Genetic contribution to disease-course severity and progression in the SUPER-Finland study, a cohort of 10,403 individuals with psychotic disorders

Genetic factors contribute to the susceptibility of psychotic disorders, but less is known how they affect psychotic disease-course development. Utilizing polygenic scores (PGSs) in combination with longitudinal healthcare data with decades of follow-up we investigated the contributing genetics to psychotic disease-course severity and diagnostic shifts in the SUPER-Finland study, encompassing 10 403 genotyped individuals with a psychotic disorder. To longitudinally track the study participants' past disease-course severity, we created a psychiatric hospitalization burden metric using the full-coverage and nation-wide Finnish in-hospital registry (data from 1969 and onwards). Using a hierarchical model, ranking the psychotic diagnoses according to clinical severity, we show that high schizophrenia PGS (SZ-PGS) was associated with progression from lower ranked psychotic disorders to schizophrenia (OR = 1.32 [1.23-1.43], p = 1.26e-12). This development manifested already at psychotic illness onset as a higher psychiatric hospitalization burden, the proxy for disease-course severity. In schizophrenia (n = 5 479), both a high SZ-PGS and a low educational attainment PGS (EA-PGS) were associated with increased psychiatric hospitalization burden (p = 1.00e-04 and p = 4.53e-10). The SZ-PGS and the EA-PGS associated with distinct patterns of hospital usage. In individuals with high SZ-PGS, the increased hospitalization burden was composed of longer individual hospital stays, while low EA-PGS associated with shorter but more frequent hospital visits. The negative effect of a low EA-PGS was found to be partly mediated via substance use disorder, a major risk factor for hospitalizations. In conclusion, we show that high SZ-PGS and low EA-PGS both impacted psychotic disease-course development negatively but resulted in different disease-course trajectories.

Enhancing identification of nonaffective psychosis in register-based studies

The Finnish Quality of Psychosis Care Register assesses nonaffective psychosis (NAP) care, acknowledging treatment outside specialized psychiatric services. This approach, while providing a holistic view, raises concerns about diagnostic inaccuracies. Here, we studied situations where the register-based diagnosis might be inaccurate, and whether the first episode can be reliably identified using a 14-year wash-out period. People with first register-based NAP (ICD-10 F20-F29) between years 2010 and 2018 and without NAP diagnoses in 1996-2009 were identified from the Care Register for Health Care. A diagnosis of NAP was deemed unreliable before age 7, when dementia preceded NAP diagnosis, and when a NAP diagnosis had been assigned at admission or during psychiatric hospitalization but was not confirmed by discharge diagnosis. Despite a 14-year follow-back the first register diagnosis may miss the first treatment episode in older patients. Register-based studies on psychotic disorders should pay attention to exclusion criteria and to the definition of treatment onset.

Geographical variation in treated psychotic and other mental disorders in Finland by region and urbanicity

PURPOSE

In Finland, prevalence of schizophrenia is higher in the eastern and northern regions and co-occurs with the distribution of schizophrenia polygenic risk scores. Both genetic and environmental factors have been hypothesized to contribute to this variation. We aimed to examine the prevalence of psychotic and other mental disorders by region and degree of urbanicity, and the impacts of socio-economic adjustments on these associations.

METHODS

Nationwide population registers from 2011 to 2017 and healthcare registers from 1975 to 2017. We used 19 administrative and three aggregate regions based on the distribution of schizophrenia polygenic risk scores, and a seven-level urban-rural classification. Prevalence ratios (PRs) were calculated by Poisson regression models and adjusted for gender, age, and calendar year (basic adjustments), and Finnish origin, residential history, urbanicity, household income, economic activity, and physical comorbidity (additional adjustments) on an individual level. Average marginal effects were used to visualize interaction effects between region and urbanicity.

RESULTS

A total of 5,898,180 individuals were observed. All mental disorders were slightly more prevalent (PR 1.03 [95% CI, 1.02-1.03]), and psychotic disorders (1.11 [1.10-1.12]) and schizophrenia (1.19 [1.17-1.21]) considerably more prevalent in eastern and northern than in western coastal regions. After the additional adjustments, however, the PRs were 0.95 (0.95-0.96), 1.00 (0.99-1.01), and 1.03 (1.02-1.04), respectively. Urban residence was associated with increased prevalence of psychotic disorders across all regions (adjusted PR 1.21 [1.20-1.22]).

CONCLUSION

After adjusting for socioeconomic and sociodemographic factors, the within-country distribution of mental disorders no longer followed the traditional east-west gradient. Urban-rural differences, on the other hand, persisted after the adjustments.

Patterns of mental health services and mood disorder disability pensions: a standard comparison of Finland's three largest hospital districts

INTRODUCTION

Mental disorders are one of the most common and disabling health conditions worldwide. There is however no consensus on the best practice of system level mental health services (MHS) provision, in order to prevent e.g. mood disorder disability pensions (DPs). We analyzed the MHS provision between Finland's three largest hospital districts Helsinki and Uusimaa (HUS), Southwest Finland and Pirkanmaa, with known differences in mood disorder DP risk but presumably equal rates of mood disorder prevalence.

METHODS

We used public MHS data analyzed with the standardized DEscription and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) mapping tool, focusing on all MHS, outpatient care provision, local services without and with gatekeeping, and centralized services. We also collected demographic data based on the European Socio-Demographic Schedule (ESDS). As a novel approach, the Gini-Simpson Diversity Index (GSDI) was calculated for the districts.

RESULTS

Evident differences were observed regarding the districts' MHS factors. As the hospital district with lower DP risk, HUS was characterized by the highest level of regional socioeconomic prosperity as well as high service richness and diversity. With a nationally average DP risk, Southwest Finland had the highest number of MHS personnel in full-time equivalents (FTE) per 100 000 inhabitants. Pirkanmaa, with a higher DP risk, had overall the lowest service richness and the lowest FTE of the three districts in all MHS, outpatient care and local services with gatekeeping.

CONCLUSIONS

Our findings indicate that greater richness and diversity of MHS, especially in outpatient and community-based settings, may serve as indicators of a balanced, high-quality service system that is more effective in preventing mood disorder DP and meeting the different needs of the population. In addition, the need for sufficient resourcing in all MHS and outpatient services is indicated. We suggest using diversity indices to complement the measuring and reporting of regional service variation.

School achievement in adolescence and the risk of mental disorders in early adulthood: a Finnish nationwide register study

School grades in adolescence have been linked to later psychiatric outcomes, but large-scale nationwide studies across the spectrum of mental disorders are scarce. In the present study, we examined the risk of a wide array of mental disorders in adulthood, as well as the risk of comorbidity, associated with school achievement in adolescence. We used population-based cohort data comprising all individuals born in Finland over the period 1980-2000 (N = 1,070,880) who were followed from age 15 or 16 until a diagnosis of mental disorder, emigration, death, or December 2017, whichever came first. Final grade average from comprehensive school was the exposure, and the first diagnosed mental disorder in a secondary healthcare setting was the outcome. The risks were assessed with Cox proportional hazards models, stratified Cox proportional hazard models within strata of full-siblings, and multinomial regression models. The cumulative incidence of mental disorders was estimated using competing risks regression. Better school achievement was associated with a smaller risk of all subsequent mental disorders and comorbidity, except for eating disorders, where better school achievement was associated with a higher risk. The largest associations were observed between school achievement and substance use disorders. Overall, individuals with school achievement more than two standard deviations below average had an absolute risk of 39.6% of a later mental disorder diagnosis. By contrast, for individuals with school achievement more than two standard deviations above average, the absolute risk of a later mental disorder diagnosis was 15.7%. The results show that the largest mental health burden accumulates among those with the poorest school achievement in adolescence.

Cohort profile: SUPER-Finland - the Finnish study for hereditary mechanisms of psychotic disorders

PURPOSE

SUPER-Finland is a large Finnish collection of psychosis cases. This cohort also represents the Finnish contribution to the Stanley Global Neuropsychiatric Genetics Initiative, which seeks to diversify genetic sample collection to include Asian, Latin American and African populations in addition to known population isolates, such as Finland.

PARTICIPANTS

10 474 individuals aged 18 years or older were recruited throughout the country. The subjects have been genotyped with a genome-wide genotyping chip and exome sequenced. A subset of 897 individuals selected from known population sub-isolates were selected for whole-genome sequencing. Recruitment was done between November 2015 and December 2018.

FINDINGS TO DATE

5757 (55.2%) had a diagnosis of schizophrenia, 944 (9.1%) schizoaffective disorder, 1612 (15.5%) type I or type II bipolar disorder, 532 (5.1 %) psychotic depression, 1047 (10.0%) other psychosis and for 530 (5.1%) self-reported psychosis at recruitment could not be confirmed from register data. Mean duration of schizophrenia was 22.0 years at the time of the recruitment. By the end of the year 2018, 204 of the recruited individuals had died. The most common cause of death was cardiovascular disease (n=61) followed by neoplasms (n=40). Ten subjects had psychiatric morbidity as the primary cause of death.

FUTURE PLANS

Compare the effects of common variants, rare variants and copy number variations (CNVs) on severity of psychotic illness. In addition, we aim to track longitudinal course of illness based on nation-wide register data to estimate how phenotypic and genetic differences alter it.

Socioeconomic position at the age of 30 and the later risk of a mental disorder: a nationwide population-based register study

BACKGROUND

A study was undertaken to examine the association between multiple indicators of socioeconomic position (SEP) at the age of 30 and the subsequent risk of the most common mental disorders.

METHODS

All persons born in Finland between 1966 and 1986 who were alive and living in Finland at the end of the year when they turned 30 were included. Educational attainment, employment status and personal total income were used as the alternative measures of SEP. Cox proportional hazards models were used to examine the association of SEP at the age of 30 with later risk of mental disorders. Additional analyses were conducted using a sibling design to account for otherwise unobserved shared family characteristics. Competing risks models were used to estimate absolute risks.

RESULTS

The study population included 1 268 768 persons, 26% of whom were later diagnosed with a mental disorder. Lower SEP at age 30 was consistently associated with a higher risk of being later diagnosed with a mental disorder, even after accounting for shared family characteristics and prior history of a mental disorder. Diagnosis-specific analyses showed that the associations were considerably stronger when substance misuse or schizophrenia spectrum disorders were used as an outcome. Absolute risk analyses showed that, by the age of 52 years, 58% of persons who had low educational attainment at the age of 30 were later diagnosed with a mental disorder.

CONCLUSIONS

Poor SEP at the age of 30 is associated with an increased risk of being later diagnosed with a mental disorder.

Differences in psychosocial functioning between psychotic disorders in the Finnish SUPER study

BACKGROUND

Psychotic disorders differ in their impact on psychosocial functioning. However, few studies have directly compared psychosocial functioning and its determinants between schizophrenia, schizoaffective disorder (SAD), bipolar disorder (BD), and major depressive disorder with psychotic features (psychotic MDD).

OBJECTIVE

We compared rates of independent living, employment, marriage, and having children between these diagnostic groups in a large national sample of participants with psychotic disorders in Finland.

METHODS

A cross-sectional substudy of participants (N = 9148) aged 18 to 65 years in the Finnish SUPER study, recruited nationwide from health- and social care settings and with advertisements. Psychosis diagnoses, age of onset, and hospitalizations were collected from healthcare registers. Participants were interviewed for psychosocial functioning. Associations of age of onset, hospitalizations, gender, and education with psychosocial functioning were analyzed using logistic regression models.

RESULTS

Of participants, 13.8% were employed or studying, 72.0% living independently and 32.5% had children. Overall, BD was associated with best, SAD and psychotic MDD with intermediate, and schizophrenia with worst level of psychosocial functioning. Greatest differences were found in independent living (OR 4.06 for BD vs. schizophrenia). In multivariate models, gender and number of hospitalizations predicted employment, marriage, and independent living in all diagnostic categories, and age of onset in some diagnostic categories.

CONCLUSIONS

Level of functioning and psychosocial outcomes differed markedly between psychotic disorders, particularly in independent living. Outcomes were worst for schizophrenia and best for BD. Across all psychotic disorders, female gender and lifetime number of hospitalizations had strong independent associations with marriage, employment, and independent living.

Reaction Time and Visual Memory in Connection to Hazardous Drinking Polygenic Scores in Schizophrenia, Schizoaffective Disorder and Bipolar Disorder

The purpose of this study was to explore the association of cognition with hazardous drinking Polygenic Scores (PGS) in 2649 schizophrenia, 558 schizoaffective disorder, and 1125 bipolar disorder patients in Finland. Hazardous drinking PGS was computed using the LDPred program. Participants performed two computerized tasks from the Cambridge Automated Neuropsychological Test Battery (CANTAB) on a tablet computer: the 5-choice serial reaction time task, or Reaction Time (RT) test, and the Paired Associative Learning (PAL) test. The association between hazardous drinking PGS and cognition was measured using four cognition variables. Log-linear regression was used in Reaction Time (RT) assessment, and logistic regression was used in PAL assessment. All analyses were conducted separately for males and females. After adjustment of age, age of onset, education, household pattern, and depressive symptoms, hazardous drinking PGS was not associated with reaction time or visual memory in male or female patients with schizophrenia, schizoaffective, and bipolar disorder.

Reaction Time and Visual Memory in Connection to Alcohol Use in Persons with Bipolar Disorder

The purpose of this study was to explore the association of cognition with hazardous drinking and alcohol-related disorder in persons with bipolar disorder (BD). The study population included 1268 persons from Finland with bipolar disorder. Alcohol use was assessed through hazardous drinking and alcohol-related disorder including alcohol use disorder (AUD). Hazardous drinking was screened with the Alcohol Use Disorders Identification Test for Consumption (AUDIT-C) screening tool. Alcohol-related disorder diagnoses were obtained from the national registrar data. Participants performed two computerized tasks from the Cambridge Automated Neuropsychological Test Battery (CANTAB) on A tablet computer: the 5-choice serial reaction time task, or reaction time (RT) test and the Paired Associative Learning (PAL) test. Depressive symptoms were assessed with the Mental Health Inventory with five items (MHI-5). However, no assessment of current manic symptoms was available. Association between RT-test and alcohol use was analyzed with log-linear regression, and eβ with 95% confidence intervals (CI) are reported. PAL first trial memory score was analyzed with linear regression, and β with 95% CI are reported. PAL total errors adjusted was analyzed with logistic regression and odds ratios (OR) with 95% CI are reported. After adjustment of age, education, housing status and depression, hazardous drinking was associated with lower median and less variable RT in females while AUD was associated with a poorer PAL test performance in terms of the total errors adjusted scores in females. Our findings of positive associations between alcohol use and cognition in persons with bipolar disorder are difficult to explain because of the methodological flaw of not being able to separately assess only participants in euthymic phase.

Reaction Time and Visual Memory in Connection with Alcohol Use in Schizophrenia and Schizoaffective Disorder

The purpose of this study was to explore the association between cognition and hazardous drinking and alcohol use disorder in schizophrenia and schizoaffective disorder. Cognition is more or less compromised in schizophrenia, and schizoaffective disorder and alcohol use might aggravate this phenomenon. The study population included 3362 individuals from Finland with diagnoses of schizophrenia or schizoaffective disorder. Hazardous drinking was screened with the AUDIT-C (Alcohol Use Disorders Identification Test for Consumption) screening tool. Alcohol use disorder (AUD) diagnoses were obtained from national registrar data. Participants performed two computerized tasks from the Cambridge Automated Neuropsychological Test Battery (CANTAB) on a tablet computer: The Five-Choice Serial Reaction Time Task (5-CSRTT) or the reaction time (RT) test and the Paired Associative Learning (PAL) test. The association between alcohol use and the RT and PAL tests was analyzed with log-linear regression and logistic regression, respectively. After adjustment for age, education, housing status, and the age at which the respondents had their first psychotic episodes, hazardous drinking was associated with a lower median RT in females and less variable RT in males, while AUD was associated with a poorer PAL test performance in terms of the total errors adjusted scores (TEASs) in females. Our findings of positive associations between alcohol and cognition in schizophrenia and schizoaffective disorder are unique.

Association of Income With the Incidence Rates of First Psychiatric Hospital Admissions in Finland, 1996-2014

IMPORTANCE

The association between income and mental health has long been a question of interest. Nationwide register data provide means to examine trends and patterns of these associations.

OBJECTIVES

To compare income-specific trends in the incidence rates of first psychiatric hospital admissions and to evaluate whether an income gradient exists in the incidence rates at all levels of household income.

DESIGN, SETTING, AND PARTICIPANTS

This population-based open cohort study used linked registry data from nationwide Finnish Hospital Discharge and Statistics Finland population registers to determine annual incidence rates of first psychiatric hospital admissions. All Finnish citizens (N = 6 258 033) living in the country at any time from January 1, 1996, through December 31, 2014, contributed to 96 184 614 person-years at risk of first inpatient treatment for mental disorders. The analyses were conducted from August 1, 2018, through September 30, 2019.

EXPOSURES

Equivalized disposable income, sex, age group, reduction in income decile in the previous 3 years, urbanicity, educational level, and living alone status.

MAIN OUTCOMES AND MEASURES

Annual percentage changes in the age-standardized incidence rates and incidence rate ratios (IRRs).

RESULTS

Altogether, 186 082 first psychiatric inpatient treatment episodes occurred (93 431 [50.2%] men), with overall age-standardized incidence rates per 1000 person-years varying from 1.59 (95% CI, 1.56-1.63) in 2014 to 2.11 (95% CI, 2.07-2.15) in 2008. In the highest income deciles, a continuous mean decrease per year of 3.71% (95% CI, 2.82%-4.59%) in men and 0.91% (95% CI, 0.01%-1.80%) in women occurred throughout the study period, in contrast to the lowest deciles, where the trends first increased (1.31% [95% CI, 0.62%-2.01%] increase in men from 1996 to 2007 and 5.61% [95% CI, 2.36%-8.96%] increase in women from 1996 to 2001). In the adult population, an income gradient was observed at all levels of household income: the lower the income decile, the higher the adjusted IRRs compared with the highest decile. The IRRs in the lowest decile varied from 2.94 (95% CI, 2.78-3.11) to 4.46 (95% CI, 4.17-4.76). In other age groups, the gradient did not persist at the highest income deciles. Diagnosis-specific income gradient was steepest in schizophrenia and related psychotic disorders, with estimated IRRs of the lowest income decile of 5.89 (95% CI, 5.77-6.02).

CONCLUSIONS AND RELEVANCE

In this cohort study, clear negative income gradient in the incidence rates of first hospital-treated mental disorders was observed in the adult population of Finland. These findings suggest that reduction in the use of inpatient care has not taken place equally between different income groups.

Employment Status and Personal Income Before and After Onset of a Severe Mental Disorder: A Case-Control Study

OBJECTIVE

Individuals with severe mental disorders have an impaired ability to work and are likely to receive income transfer payments as their main source of income. However, the magnitude of this phenomenon remains unclear. Using longitudinal population cohort register data, the authors conducted a case-control study to examine the levels of employment and personal income before and after a first hospitalization for a serious mental disorder.

METHODS

All individuals (N=50,551) who had been hospitalized for schizophrenia, other nonaffective psychosis, or bipolar disorder in Finland between 1988 and 2015 were identified and matched with five randomly selected participants who were the same sex and who had the same birth year and month. Employment status and earnings, income transfer payments, and total income in euros were measured annually from 1988 to 2015.

RESULTS

Individuals with serious mental disorders had notably low levels of employment before, and especially after, the diagnosis of a severe mental disorder. Their total income was mostly constituted of transfer payments, and this was especially true for those diagnosed as having schizophrenia. More than half of all individuals with a serious mental disorder did not have any employment earnings after they received the diagnosis.

CONCLUSIONS

The current study shows how most individuals in Finland depend solely on income transfer payments after an onset of a severe mental disorder.

Pain in SCN4A Mutated P.A1156T muscle sodium channelopathy-a postal survey

INTRODUCTION

The p.A1156T mutation alters the function of the voltage-gated sodium channel Nav1.4 on the muscle sarcolemma, causing a channelopathy without overt myotonia or periodic paralysis but with myalgic pain.

METHODS

A postal survey was conducted to assess the prevalence and characteristics of pain and related symptoms in individuals with the p.A1156T mutation. A specific questionnaire, intensity and interference subscales of the Brief Pain Inventory, pain drawing, Widespread Pain Index, quality of life (RAND-36), and the Beck Depression Inventory were completed.

RESULTS

Twenty of 24 patients replied. Current pain was reported by 16 respondents; the other 4 had experienced pain previously. Most commonly, pain was widespread and exercise-induced. The severity and the impact of pain on daily life were considerable, although varied.

DISCUSSION

This sodium channelopathy is another entity in the growing number of diseases causing widespread myalgic pain that resembles the pain seen in fibromyalgia syndrome. Muscle Nerve 57: 1014-1017, 2018.

[Autoimmune encephalitis as a cause of psychosis]

Antibodies directed to the surface structures of nerve cells may cause autoimmune encephalitis. It may cause limbic encephalitis requiring intensive care, or symptoms are restricted to psychosis. This disease may be impossible to distinguish clinically from a functional psychotic illness. Some of the cases are paraneoplastic, i.e. associated with a diagnosed or latent malignant neoplasia, most commonly ovarian teratoma. The first line treatment for autoimmune encephalitis is an immunomodulatory combination therapy with immunoglobulin and methylprednisolone. We recommend screening of the most common NMDAR and VGKC antibodies related to autoimmune encephalitis from patients having developed a new psychosis.