in the risk of ACS in RA compared with the general population, despite modern therapeutic strategies, was noted. Neither exposure nor response to treatment with TNFi was associated with any modification of the risk for ACS.

Syftet med studien var att undersöka hur samarbetet för individer med samsjuklighet ser ut mellan kommun och landsting samt hur möjligheterna ser ut till samordnad vård och behandling. Frågeställningarna var att ta reda på hur samarbetet ser ut mellan kommun och landsting gällande individer med samsjuklighet samt vilka tillvägagångssätt som finns för att förbättra samordnad vård och behandling mellan kommun och landsting. Studien genomfördes med kvalitativa semistrukturerade intervjuer. Den teoretiska utgångspunkten var Fridolfs (2004) fyra motiv till ett bra samarbete. Utifrån det hermeneutiska synsättet tolkades intervjuerna inför resultatet med hjälp av innehållsanalys. Resultatet visar att det finns ett samarbete mellan kommun och landsting men för förbättring behövs det mer erfarenhet och kunskap om varandras arbetsuppgifter. Slutsatsen av resultatet är att mer forskning fordras om hur och på vilket sätt samarbete mellan kommun och landsting kan förbättras. Kan en gemensam huvudman vara ett alternativ?

Four interrelated studies on drug users in prison are presented within the framework of a proposed model for approaching the enhancement of health for persons that builds on an existential view of prisoners’ needs, as well as the risk management and “good lives” perspectives. Risk management is the major focus in current offender rehabilitation based on research on “what works,” which has shown that focusing treatment on risk factors termed “criminogenic needs,” such as impulsivity, poor family relations and drug abuse, reduces recidivism by 10-15 percentage points. The “good lives” perspective proposes that offender rehabilitation should go beyond risk management and also address non-criminogenic needs such as autonomy, relatedness and competence as foundations for building personally meaningful lives. Study I explores the assessment of drug use problems, and describes the psychometric evaluation of the Drug Use Disorders Identification Test (DUDIT), a newly developed 11-item test for quick screening of drug-related problems. Studies II-IV explore treatment for offenders in prison identified as drug users. Study II is a randomized controlled trial of two auricular acupuncture treatments for men and women in prison, inconclusive with regard to point specificity but showing that participants in both groups reported reduced symptoms of discomfort and improved night-time sleep. Study III evaluates the Reasoning & Rehabilitation program, an internationally widespread cognitive-behavioral program for groups of offenders. Results showed significant pro-social short-term changes in sense of coherence, impulsivity and attitudes towards the criminal justice system, as well as a 25% lower risk of reconviction among program completers compared to matched controls. However, the quasi-experimental nature of the study precludes any certainty regarding program effects; a selection bias whereby more motivated program participants are recruited could explain the findings. Study IV is a pilot project exploring the special needs of a subgroup of drug-using inmates with psychiatric and/or violent co-morbidity. Inmates housed in psychiatric prison units were offered long-term auricular acupuncture treatment. Half of the 22 inmates in the study received treatment twice a week for over eight weeks, and those treated over 25 times had lower psychopharmacological medication levels than untreated controls. Studies I-IV address individual facets of a proposed model for enhancing health among drug users in prison. The health enhancement model approaches offender rehabilitation from perspectives of existential psychology, good lives and risk management. Specific definitions of physical, social, psychological/personal and spiritual needs indicate a framework according to which prison treatment can help drug-using offenders find ways to secure healthy need satisfaction.

Den sociala ångesten många känner i olika situationer kan leda till undvikande, isolering och ibland även kompliceras av depressiva symtom och/eller alkoholanvändning. Huruvida ett samband mellan dessa problem kan visa sig i 16-17 årsåldern undersöktes genom en enkät om nedstämdhet, alkoholanvändning och social ångest. Resultatet visade att nedstämdhet hade en inverkan på grad av social ångest hos båda könen. Dock var tjejer i högre grad än killar mer nedstämda. Tjejer som drack mindre uppvisade en högre grad av social ångest. Alkoholanvändning hängde inte ihop med killars hantering av social ångest. Resultatet tyder på att samband mellan variablerna kan visa sig tidigt. Därför borde resurser sättas in tidigt för att förhindra en negativ utveckling, så att personer kan fungera i samhället. / The social anxiety many people feel in different situations can lead to avoidance, isolation and be complicated with depressive symptoms and/or alcoholuse. Whether it’s possible to find relationships between these syndromes in age 16-17 was investigated through a survey about depression, alcoholuse and social anxiety. The result showed that depression had an impact on level of social anxiety for both sexes. Gals were more depressed than guys, though. Gals who drank less had a higher level of social anxiety. Alcoholuse had no impact in coping with social anxiety for guys. The result showes a connection between the variables that can be seen early. Therefore, resources should be available to prevent a negative development, so that people can function in society.

Hintergrund: Angststörungen gehören zu den häufigsten psychischen Störungen im Jugend- und Erwachsenenalter. Ein Großteil der Betroffenen bleibt meist unbehandelt. Informationen über die Behandlungswahrscheinlichkeit bei Jugendlichen und jungen Erwachsenen in Abhängigkeit von der Störungs- und Behandlungsart, Lebensalter, Geschlecht und Komorbidität liegen bisher nicht vor. Methode: In einer repräsentativen Stichprobe 14- bis 34-Jähriger aus dem Großraum München (Early Developmental Stages of Psychopathology Studie, N = 3021) werden die Prävalenz und Lebenszeitinzidenz von Angststörungen sowie ihre Behandlungsraten mittels M-CIDI erfasst und differenziert für Lebensalter, Komorbidität und Geschlecht präsentiert. Ergebnisse: 30% der Befragten berichteten mindestens eine Angststörung in ihrem Leben. Fast die Hälfte der Betroffenen (43%) suchte irgendeine Behandlung, ein Drittel (28%) suchte einen Psychotherapeuten auf. Für die meisten Angststörungen lagen hohe Quoten psychotherapeutischer Behandlungen vor (Range: 50–61%). Jugendliche berichteten seltener als Erwachsene irgendeine Behandlung, eine psychotherapeutische Behandlung, die Konsultation eines Psychiaters oder Hausarztes. Frauen nahmen häufiger eine Psychotherapie in Anspruch als Männer. Das Vorliegen einer komorbiden Angst- oder depressiven Störung erhöhte die Behandlungswahrscheinlichkeit. Diskussion: Verglichen mit europäischen Studien berichtete die Stichprobe relativ häufig eine Behandlung, auch eine psychotherapeutische. Dies kann eine Folge des großen Behandlungsangebotes in München sein. Dennoch bleibt der Großteil der jungen Betroffenen unbehandelt. Zur Prävention langfristiger Beeinträchtigungen sowie sekundärer psychischer Störungen sollte das Versorgungssystem verstärkt auf diese Bevölkerungsgruppe ausgerichtet werden. / Background: Anxiety disorders are among the most frequent mental disorders in adolescence and adulthood. Most of the affected individuals do not receive treatment. Information about treatment use among adolescents and young adults, differentiated for the kind of treatment and anxiety disorder, age, gender and co-morbidity, is still missing. Methods: In a representative sample of 14–34 year-old adolescents and young adults of the Munich area (Early Developmental Stages of Psychopathology study, N = 3,021) prevalence and lifetime incidence of anxiety disorders and treatment use are assessed using the M-CIDI and will be presented for age, co-morbidity and gender. Results: 30% of all participants reported at least one lifetime diagnosis of an anxiety disorder. Almost half of those affected (43%) received some kind of treatment; one third (28%) received psychotherapy. Psychotherapy use was frequent in most anxiety disorders (range: 50–61%). Older individuals more frequently reported any treatment, psychotherapy, consultations with psychiatrists or general practitioners. Women used psychotherapy more often than men. Co-morbid anxiety or depressive disorders increased the probability of treatment use. Discussion: As compared to European estimations, we found relatively high rates of treatment use. This may be due to the many treatment possibilities in the Munich area. Nevertheless, most young people affected do not receive treatment. Considering the long-term effects of anxiety disorders and in order to prevent secondary disorders, efforts should be increased to reach these young individuals.

Hintergrund: Angststörungen gehören zu den häufigsten psychischen Störungen im Jugend- und Erwachsenenalter. Ein Großteil der Betroffenen bleibt meist unbehandelt. Informationen über die Behandlungswahrscheinlichkeit bei Jugendlichen und jungen Erwachsenen in Abhängigkeit von der Störungs- und Behandlungsart, Lebensalter, Geschlecht und Komorbidität liegen bisher nicht vor. Methode: In einer repräsentativen Stichprobe 14- bis 34-Jähriger aus dem Großraum München (Early Developmental Stages of Psychopathology Studie, N = 3021) werden die Prävalenz und Lebenszeitinzidenz von Angststörungen sowie ihre Behandlungsraten mittels M-CIDI erfasst und differenziert für Lebensalter, Komorbidität und Geschlecht präsentiert. Ergebnisse: 30% der Befragten berichteten mindestens eine Angststörung in ihrem Leben. Fast die Hälfte der Betroffenen (43%) suchte irgendeine Behandlung, ein Drittel (28%) suchte einen Psychotherapeuten auf. Für die meisten Angststörungen lagen hohe Quoten psychotherapeutischer Behandlungen vor (Range: 50–61%). Jugendliche berichteten seltener als Erwachsene irgendeine Behandlung, eine psychotherapeutische Behandlung, die Konsultation eines Psychiaters oder Hausarztes. Frauen nahmen häufiger eine Psychotherapie in Anspruch als Männer. Das Vorliegen einer komorbiden Angst- oder depressiven Störung erhöhte die Behandlungswahrscheinlichkeit. Diskussion: Verglichen mit europäischen Studien berichtete die Stichprobe relativ häufig eine Behandlung, auch eine psychotherapeutische. Dies kann eine Folge des großen Behandlungsangebotes in München sein. Dennoch bleibt der Großteil der jungen Betroffenen unbehandelt. Zur Prävention langfristiger Beeinträchtigungen sowie sekundärer psychischer Störungen sollte das Versorgungssystem verstärkt auf diese Bevölkerungsgruppe ausgerichtet werden. / Background: Anxiety disorders are among the most frequent mental disorders in adolescence and adulthood. Most of the affected individuals do not receive treatment. Information about treatment use among adolescents and young adults, differentiated for the kind of treatment and anxiety disorder, age, gender and co-morbidity, is still missing. Methods: In a representative sample of 14–34 year-old adolescents and young adults of the Munich area (Early Developmental Stages of Psychopathology study, N = 3,021) prevalence and lifetime incidence of anxiety disorders and treatment use are assessed using the M-CIDI and will be presented for age, co-morbidity and gender. Results: 30% of all participants reported at least one lifetime diagnosis of an anxiety disorder. Almost half of those affected (43%) received some kind of treatment; one third (28%) received psychotherapy. Psychotherapy use was frequent in most anxiety disorders (range: 50–61%). Older individuals more frequently reported any treatment, psychotherapy, consultations with psychiatrists or general practitioners. Women used psychotherapy more often than men. Co-morbid anxiety or depressive disorders increased the probability of treatment use. Discussion: As compared to European estimations, we found relatively high rates of treatment use. This may be due to the many treatment possibilities in the Munich area. Nevertheless, most young people affected do not receive treatment. Considering the long-term effects of anxiety disorders and in order to prevent secondary disorders, efforts should be increased to reach these young individuals.

Background. General population data were used to study co-morbidities between lifetime social phobia and mood disorders. Methods. Data come from the US National Comorbidity Survey (NCS). Results. Strong associations exist between lifetime social phobia and major depressive disorder (odds ratio 2·9), dysthymia (2·7) and bipolar disorder (5·9). Odds ratios increase in magnitude with number of social fears. Reported age of onset is earlier for social phobia than mood disorders in the vast majority of co-morbid cases. Temporally-primary social phobia predicts subsequent onset of mood disorders, with population attributable risk proportions of 10–15%. Social phobia is also associated with severity and persistence of co-morbid mood disorders. Conclusions. Social phobia is a commonly occurring, chronic and seriously impairing disorder that is seldom treated unless it occurs in conjunction with another co-morbid condition. The adverse consequences of social phobia include increased risk of onset, severity and course of subsequent mood disorders. Early outreach and treatment of primary social phobia might not only reduce the prevalence of this disorder itself, but also the subsequent onset of mood disorders.

Tuberculosis (TB) and human immunodeficiency virus (HIV) are difficult conditions to manage, in tandem they pose even more challenges to public health programs in identifying coinfection to ensure that all TB cases are treated to completion of therapy (COT). The purpose of this study was to test variables that predicted COT among the HIV/TB coinfected population of non-Hispanic, U.S.-born Blacks alive at the time of diagnosis. Social determinants of health were the theoretical foundation used to guide the study based on data from the Report of Verified Cases of TB (RVCT) between 2009 and 2014. Relationships were tested between ethnic/racial group membership and the likelihood of COT, and whether any association to COT was moderated by COT eligibility; a Centers for Disease Control and Prevention calculated algorithm considering disease severity, site, age, and disease complexity. The research design was a longitudinal quantitative approach using binary logistic regression to identify correlated variables associated with COT in the final model. The results showed no statistically significant differences among racial/ethnic groups, age, and gender for COT. COT was moderated by COT eligibility; odds ratio (5.4 - 11.6) times more likely to complete therapy. This study supports positive social change for programs by providing data driven outcomes to providers that support outreach, patient education, and disease prevention. In addition, this research describes an evaluation metric based on performance to set a foundation for collaboration among partners who manage other comorbidities in the United States.

Spelberoende är ett allvarligt folkhälsoproblem som förorsakar en rad negativa konsekvenser för individer, där spelberoendet ofta är kombinerat med samsjuklighet, vilket gör problematiken mer komplex. På grund av denna problematik är det viktigt att ta reda på hur behandlare uppfattar behandlingsmetoder. Syftet med denna studie var att undersöka behandlares uppfattningar av behandlingsarbetet med personer som har spelberoende i kombination med samsjuklighet. Utifrån en kvalitativ ansats genomfördes sex semi-strukturerade intervjuer med behandlare. Materialet analyserades genom en tematisk analys. Resultatet visar att behandlarna belyser vikten av att integrera och anpassa olika metoder, teorier, besitta ett brett förhållningssätt och att samverka med andra aktörer för att kunna bemöta och behandla denna komplexa målgrupp. En slutsats är att behandlarna tycks ha en medvetenhet av behandlingsarbetet som tvärdisciplinärt där arbetet med olika behandlingsmetoder används eklektiskt. Studien påvisar behovet av ytterligare forskning och mer förebyggande arbete. / Gambling addiction is a public health problem that causes negative consequences for individuals, where gambling addiction is often combined with co-morbidity, which makes the problem more complex. Because of this problem, it is important to examinate how therapists perceive treatment methods. This study aimed to investigate therapists' perceptions of the treatment work, with people who have gambling addiction combined with co-morbidity. Six semi-structured interviews were conducted with therapists based on a qualitative approach. The material was analyzed through thematic analysis. The results indicate that the therapists highlight the importance of integrating and adapting different methods and theories, having a broad approach and cooperation with other actors to treat this complex target group. A conclusion is that the therapists seem to be aware that the treatment work is interdisciplinary where the work with different treatment methods is used eclectically. The study demonstrates the need for further research and preventive work.

Missbruksproblematik är ett globalt samhällsproblem som kräver insatser, särskilt från verksamheter som socialtjänsten. Missbruk i kombination med psykisk ohälsa är komplextoch utmanande för individen. Det innebär att socialsekreterare, vårdpersonal och behandlare behöver samverka för att uppnå effektiv behandling. Studien syftar till att förstå socialsekreterares och behandlares upplevelser av samverkan, gällande klienter som lider av dubbbelproblematik i form av psykisk ohälsa och missbruk. Detta är en kvalitativ studie som använder sig av sociala representationer, handlingsutrymme och makt som teoretiska utgångspunkter. Genom sju semistrukturerade intervjuer samlades data in för att vidare analyseras utifrån de teoretiska utgångspunkterna i den tematiska analysen.Resultatet visar att de intervjuade socialsekreterarna och behandlarna upplever att samverkan är hjälpsam och nödvändig för personer med missbruk och dubbelproblematik. Trots detta framhålls det svårigheter med samverkan när yrkesverksammas åsikter kring insatser skiljer sig åt. Det framkommer otydligheter gällande ansvarsområden, där socialsekreterare och behandlare upplever att klienter flyttas mellan psykiatrin och socialtjänsten. Det visar även att socialsekreterare upplever hinder inom ansvarsområden vid början av ärendet, medan behandlare uttrycker liknande utmaningar under pågående behandling. Resultatet visar att behandlares handlingsutrymme verkar vara mer flexibelt än socialsekreterares vid val av metoder och strategier. Några faktorer som påverkar socialsekreterarnas handlingsutrymme är ekonomiska ramar, politiska begränsningar och brist på resurser. Avslutningsvis lyfter studien i sin helhet förståelsen för hur samverkan kan påverkas av olika faktorer, men även hur det kan påverka yrkesverksammas möjligheter att hjälpa klienter. / Substance abuse is a global societal issue that requires efforts, especially from social services. Substance abuse in combination with mental illness is complex and challenging for the individual. This means that social secretary, therapists and psychiatry need to cooperate to achieve effective treatment. The study aims to understand social workers and therapist experience of collaboration regarding clients who suffer from co-morbidity in form of mental illness and addiction. This is a qualitative study that utilizes social representations, space for action and power as theoretical foundations. Through seven semi-structured interviews. data is collected and further analyzed based on the theoretical foundations in thematic analyses.The results indicate that the interviewed social workers and therapists perceive collaboration as helpful and necessary for individuals with substance abuse and co-morbidity. Although, it appears difficulties with collaboration when professionals have differing opinions on interventions. Difficulties in collaboration are highlighted regarding responsibilities where social workers feel that clients are shifted between psychiatry and social services. The study's results showed that therapists appear to have more flexible space for action than social workers in choosing methods and strategies. Some factors affecting social workers' space for action are financial constraints, political limitations and lack of resources. In conclusion, the study highlights overall understanding of how cooperation can be influenced by various factors but also how it can impact the roles of professionals.