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Lindsäter E, Svärdman F, Wallert J, Ivanova E, Söderholm A, Fondberg R, Nilsonne G, Cervenka S, Lekander M, Rück C. Exhaustion disorder: scoping review of research on a recently introduced stress-related diagnosis. BJPsych Open 2022; 8:e159. [PMID: 36458830 PMCID: PMC9438479 DOI: 10.1192/bjo.2022.559] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/17/2022] [Accepted: 07/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Symptoms related to chronic stress are prevalent and entail high societal costs, yet there is a lack of international consensus regarding diagnostics and treatment. A new stress-related diagnosis, exhaustion disorder, was introduced into the Swedish version of ICD-10 in 2005. Since then, use of the diagnosis has increased rapidly. AIMS To create the first comprehensive synthesis of research on exhaustion disorder to report on the current state of knowledge. Preregistration: Open Science Framework (http://www.w3.org/1999/xlink">osf.io), doi 10.17605/OSF.IO/VFDKW. METHOD A PRISMA-guided scoping review of all empirical studies of exhaustion disorder was conducted. Searches were run in the MEDLINE, PsycInfo and Web of Science databases. Data were systematically charted and thematically categorised based on primary area of investigation. RESULTS Eighty-nine included studies were sorted into six themes relating to lived experience of exhaustion disorder (n = 9), symptom presentation and course (n = 13), cognitive functioning (n = 10), biological measures (n = 24), symptom measurement scales (n = 4) and treatment (n = 29). Several studies indicated that individuals with exhaustion disorder experience a range of psychiatric and somatic symptoms beyond fatigue, but robust findings within most thematic categories were scarce. The limited number of studies, lack of replication of findings and methodological limitations (e.g. small samples and scarcity of specified primary outcomes) preclude firm conclusions about the diagnostic construct. CONCLUSIONS More research is needed to build a solid knowledge base for exhaustion disorder. International collaboration regarding the conceptualisation of chronic stress and fatigue is warranted to accelerate the growth of evidence.
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Affiliation(s)
- Elin Lindsäter
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm, Sweden; and Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Frank Svärdman
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; and Stockholm Health Care Services, Stockholm, Sweden
| | - John Wallert
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; and Stockholm Health Care Services, Stockholm, Sweden
| | - Ekaterina Ivanova
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; and Stockholm Health Care Services, Stockholm, Sweden
| | - Anna Söderholm
- Department of Psychology, Umeå Universitet, Umeå, Sweden
| | - Robin Fondberg
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; and Stockholm Health Care Services, Stockholm, Sweden
| | - Gustav Nilsonne
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; and Stress Research Institute, Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Simon Cervenka
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm, Sweden; and Department of Medical Sciences, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Mats Lekander
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stress Research Institute, Department of Psychology, Stockholm University, Sweden; and Osher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Christian Rück
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; and Stockholm Health Care Services, Stockholm, Sweden
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Af Winklerfelt Hammarberg S, Westman J, Hange D, Finnes A, Björkelund C, Hällgren J, Skoglund I, Nager A. Outcomes of psychiatric interviews and self-rated symptom scales in people on sick leave for common mental disorders: an observational study. BMJ Open 2022; 12:e057745. [PMID: 35732382 PMCID: PMC9226864 DOI: 10.1136/bmjopen-2021-057745] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To investigate the correspondence between diagnoses on sick leave certificates and diagnoses made in structured psychiatric interviews. Secondary aims were to investigate length of sick leave by diagnoses on sick leave certificates, diagnoses made in structured interviews and symptom severity. DESIGN Observational study consisting of a secondary analysis of data from a randomised controlled trial and an observational study. SETTING The regions of Stockholm and Västra Götaland, Sweden. PARTICIPANTS 480 people on sick leave for common mental disorders. INTERVENTIONS Participants were examined with structured psychiatric interviews and self-rated symptom severity scales. OUTCOME MEASURES (1) Sick leave certificate diagnoses, (2) diagnoses from the Mini International Neuropsychiatric Interview and the Self-rated Stress-Induced Exhaustion Disorder (SED) Instrument (s-ED), (3) symptom severity (Montgomery-Asberg Depression Rating Scale-self-rating version and the Karolinska Exhaustion Disorder Scale) and (4) number of sick leave days. RESULTS There was little correspondence between diagnoses on sick leave certificates and diagnoses made in structured psychiatric interviews. Many participants on sick leave for SED, anxiety disorder or depression fulfilled criteria for other mental disorders. Most on sick leave for SED (76%) and anxiety disorder (67%) had depression (p=0.041). Length of sick leave did not differ by certificate diagnoses. Participants with SED (s-ED) had longer sick leave than participants without SED (144 vs 84 days; 1.72 (1.37-2.16); p<0.001). More severe symptoms were associated with longer sick leave. CONCLUSION Diagnoses on sick leave certificates did not reflect the complex and overlapping nature of the diagnoses found in the structured psychiatric interviews. This finding is relevant to the interpretation of information from health data registers, including studies and guidelines based on these data. A result of clinical interest was that more severe symptoms predicted long-term sick leave better than actual diagnoses.
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Affiliation(s)
- Sandra Af Winklerfelt Hammarberg
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Region of Stockholm, Academic Primary Care Centre, Stockholm, Sweden
| | - Jeanette Westman
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Region of Stockholm, Academic Primary Care Centre, Stockholm, Sweden
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - Dominique Hange
- Primary Health Care, School of Public Health and Community Medicine, Institutet of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
| | - Anna Finnes
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Björkelund
- Primary Health Care, School of Public Health and Community Medicine, Institutet of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden, Gothenburg, Sweden
| | - Jonas Hällgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ingmarie Skoglund
- Primary Health Care, School of Public Health and Community Medicine, Institutet of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
| | - Anna Nager
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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Kasper S, Bonelli A, Cattaneo A, Comandini A, Di Dato G, Heiman F, Pegoraro V, Palao D, Roca M, Volz HP. Predictors of sick leave days in patients affected by major depressive disorder receiving antidepressant treatment in general practice setting in Germany. Int J Psychiatry Clin Pract 2021; 25:393-402. [PMID: 34543170 DOI: 10.1080/13651501.2021.1972120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To identify sick leave days (SLD) predictors after starting antidepressant (AD) treatment in patients affected by major depressive disorder (MDD), managed by general practitioners, with a focus on different AD therapeutic approaches. METHODS Retrospective study on German IQVIA® Disease Analyser database. 19-64 year old MDD patients initiating AD treatment between July-2016 and June-2018 were grouped by therapeutic approach (AD monotherapy versus combination/switch/add-on). Data were analysed descriptively by AD therapeutic approach, while a zero-inflated Poisson (ZIP) multiple regression model was run to evaluate SLD predictors. RESULTS 8,891 patients met inclusion criteria (monotherapy: 66%; combination/switch/add-on: 34%). All covariates had an influence on SLD after AD treatment initiation. Focussing on variables that physicians may more easily intervene to improve outcomes, it was found that the expected SLD number of combination/switch/add-on patients was 1.6 times that of monotherapy patients, and the expected SLD number of patients diagnosed with MDD before the decision to start AD treatment was 1.2 times that of patients not diagnosed with MDD. CONCLUSIONS A patient tailored approach in the selection of AD treatment at the time of MDD diagnosis may improve functional recovery and help to reduce the socio-economic burden of the disease.KEY POINTSFew studies previously investigated the effect of antidepressant treatment approaches on sick leave days in major depressive disorder.To the authors' knowledge, this is the first study evaluating the effect of different antidepressant treatment approaches on sick leave days in major depressive disorder in German patients.Patients receiving antidepressant monotherapy treatment seemed to lose fewer working days than patients receiving antidepressants combination/switch/add-on therapy, both before and after starting treatment, even if differences were more pronounced after treatment has started.The use of antidepressant monotherapy or combination/switch/add-on therapy was the strongest predictor of sick leave days after starting antidepressant treatment: the expected number of sick leave days for the combination/switch/add-on group was 1.6 times that of the monotherapy group.Among factors associated with increased sick leave days, antidepressant therapeutic approach and the promptness of starting the antidepressant treatment when major depressive disorder is diagnosed, are those on which physicians may more easily intervene to improve outcomes.Findings from the present study suggest that a patient tailored approach may improve functional recovery and help reducing the socio-economic burden of the disease.
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Affiliation(s)
- Siegfried Kasper
- Center for Brain Research, Medical University of Vienna, Austria
| | | | | | | | | | | | | | - Diego Palao
- Department of Mental Health, Parc Taulí-University Hospital of Sabadell, Department of Psychiatry and Forensic Medicine, Unitat de Neurociència Traslacional I3PT-INc Autonomous University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Miquel Roca
- Department of Medicine, IUNICS/IDISBA, University of Balearic Islands, Palma, Spain
| | - Hans-Peter Volz
- Hospital for Psychiatry, Psychotherapy and Psychosomatic Medicine, Werneck, Germany
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Hange D, Ariai N, Björkelund C, Svenningsson I, Nejati S, Petersson EL, Augustsson P, Skoglund I. Associations between antidepressant therapy, work ability, and sick leave for patients with common mental disorders within a two-year perspective - A longitudinal observational cohort study in Swedish primary care. Heliyon 2021; 7:e07116. [PMID: 34113733 PMCID: PMC8170496 DOI: 10.1016/j.heliyon.2021.e07116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/31/2021] [Accepted: 05/17/2021] [Indexed: 11/18/2022] Open
Abstract
Background An increasing number of patients are on sick leave because of common mental disorders (CMD), with or without antidepressant therapy. There is a lack of long-term follow-up studies in the primary care context, where most of the patients are treated. The importance of identifying potential factors associated with work ability for CMD patients is increasingly in focus. Objective To investigate the associations between using antidepressants, sick leave duration, reported work ability and psychological symptoms among patients with CMD during a two-year observation period in the primary care context. Methods Longitudinal observational cohort study at 28 Primary Care Centers in Region Västra Götaland, Sweden, including 182 patients with an employment and on sick leave for CMD. The following outcomes were assessed: work ability measured with WAI, depressive symptoms with MADRS-S, anxiety symptoms with BAI, fatigue symptoms with KEDS, quality of life with EQ-5D, and days of sick leave. The data were compared between the groups that used and did not use antidepressants, during the 24-months observation period. Results Work ability and health-related quality of life increased over time in both groups. A steeper decrease of depressive symptoms, anxiety symptoms as well as an increased health-related quality of life at 3, 6 and 12 months was found in the group without antidepressants, although both groups levelled off at 24 months. In both groups, a higher work ability at baseline was associated with less two-year sick leave. Conclusion Our study indicates that a high work ability at baseline has a strong association with a lower total net and gross sick leave duration during the entire two-year follow-up period for patients with CMD in primary health care, irrespective of use of antidepressants. Using WAI in primary health care could therefore be helpful in predicting return to work. Use of antidepressants during the CMD episode could indicate initially a more pronounced overall symptom pattern, motivating introduction of antidepressants, rather than prolonging the sick leave period.
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Affiliation(s)
- Dominique Hange
- Primary Health Care/School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- Corresponding author.
| | - Nashmil Ariai
- Primary Health Care/School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Cecilia Björkelund
- Primary Health Care/School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Irene Svenningsson
- Primary Health Care/School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Shabnam Nejati
- Primary Health Care/School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Eva-Lisa Petersson
- Primary Health Care/School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Pia Augustsson
- Primary Health Care/School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ingmarie Skoglund
- Primary Health Care/School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
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Petersson EL, Törnbom K, Hange D, Nejati S, Jerlock M, Wikberg C, Björkelund C, Svenningsson I. The experiences of care managers and rehabilitation coordinators of a primary care intervention to promote return to work for patients with common mental disorders: a qualitative study. BMC FAMILY PRACTICE 2020; 21:272. [PMID: 33339512 PMCID: PMC7749497 DOI: 10.1186/s12875-020-01348-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/07/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND In an earlier study, PRIM-CARE RCT, a care manager implementation at the primary care centre showed improved return to work and reduced sick leave for patients with CMD. To further improve return to work, the project Co-Work-Care added a person-centered dialogue meeting between the patient, the employer and the rehabilitation coordinator, preceded by an increased collaboration between care manager, rehabilitation coordinator and GP. In this first qualitative study of the Co-Work-Care project, we explored how care managers and rehabilitation coordinators experienced the Co-Work-Care model. The purpose of this study was to explore care managers' and rehabilitation coordinators' perceptions and experiences of a close collaboration and the use of the person-centred dialogue meeting. METHODS From an ongoing RCT with 20 primary care centres, care managers (CMs) (n = 13) and rehabilitation coordinators (RCs) (n = 12) participated in a qualitative study with focus groups. The study was conducted in the primary health care in a Swedish region. The data was analysed with Systematic Text Condensation by Malterud. RESULTS Seven codes describing the participants' experiences of the Co-Work-Care model were identified: 1) The importance of collaboration at the primary care centre, 2) Collaboration and division of roles between the RC and the CM, 3) Collaboration with the General practitioner (GP), 4) The person-centred dialogue meeting, 5) Initiating the person-centred dialogue meeting, 6) The person-centred dialogue meeting to improve collaboration with the employer, and 7) The person-centred dialogue meeting to teach about the return to work process. CONCLUSION The increased collaboration within the Co-Work-Care model created a common picture and understanding of the patient's situation. The person-centred dialogue meeting in the rehabilitation process became a bridge between the employer and the patient. TRIAL REGISTRATION NCT03250026 (registered August 15, 2017).
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Affiliation(s)
- Eva-Lisa Petersson
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research and Development Primary Health Care, Region Västra Götaland, Göteborg, Sweden
| | - Karin Törnbom
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Social Work, University of Gothenburg, Gothenburg, Sweden
| | - Dominique Hange
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research and Development Primary Health Care, Region Västra Götaland, Göteborg, Sweden
| | - Shabnam Nejati
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Margareta Jerlock
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carl Wikberg
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research and Development Primary Health Care, Region Västra Götaland, Göteborg, Sweden
| | - Irene Svenningsson
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research and Development Primary Health Care, Region Västra Götaland, Göteborg, Sweden
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Nejati S, Ariai N, Björkelund C, Skoglund I, Petersson EL, Augustsson P, Hange D, Svenningsson I. Correspondence Between the Neuropsychiatric Interview M.I.N.I. and the BDI-II and MADRS-S Self-Rating Instruments as Diagnostic Tools in Primary Care Patients with Depression. Int J Gen Med 2020; 13:177-183. [PMID: 32523369 PMCID: PMC7234955 DOI: 10.2147/ijgm.s243150] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/27/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To investigate the correspondence between the diagnoses received by patients with symptoms of common mental disorder attending primary care, based on the diagnostic instrument International Neuropsychiatric Interview (M.I.N.I.) and the self-assessment instruments such as Beck Depression Inventory (BDI-II) and Montgomery-Asberg Depression Rating Scale - self-rating version (MADRS-S), respectively. Design Data were collected from a prospective observational study, ADAS, between 2014 and 2015. Setting Twenty-eight primary care centers in Region Västra Gotaland, Sweden. Patients A total of 192 patients, 18-60 years of age, on sick leave ≥14 days, with mild/moderate depression, anxiety syndrome, and stress-related mental illness were included. Main Outcome Measures Scores of the assessment instruments (BDI-II and MADRS-S) on inclusion, sensitivity, specificity, positive (PPV) and negative predictive value (NPV) for BDI-II and MADRS-S, respectively, with M.I.N.I used as diagnostic instrument. Results Using M.I.N.I. as gold standard, the BDI-II and MADRS-S showed almost the same sensitivity (86.9% and 87.4%, respectively), but specificity for MADRS-S was doubled compared to BDI-II (36% and 18%, respectively). There was a significant association between MADRS-S and M.I.N.I. (p=0.027). However, the same analysis between BDI and M.I.N.I. was not statistically significant (p= 0.635). NPV and PPV were calculated from assumed prevalences (10% and 75%) and were higher for MADRS-S compared to BDI-II. The PPV differences were between 2% and 7% and NPV differences were between 3% and 19%. Conclusion With M.I.N.I. as gold standard, MADRS-S performs better than BDI-II as a self-assessment tool in the primary care context for depression diagnostics.
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Affiliation(s)
- Shabnam Nejati
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Nashmil Ariai
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Cecilia Björkelund
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ingmarie Skoglund
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,Narhalsan Research and Development Primary Health Care, Region Vastra Gotaland, Gothenburg, Sweden
| | - Eva-Lisa Petersson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,Narhalsan Research and Development Primary Health Care, Region Vastra Gotaland, Gothenburg, Sweden
| | - Pia Augustsson
- Narhalsan Research and Development Primary Health Care, Region Vastra Gotaland, Gothenburg, Sweden
| | - Dominique Hange
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,Narhalsan Research and Development Primary Health Care, Region Vastra Gotaland, Gothenburg, Sweden
| | - Irene Svenningsson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,Narhalsan Research and Development Primary Health Care, Region Vastra Gotaland, Gothenburg, Sweden
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