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Brummelhuis IAM, Videler AC, Kop WJ. Association of parental mental illness with anxiety and depression in adulthood: The role of potentially contributing factors. J Affect Disord 2024; 350:174-181. [PMID: 38218251 DOI: 10.1016/j.jad.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/03/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVE Children of parents with a mental illness (COPMI) are at risk of developing mental disorders in adulthood, especially anxiety disorders and depression. The role of the family environment and demographic factors as related to adult anxiety and depression is insufficiently understood. We examined potentially contributing factors in the associations between a COPMI background with anxiety and depressive symptoms in adulthood. METHOD Cross-sectional general population-based study. Instruments were the General Anxiety Disorder scale (GAD-7), Patient Health Questionnaire (PHQ-9) and a questionnaire to evaluate self-reported history of a COPMI background and family-related experiences (CEPMIF). Multiple regression analyses were used to examine the role of demographic and family-related factors in the association of a self-reported COPMI background with the level of anxiety and depressive symptoms. RESULTS Of the 942 participants (mean age 48.1 (SD = 16.2) years; 53.7 % women), 116 (12.3 %) had a COPMI background. A COPMI background was associated with higher levels of anxiety and depressive symptoms. Within individuals with a COPMI background, relationship problems within the family were associated with elevated levels of anxiety and depression. LIMITATIONS The cross-sectional design does not allow for causal inferences, COPMI background was based on participant's self-report, and the type of parental mental disorder was not considered. CONCLUSIONS Adults with a COPMI background have higher levels of anxiety and depressive symptoms. Dysfunctional family relationships during childhood were associated with the severity of mental health problems of adults who grew up with a mentally ill parent. There is a need for targeted interventions for adult COPMI.
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Affiliation(s)
- Ingrid A M Brummelhuis
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, the Netherlands; Department Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, the Netherlands.
| | - Arjan C Videler
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, the Netherlands; Department Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, the Netherlands; Clinical Centre of Excellence for Personality and Developmental Disorders in Older Adults, GGz Breburg, Tilburg, the Netherlands.
| | - Willem J Kop
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, the Netherlands; Department of Medical and Clinical Psychology, Center of Research in Psychological Disorders and Somatic Diseases (CoRPS), Tilburg University, Tilburg, the Netherlands
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2
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Brummelhuis IAM, Kop WJ, Videler AC. Psychological and physical wellbeing in adults who grew up with a mentally ill parent: A systematic mixed-studies review. Gen Hosp Psychiatry 2022; 79:162-176. [PMID: 36471514 DOI: 10.1016/j.genhosppsych.2022.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Genetic vulnerability factors and adverse childhood experiences (ACE) are associated with an increased risk of psychopathology and other adverse health outcomes across the lifespan. However, less is known about how childhood experiences of parental mental illness affect psychological and physical wellbeing in adulthood. This review synthesizes research on the consequences of growing up as a child of a parent with mental illness (COPMI) for adult psychological and physical wellbeing. METHODS A systematic review was conducted following PRISMA guidelines using a mixed-method-studies approach to enable evaluation of the broad array of research designs (Prospero registration #CRD42020221983). RESULTS Qualitative studies (k = 10; N = 361) revealed that a COPMI background is associated with substantial psychological challenges in adulthood. Quantitative studies (k = 21; N = 865.402) suggested that COPMI are at increased risk of adult psychopathology, including anxiety and depressive disorders, suicidality, somatoform disorders, substance abuse, but also general medical morbidity and mortality. CONCLUSIONS Growing up with a mentally ill parent is associated with adverse psychological and physical outcomes in adulthood, but the evidence-base is limited. Longitudinal studies are needed that go beyond establishing genetic and environmental risk factors to further evaluate how a COPMI background influences wellbeing in adulthood and which targeted clinical interventions could be developed.
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Affiliation(s)
- Ingrid A M Brummelhuis
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, the Netherlands; Department Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, the Netherlands
| | - Willem J Kop
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, the Netherlands; Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands.
| | - Arjan C Videler
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, the Netherlands; Department Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, the Netherlands; Clinical Centre of Excellence for Personality Disorders and Autism in Older Adults, GGz Breburg, Tilburg, the Netherlands
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3
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Dobewall H, Keltikangas-Järvinen L, Saarinen A, Lyytikäinen LP, Zwir I, Cloninger R, Raitakari OT, Lehtimäki T, Hintsanen M. Genetic differential susceptibility to the parent-child relationship quality and the life span development of compassion. Dev Psychobiol 2021; 63:e22184. [PMID: 34423428 DOI: 10.1002/dev.22184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 06/26/2021] [Accepted: 07/06/2021] [Indexed: 11/11/2022]
Abstract
The development of compassion for others might be influenced by the social experiences made during childhood and has a genetic component. No research has yet investigated whether the parent-child relationship quality interacts with genetic variation in the oxytocin and dopamine systems in predicting compassion over the life span. In the prospective Young Finns Study (N = 2099, 43.9% men), we examined the interaction between mother-reported emotional warmth and intolerance toward their child assessed in 1980 (age of participants, 3-18 years) and two established genetic risk scores for oxytocin levels and dopamine signaling activity. Dispositional compassion for others was measured with the Temperament and Character Inventory 1997, 2001, and 2012 (age of participants, 20-50 years). We found a gene-environment interaction (p = .031) that remained marginally significant after adjustment for multiple testing. In line with the differential susceptibility hypothesis, only participants who carry alleles associated with low dopamine signaling activity had higher levels of compassion when growing up with emotionally warm parents, whereas they had lower levels of compassion when their parents were emotionally cold. Children's genetic variability in the dopamine system might result in plasticity to early environmental influences that have a long-lasting effect on the development of compassion. However, our findings need replication.
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Affiliation(s)
- Henrik Dobewall
- Division of Psychology, Faculty of Education, University of Oulu, Oulu, Finland.,Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of Clinical Chemistry, Fimlab Laboratories, and Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Aino Saarinen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Leo-Pekka Lyytikäinen
- Department of Clinical Chemistry, Fimlab Laboratories, and Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Finnish Cardiovascular Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Igor Zwir
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, United States.,Department of Computer Science, University of Granada, Granada, Spain
| | - Robert Cloninger
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Olli T Raitakari
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland.,Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Terho Lehtimäki
- Department of Clinical Chemistry, Fimlab Laboratories, and Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Finnish Cardiovascular Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Mirka Hintsanen
- Division of Psychology, Faculty of Education, University of Oulu, Oulu, Finland
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Saarinen A, Keltikangas-Järvinen L, Dobewall H, Ahola-Olli A, Salmi M, Lehtimäki T, Raitakari O, Jalkanen S, Hintsanen M. Risky emotional family environment in childhood and depression-related cytokines in adulthood: The protective role of compassion. Dev Psychobiol 2021; 63:1190-1201. [PMID: 33421111 DOI: 10.1002/dev.22070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/16/2020] [Accepted: 11/06/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Previously, compassion has been found to protect against depressive symptoms, while emotional adversities in childhood are suggested to increase inflammatory responses. The current study investigated (a) whether emotional family environment in childhood predicts levels of such cytokines in adulthood that are previously found to be elevated in depression (interleukin [IL]-2, IL-6, IL-1b, monocyte chemoattractant protein-1, interferon-gamma [IFN-γ], and tumor necrosis factor alpha [TNF-α]) and (b) whether these associations are modified by compassion in adulthood. METHODS The participants (N = 1,198-1,523) came from the prospective population-based Young Finns data. Emotional family environment and parental socioeconomic factors were evaluated in 1980; participants' compassion in 2001; and participants' cytokine levels and adulthood covariates in 2007. RESULTS Risky emotional family environment in childhood predicted higher levels of IL-2, IL-6, IFN-γ, and TNF-α in adulthood. Additionally, there were significant interaction effects between compassion and emotional risk in childhood, when predicting IL-2, IL-6, and TNF-α. Specifically, individuals who grew up in a risky emotional family environment had on average higher levels of IL-2, IL-6, and TNF-α in adulthood when combined with low compassion. CONCLUSIONS In individuals coming from risky emotional family environments, high compassion for others may protect against elevated levels of cytokines previously linked with depression.
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Affiliation(s)
- Aino Saarinen
- Research Unit of Psychology, University of Oulu, Oulu, Finland.,Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Henrik Dobewall
- Research Unit of Psychology, University of Oulu, Oulu, Finland
| | - Ari Ahola-Olli
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Marko Salmi
- MediCity Research Laboratory and Institute of Biomedicine, University of Turku, Turku, Finland
| | - Terho Lehtimäki
- Department of Clinical Chemistry, Fimlab Laboratories and Finnish Cardiovascular Research Center-Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Olli Raitakari
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland.,Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Sirpa Jalkanen
- MediCity Research Laboratory and Institute of Biomedicine, University of Turku, Turku, Finland
| | - Mirka Hintsanen
- Research Unit of Psychology, University of Oulu, Oulu, Finland
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5
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Cong X, Hosler AS, Tracy M, Appleton AA. The relationship between parental involvement in childhood and depression in early adulthood. J Affect Disord 2020; 273:173-182. [PMID: 32421599 DOI: 10.1016/j.jad.2020.03.108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 02/01/2020] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Positive early life experiences may help prevent depression later in life. We examined the accumulated benefit, timing, and trajectories of positive parental involvement in childhood in association with incident depression in early adulthood. METHODS Prospectively assessed Avon Longitudinal Study of Parents and Children (ALSPAC) data (n = 7120) were analyzed. Overall and developmental stage-specific parental involvement scores were estimated from multiple measures from birth to age 7 years. Trajectory groups of parental involvement were derived via latent class growth analysis. At 18 years, depression cases were identified with diagnostic instruments. Multiple imputation was used to handle missingness. We constructed logistic regression models with potential confounders adjusted. RESULTS Participants from trajectory groups with higher average parenting scores over time had 30% to 40% lower odds of developing depression in early adulthood than participants from the group with the lowest average parenting score over time. However, the relationship became non-significant when all covariates were adjusted. A one-unit increase in the overall parenting score corresponded to 12% lower odds of developing depression (adjusted OR=0.88 [0.79-0.98]). Protective effects on incident depression in early adulthood from parental involvement in school age (5-7 years), and not at other ages, were observed (OR=0.87 [0.77-0.99] for a one-unit increase in the parenting score at school age). However, the relationship became non-significant when all covariates were adjusted (OR=0.91 [0.80-1.03]). LIMITATIONS Measurements of parental involvement were only based on maternal report. The study has limited generalizability to other racial/ethnic groups. CONCLUSION Higher level of parental involvement during childhood lowers the risk of developing depression in early adulthood. These results suggest positive early life experiences may promote mental health across the life course.
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Affiliation(s)
- Xiao Cong
- Department of Epidemiology and Biostatistics, School of Public Health, State University of New York at Albany, One University Place, Rensselaer 12144-3456, NY, United States.
| | - Akiko S Hosler
- Department of Epidemiology and Biostatistics, School of Public Health, State University of New York at Albany, One University Place, Rensselaer 12144-3456, NY, United States.
| | - Melissa Tracy
- Department of Epidemiology and Biostatistics, School of Public Health, State University of New York at Albany, One University Place, Rensselaer 12144-3456, NY, United States.
| | - Allison A Appleton
- Department of Epidemiology and Biostatistics, School of Public Health, State University of New York at Albany, One University Place, Rensselaer 12144-3456, NY, United States.
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Havewala M, Felton JW, Lejuez CW. Friendship Quality Moderates the Relation Between Maternal Anxiety and Trajectories of Adolescent Internalizing Symptoms. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2019; 41:495-506. [PMID: 31983803 DOI: 10.1007/s10862-019-09742-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The current study examined the moderating role of friendship quality on the relation between maternal anxiety and internalizing symptoms in a 3-year prospective study of adolescent development. Participants included 177 adolescents (M age = 16.05, SD age = 0.91) and their mothers. Mothers reported their own levels of anxiety; youth completed self-reports of internalizing symptoms and friendship quality. Positive friendship quality moderated the relation between maternal anxiety and initial levels of internalizing symptoms. Maternal anxiety was associated with steeper increases in internalizing symptoms over time, but only for those with greater negative peer interactions. Findings underscore the important role of both parental and peer relationships in the development of internalizing symptoms and highlight specific avenues for clinical interventions.
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Affiliation(s)
- Mazneen Havewala
- Department of Psychology, University of Maryland, College Park, MD
| | - Julia W Felton
- Division of Public Health, Michigan State University, Flint, MI
| | - Carl W Lejuez
- Department of Psychology, University of Kansas, Lawrence, KS
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7
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Dobewall H, Savelieva K, Seppälä I, Knafo-Noam A, Hakulinen C, Elovainio M, Keltikangas-Järvinen L, Pulkki-Råback L, Raitakari OT, Lehtimäki T, Hintsanen M. Gene-environment correlations in parental emotional warmth and intolerance: genome-wide analysis over two generations of the Young Finns Study. J Child Psychol Psychiatry 2019; 60:277-285. [PMID: 30357825 DOI: 10.1111/jcpp.12995] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Genomic analysis of the child might offer new potential to illuminate human parenting. We examined whether offspring (G2) genome-wide genotype variation (SNPs) is associated with their mother's (G1) emotional warmth and intolerance, indicating a gene-environment correlation. If this association is stronger than between G2's genes and their emotional warmth and intolerance toward their own children, then this would indicate the presence of an evocative gene-environment correlation. To further understand how G1 mother's parenting has been evoked by genetically influenced characteristics of the child (G2), we examined whether child (G2) temperament partially accounted for the association between offspring genes and parental responses. METHODS Participants were from the Young Finns Study. G1 mothers (N = 2,349; mean age 39 years) self-reported the emotional warmth and intolerance toward G2 in 1980 when the participants were from 3 to 18 years old. G2 participants answered the same parenting scales in 2007/2012 (N = 1,378; mean age = 38 years in 2007; 59% female) when their children were on average 11 years old. Offspring temperament traits were self-reported in 1992 (G2 age range 15-30 years). Estimation of the phenotypic variance explained by the SNPs of G2 was done by genome-wide complex trait analysis with restricted maximum likelihood (GCTA-GREML). RESULTS Results showed that the SNPs of a child (G2) explained 22.6% of the phenotypic variance of maternal intolerance (G1; p-value = .039). G2 temperament trait negative emotionality explained only 2.4% points of this association. G2 genes did not explain G1 emotional warmth or G2's own emotional warmth and intolerance. However, further analyses of a combined measure of both G1 parenting scales found genetic effects. Parent or child gender did not moderate the observed associations. CONCLUSIONS Presented genome-wide evidence is pointing to the important role a child plays in affecting and shaping his/her family environment, though the underlying mechanisms remain unclear.
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Affiliation(s)
- Henrik Dobewall
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Faculty of Social Sciences, Health Sciences, University of Tampere, Tampere, Finland
| | - Kateryna Savelieva
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Ilkka Seppälä
- Department of Clinical Chemistry, Fimlab Laboratories, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Ariel Knafo-Noam
- Department of Psychology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Christian Hakulinen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Marko Elovainio
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Laura Pulkki-Råback
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Olli T Raitakari
- Research Collegium for Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
| | - Terho Lehtimäki
- Department of Clinical Chemistry, Fimlab Laboratories, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Hein S, Thomas T, Yu. Naumova O, Luthar SS, Grigorenko EL. Negative parenting modulates the association between mother’s DNA methylation profiles and adult offspring depression. Dev Psychobiol 2018; 61:304-310. [DOI: 10.1002/dev.21789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/27/2018] [Accepted: 09/13/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | | | - Oxana Yu. Naumova
- University of Houston; Houston Texas
- Vavilov Institute of General Genetics RAS; St. Petersburg State University; Saint Petersburg Russia
| | | | - Elena L. Grigorenko
- University of Houston; Houston Texas
- St. Petersburg State University; Saint Petersburg Russia
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9
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Dobewall H, Hakulinen C, Keltikangas-Järvinen L, Pulkki-Råback L, Seppälä I, Lehtimäki T, Raitakari OT, Hintsanen M. Oxytocin receptor gene (OXTR) variant rs1042778 moderates the influence of family environment on changes in perceived social support over time. J Affect Disord 2018; 235:480-488. [PMID: 29680729 DOI: 10.1016/j.jad.2018.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 03/02/2018] [Accepted: 04/02/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lack of social support is an established risk factor across health outcomes, making it important to examine its family environmental and genetic determinants. METHODS In a 27-year follow-up of the Young Finns Study (N = 2341), we examined with a latent growth curve model whether genes involved in the oxytocin signaling pathway-namely, oxytocin receptor gene (OXTR) variants rs1042778, rs2254298, and rs53576-moderate the effect of early-life social experiences on perceived social support across the life span. Mothers reported the emotional warmth and acceptance towards their children at baseline when the participants were from 3 to 18 years old (1980). Perceived family support and support from friends and peripheral sources were assessed in five follow-ups 18 years apart (1989-2007). RESULTS Maternal emotional warmth and acceptance predicted the initial level of perceived social support across subscales, while the rate of change in family support was affected by the family environment only if participants carried the T-allele of OXTR rs1042778. This gene-environment interaction was not found for the rate of change in support from friends and peripheral sources and we also did not find associations between latent growth in perceived social support and OXTR variants rs53576 and rs2254298. LIMITATIONS Selective attrition in perceived social support, maternal emotional warmth and acceptance, gender, and SES. Family environment was assessed by a non-standardized measure. CONCLUSIONS OXTR rs1042778 polymorphism seems to contribute to changes in perceived family support in that way that some individuals (T-allele carriers) 'recover', to some extent, from the effects of early-life social experiences, whereas others (G/G genotype carriers) do not.
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Affiliation(s)
- Henrik Dobewall
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Faculty of Social Sciences, Health Sciences, University of Tampere, Tampere, Finland
| | - Christian Hakulinen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Laura Pulkki-Råback
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Helsinki Collegium for Advanced Studies, University of Helsinki, Helsinki, Finland
| | - Ilkka Seppälä
- Department of Clinical Chemistry, Fimlab Laboratories, Finnish Cardiovascular Research Center-Tampere, Faculty of Medicine and Life Sciences, University of Tampere, Finland
| | - Terho Lehtimäki
- Department of Clinical Chemistry, Fimlab Laboratories, Finnish Cardiovascular Research Center-Tampere, Faculty of Medicine and Life Sciences, University of Tampere, Finland
| | - Olli T Raitakari
- Research Collegium for Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
| | - Mirka Hintsanen
- Research Unit of Psychology, University of Oulu, Oulu, Finland; Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
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