Publications by authors named "Vita Postuvan"

48 Publications

Excessive and pathological Internet use - Risk-behavior or psychopathology?

Addict Behav 2021 12 9;123:107045. Epub 2021 Jul 9.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institutet, Stockholm, Sweden.

Pathological Internet use (but only with respect to gaming) is classified as mental disorder in the ICD-11. However, there is a large group of adolescents showing excessive Internet use, which may rather be considered adolescent risk-behavior. The aim was to test whether pathological and excessive Internet use should be considered as "psychopathology" or "risk-behavior". A representative, cross-sectional sample of 11.110 students from 10 European Union countries was analyzed. Structural equation models, including the factors "risk-behavior" and "psychopathology" and the variables excessive and pathological Internet use, were tested against each other. "Risk-behavior" was operationalized by several risk-behaviors (e.g. drug abuse, truancy, etc). "Psychopathology" included measures of several mental disorders (e.g. depression, hyperactivity, etc). Excessive Internet use was assessed as the duration and frequency of Internet use. Pathological Internet use was assessed with the Young Diagnostic Questionnaire (i.e., presence of addiction criteria). Excessive Internet use loaded on "risk-behavior" (λ = 0.484, p < .001) and on "psychopathology" (λ = 0.071, p < .007). Pathological Internet use loaded on "risk-behavior" (λ = 0.333, p < .001) and on "psychopathology" (λ = 0.852, p < .001). Chi-square tests determined that the loadings of excessive Internet use (χ (1) = 81.98, p < .001) were significantly stronger on "risk-behavior" than "psychopathology". Vice versa, pathological Internet use loaded significantly stronger on "psychopathology" (χ (1) = 107.10, p < .001). The results indicate that pathological Internet use should rather be considered as psychopathology. Excessive Internet use on the other hand, should be classified as adolescent risk-behavior.
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http://dx.doi.org/10.1016/j.addbeh.2021.107045DOI Listing
December 2021

Excessive and pathological Internet use - Risk-behavior or psychopathology?

Addict Behav 2021 12 9;123:107045. Epub 2021 Jul 9.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institutet, Stockholm, Sweden.

Pathological Internet use (but only with respect to gaming) is classified as mental disorder in the ICD-11. However, there is a large group of adolescents showing excessive Internet use, which may rather be considered adolescent risk-behavior. The aim was to test whether pathological and excessive Internet use should be considered as "psychopathology" or "risk-behavior". A representative, cross-sectional sample of 11.110 students from 10 European Union countries was analyzed. Structural equation models, including the factors "risk-behavior" and "psychopathology" and the variables excessive and pathological Internet use, were tested against each other. "Risk-behavior" was operationalized by several risk-behaviors (e.g. drug abuse, truancy, etc). "Psychopathology" included measures of several mental disorders (e.g. depression, hyperactivity, etc). Excessive Internet use was assessed as the duration and frequency of Internet use. Pathological Internet use was assessed with the Young Diagnostic Questionnaire (i.e., presence of addiction criteria). Excessive Internet use loaded on "risk-behavior" (λ = 0.484, p < .001) and on "psychopathology" (λ = 0.071, p < .007). Pathological Internet use loaded on "risk-behavior" (λ = 0.333, p < .001) and on "psychopathology" (λ = 0.852, p < .001). Chi-square tests determined that the loadings of excessive Internet use (χ (1) = 81.98, p < .001) were significantly stronger on "risk-behavior" than "psychopathology". Vice versa, pathological Internet use loaded significantly stronger on "psychopathology" (χ (1) = 107.10, p < .001). The results indicate that pathological Internet use should rather be considered as psychopathology. Excessive Internet use on the other hand, should be classified as adolescent risk-behavior.
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http://dx.doi.org/10.1016/j.addbeh.2021.107045DOI Listing
December 2021

A randomized controlled trial to improve psychological detachment from work and well-being among employees: a study protocol comparing online CBT-based and mindfulness interventions.

BMC Public Health 2020 Nov 16;20(1):1708. Epub 2020 Nov 16.

Department of Psychology, University of Maribor, Faculty of Arts, Koroska 160, SI-2000, Maribor, Slovenia.

Background: The changing landscape of the work environment, which often encompasses expectations of employees being continuously available, makes it difficult to disengage from work and recover. This can have a negative impact on employees' well-being, resulting in burnout, depression and anxiety, among other difficulties. The current study will test the effectiveness of two different online interventions (i.e., cognitive behavioral therapy; CBT and mindfulness-based stress reduction; MBSR) on employees' psychological detachment, burnout and other variables related to general (e.g., life satisfaction) and work-specific (e.g., work engagement) well-being.

Methods/design: The study is designed as a randomized control trial with two intervention groups (i.e., CBT, MBSR) and a waitlist control group. Participants will be full-time employees from a wide range of organizations from Slovenia, who report moderate difficulties with psychological detachment from work and burnout and are not receiving any other form of treatment. The online interventions will encompass 12 sessions over 6 weeks (2 sessions per week); each session will include 1) an active audio-guided session and 2) home assignments, accompanied by handouts and worksheets. The study outcomes (i.e., psychological detachment, burnout, general and work-specific well-being), potential mechanisms (i.e., work-related maladaptive thinking patterns, mindfulness) and moderators (e.g., supervisor support for recovery) will be assessed immediately before and after the interventions (pre and post measurement) and 3 months after intervention completion (follow-up). Additionally, participants will fill out questionnaires for the assessment of the central mechanisms and study outcomes each week.

Discussion: We expect that the CBT-based intervention will lead to greater improvements in psychological detachment from work and burnout compared to the MBSR and the waitlist control group. Additionally, we expect that the CBT-based intervention will also lead to greater enhancement of both general and work-related well-being.

Trial Registration: https://doi.org/10.1186/ISRCTN98347361 [May 19, 2020].
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http://dx.doi.org/10.1186/s12889-020-09691-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667737PMC
November 2020

Loneliness within the general population of Slovenia.

Int J Soc Psychiatry 2021 Mar 18;67(2):182-187. Epub 2020 Jul 18.

Slovene Centre for Suicide Research, Andrej Marušič Institute, University of Primorska, Koper, Slovenia.

Background: While loneliness is recognized as a risk to mental and physical health, there is a lack of data covering a broad age range. This study used a Slovenian adult sample to investigate loneliness.

Aims: To examine levels of social, emotional and general loneliness within the general population.

Method: A survey on a sample representative of the general population ( = 1,189; aged between 18 and 95 years old ( = 46.74, standard deviation () = 16.18); 49.7% were men) was conducted in Slovenia by means of an online questionnaire, covering data on demographic variables and levels of emotional, social and general loneliness.

Results: In general, people experienced more social than emotional loneliness. Demographic variables that were significant for emotional, social and general loneliness were the history of past mental illness, civil status and employment status. Other demographic variables played different roles in different types of loneliness.

Conclusions: Our study shows that differences in loneliness among demographic subgroups are an important factor in understanding and studying loneliness, especially with regard to the distinction between social and emotional loneliness. Given that loneliness represents today not only a social threat but also a significant health problem, it is important to understand which demographic subgroups are more at risk and how we can help them.
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http://dx.doi.org/10.1177/0020764020943230DOI Listing
March 2021

Loneliness within the general population of Slovenia.

Int J Soc Psychiatry 2021 Mar 18;67(2):182-187. Epub 2020 Jul 18.

Slovene Centre for Suicide Research, Andrej Marušič Institute, University of Primorska, Koper, Slovenia.

Background: While loneliness is recognized as a risk to mental and physical health, there is a lack of data covering a broad age range. This study used a Slovenian adult sample to investigate loneliness.

Aims: To examine levels of social, emotional and general loneliness within the general population.

Method: A survey on a sample representative of the general population ( = 1,189; aged between 18 and 95 years old ( = 46.74, standard deviation () = 16.18); 49.7% were men) was conducted in Slovenia by means of an online questionnaire, covering data on demographic variables and levels of emotional, social and general loneliness.

Results: In general, people experienced more social than emotional loneliness. Demographic variables that were significant for emotional, social and general loneliness were the history of past mental illness, civil status and employment status. Other demographic variables played different roles in different types of loneliness.

Conclusions: Our study shows that differences in loneliness among demographic subgroups are an important factor in understanding and studying loneliness, especially with regard to the distinction between social and emotional loneliness. Given that loneliness represents today not only a social threat but also a significant health problem, it is important to understand which demographic subgroups are more at risk and how we can help them.
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http://dx.doi.org/10.1177/0020764020943230DOI Listing
March 2021

The Breast Size Satisfaction Survey (BSSS): Breast size dissatisfaction and its antecedents and outcomes in women from 40 nations.

Body Image 2020 Mar 4;32:199-217. Epub 2020 Feb 4.

Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, Netherlands.

The Breast Size Satisfaction Survey (BSSS) was established to assess women's breast size dissatisfaction and breasted experiences from a cross-national perspective. A total of 18,541 women were recruited from 61 research sites across 40 nations and completed measures of current-ideal breast size discrepancy, as well as measures of theorised antecedents (personality, Western and local media exposure, and proxies of socioeconomic status) and outcomes (weight and appearance dissatisfaction, breast awareness, and psychological well-being). In the total dataset, 47.5 % of women wanted larger breasts than they currently had, 23.2 % wanted smaller breasts, and 29.3 % were satisfied with their current breast size. There were significant cross-national differences in mean ideal breast size and absolute breast size dissatisfaction, but effect sizes were small (η = .02-.03). The results of multilevel modelling showed that greater Neuroticism, lower Conscientiousness, lower Western media exposure, greater local media exposure, lower financial security, and younger age were associated with greater breast size dissatisfaction across nations. In addition, greater absolute breast size dissatisfaction was associated with greater weight and appearance dissatisfaction, poorer breast awareness, and poorer psychological well-being across nations. These results indicate that breast size dissatisfaction is a global public health concern linked to women's psychological and physical well-being.
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http://dx.doi.org/10.1016/j.bodyim.2020.01.006DOI Listing
March 2020

The Breast Size Satisfaction Survey (BSSS): Breast size dissatisfaction and its antecedents and outcomes in women from 40 nations.

Body Image 2020 Mar 4;32:199-217. Epub 2020 Feb 4.

Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, Netherlands.

The Breast Size Satisfaction Survey (BSSS) was established to assess women's breast size dissatisfaction and breasted experiences from a cross-national perspective. A total of 18,541 women were recruited from 61 research sites across 40 nations and completed measures of current-ideal breast size discrepancy, as well as measures of theorised antecedents (personality, Western and local media exposure, and proxies of socioeconomic status) and outcomes (weight and appearance dissatisfaction, breast awareness, and psychological well-being). In the total dataset, 47.5 % of women wanted larger breasts than they currently had, 23.2 % wanted smaller breasts, and 29.3 % were satisfied with their current breast size. There were significant cross-national differences in mean ideal breast size and absolute breast size dissatisfaction, but effect sizes were small (η = .02-.03). The results of multilevel modelling showed that greater Neuroticism, lower Conscientiousness, lower Western media exposure, greater local media exposure, lower financial security, and younger age were associated with greater breast size dissatisfaction across nations. In addition, greater absolute breast size dissatisfaction was associated with greater weight and appearance dissatisfaction, poorer breast awareness, and poorer psychological well-being across nations. These results indicate that breast size dissatisfaction is a global public health concern linked to women's psychological and physical well-being.
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http://dx.doi.org/10.1016/j.bodyim.2020.01.006DOI Listing
March 2020

Progress in Postvention.

Crisis 2019 Nov;40(6):379-382

Suicide Bereavement UK, Manchester, UK.

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http://dx.doi.org/10.1027/0227-5910/a000620DOI Listing
November 2019

Life Events Predicting the First Onset of Adolescent Direct Self-Injurious Behavior-A Prospective Multicenter Study.

J Adolesc Health 2020 02 31;66(2):195-201. Epub 2019 Oct 31.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden.

Purpose: Self-injurious behavior is a frequent phenomenon in adolescence. The present study prospectively examined life events as risk factors for the first onset of direct self-injurious behavior (D-SIB) in the Saving and Empowering Young Lives in Europe school-based multicenter sample.

Methods: Longitudinal assessments with an interval of 1 year were performed within a sample of 1,933 adolescents (51.47% females; mean age 14.84 ± .9 years) from 10 European countries and Israel.

Results: The number of life events during the past 6 months predicted the first onset of D-SIB in the following year. Gender neither predicted the onset of D-SIB nor moderated the association with life events. Moreover, analyses of individual events identified a range of mainly interpersonal events within both family and peer group as proximal risk factors for first episode D-SIB.

Conclusions: The results support the critical role of interpersonal life events in the development of D-SIB for both genders and refine the conceptualization of proximal risk factors in terms of accumulated stressors and interpersonal events.
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http://dx.doi.org/10.1016/j.jadohealth.2019.08.018DOI Listing
February 2020

Life Events Predicting the First Onset of Adolescent Direct Self-Injurious Behavior-A Prospective Multicenter Study.

J Adolesc Health 2020 02 31;66(2):195-201. Epub 2019 Oct 31.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden.

Purpose: Self-injurious behavior is a frequent phenomenon in adolescence. The present study prospectively examined life events as risk factors for the first onset of direct self-injurious behavior (D-SIB) in the Saving and Empowering Young Lives in Europe school-based multicenter sample.

Methods: Longitudinal assessments with an interval of 1 year were performed within a sample of 1,933 adolescents (51.47% females; mean age 14.84 ± .9 years) from 10 European countries and Israel.

Results: The number of life events during the past 6 months predicted the first onset of D-SIB in the following year. Gender neither predicted the onset of D-SIB nor moderated the association with life events. Moreover, analyses of individual events identified a range of mainly interpersonal events within both family and peer group as proximal risk factors for first episode D-SIB.

Conclusions: The results support the critical role of interpersonal life events in the development of D-SIB for both genders and refine the conceptualization of proximal risk factors in terms of accumulated stressors and interpersonal events.
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http://dx.doi.org/10.1016/j.jadohealth.2019.08.018DOI Listing
February 2020

Life Events Predicting the First Onset of Adolescent Direct Self-Injurious Behavior-A Prospective Multicenter Study.

J Adolesc Health 2020 02 31;66(2):195-201. Epub 2019 Oct 31.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden.

Purpose: Self-injurious behavior is a frequent phenomenon in adolescence. The present study prospectively examined life events as risk factors for the first onset of direct self-injurious behavior (D-SIB) in the Saving and Empowering Young Lives in Europe school-based multicenter sample.

Methods: Longitudinal assessments with an interval of 1 year were performed within a sample of 1,933 adolescents (51.47% females; mean age 14.84 ± .9 years) from 10 European countries and Israel.

Results: The number of life events during the past 6 months predicted the first onset of D-SIB in the following year. Gender neither predicted the onset of D-SIB nor moderated the association with life events. Moreover, analyses of individual events identified a range of mainly interpersonal events within both family and peer group as proximal risk factors for first episode D-SIB.

Conclusions: The results support the critical role of interpersonal life events in the development of D-SIB for both genders and refine the conceptualization of proximal risk factors in terms of accumulated stressors and interpersonal events.
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http://dx.doi.org/10.1016/j.jadohealth.2019.08.018DOI Listing
February 2020

Psychopathology is associated with reproductive health risk in European adolescents.

Reprod Health 2018 Nov 6;15(1):186. Epub 2018 Nov 6.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, 171 77, Stockholm, Sweden.

Background: Reproductive and mental health are key domains of adolescent wellbeing but possible interrelationships are poorly understood. This cross-sectional study evaluated the association between psychopathology and reproductive health risk among European adolescents.

Methods: A structured self-report questionnaire was delivered to 12,395 pupils of 179 randomly selected schools in 11 European countries within the EU funded "Saving and Empowering Young Lives in Europe" (SEYLE) project. The questionnaire included items about sexual initiation and reproductive health risk factors, such as number of sexual partners, frequency of condom use, and pregnancy involvement. Psychopathology was evaluated with validated instruments and/or ad-hoc questions.

Results: Of 11,406 respondents (median age 15; interquartile range [IQR] 14-15; 57% females), 18.8% reported sexual initiation. Sixty percent of them also reported at least one reproductive risk factor. Sexual initiation was significantly more common among pupils older than 15 years (38% versus 13.2% younger pupils) and males (21.3% versus 16.9% females). It was also more common among pupils with depression (age/sex-adjusted odds ratio [aOR] 1.871), anxiety (aOR 2.190), severe suicidal ideation (aOR 2.259), self-injurious behaviour (aOR 2.892), and suicide attempts (aOR 3.091). These associations were particularly strong among pupils ≤15 years old and, for overt psychopathology, among pupils with low non-sexual risk behaviour profile and females. Depression (aOR 1.937), anxiety (aOR 2.282), severe suicidal ideation (aOR 2.354), self-injurious behaviour (aOR 3.022), and suicide attempts (aOR 3.284) were associated with higher reproductive health risk, defined by an increasing number of coexisting reproductive risk factors.

Conclusions: These findings suggest an alignment between mental and reproductive health risk and support the value of cross-domain collaboration in adolescent health. The association between psychopathology and reproductive health risk, as well as its variations with age, sex, and associated risk behaviours, should be considered when designing health-promoting or disease-preventing interventions for adolescents.
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http://dx.doi.org/10.1186/s12978-018-0618-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220505PMC
November 2018

Comorbidity of Physical and Anxiety Symptoms in Adolescent: Functional Impairment, Self-Rated Health and Subjective Well-Being.

Int J Environ Res Public Health 2018 08 9;15(8). Epub 2018 Aug 9.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, SE-171 77 Stockholm, Sweden.

Physical disorders and anxiety are frequently comorbid. This study investigates the characteristics of physical disorders, self-rated heath, subjective well-being and anxiety in adolescents. Data were drawn from the cohort study. From 11 countries 11,230 adolescents, aged 14⁻16 years were included. Zung Self-Rating Anxiety Scale (SAS), WHO-5 Well-Being Index and five questions prepared for this study to evaluate physical illnesses and self-rated heath were administered. Anxiety levels were significantly higher in adolescents who reported having physical disability ( < 0.001, Cohen's = 0.40), suffering from chronic illnesses ( < 0.001, Cohen's = 0.40), impairments associated to health conditions ( < 0.001, Cohen's = 0.61), or reported poor to very poor self-rated health ( < 0.001, Cohen's = 1.11). Mediational analyses revealed no direct effect of having a chronic illness/physical disability on subjective well-being, but the indirect effects through higher levels of anxiety were significant. Functional impairment related to health conditions was both directly and indirectly (through higher levels of anxiety) associated with lower well-being. The co-occurrence of anxiety and physical disorders may confer a greater level of disability and lower levels of subjective well-being. Clinicians have to screen anxiety, even in a subthreshold level in patients with choric physical illness or with medically unexplained physical symptoms.
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http://dx.doi.org/10.3390/ijerph15081698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121583PMC
August 2018

Comorbidity of Physical and Anxiety Symptoms in Adolescent: Functional Impairment, Self-Rated Health and Subjective Well-Being.

Int J Environ Res Public Health 2018 08 9;15(8). Epub 2018 Aug 9.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, SE-171 77 Stockholm, Sweden.

Physical disorders and anxiety are frequently comorbid. This study investigates the characteristics of physical disorders, self-rated heath, subjective well-being and anxiety in adolescents. Data were drawn from the cohort study. From 11 countries 11,230 adolescents, aged 14⁻16 years were included. Zung Self-Rating Anxiety Scale (SAS), WHO-5 Well-Being Index and five questions prepared for this study to evaluate physical illnesses and self-rated heath were administered. Anxiety levels were significantly higher in adolescents who reported having physical disability ( < 0.001, Cohen's = 0.40), suffering from chronic illnesses ( < 0.001, Cohen's = 0.40), impairments associated to health conditions ( < 0.001, Cohen's = 0.61), or reported poor to very poor self-rated health ( < 0.001, Cohen's = 1.11). Mediational analyses revealed no direct effect of having a chronic illness/physical disability on subjective well-being, but the indirect effects through higher levels of anxiety were significant. Functional impairment related to health conditions was both directly and indirectly (through higher levels of anxiety) associated with lower well-being. The co-occurrence of anxiety and physical disorders may confer a greater level of disability and lower levels of subjective well-being. Clinicians have to screen anxiety, even in a subthreshold level in patients with choric physical illness or with medically unexplained physical symptoms.
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http://dx.doi.org/10.3390/ijerph15081698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121583PMC
August 2018

Comorbidity of Physical and Anxiety Symptoms in Adolescent: Functional Impairment, Self-Rated Health and Subjective Well-Being.

Int J Environ Res Public Health 2018 08 9;15(8). Epub 2018 Aug 9.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, SE-171 77 Stockholm, Sweden.

Physical disorders and anxiety are frequently comorbid. This study investigates the characteristics of physical disorders, self-rated heath, subjective well-being and anxiety in adolescents. Data were drawn from the cohort study. From 11 countries 11,230 adolescents, aged 14⁻16 years were included. Zung Self-Rating Anxiety Scale (SAS), WHO-5 Well-Being Index and five questions prepared for this study to evaluate physical illnesses and self-rated heath were administered. Anxiety levels were significantly higher in adolescents who reported having physical disability ( < 0.001, Cohen's = 0.40), suffering from chronic illnesses ( < 0.001, Cohen's = 0.40), impairments associated to health conditions ( < 0.001, Cohen's = 0.61), or reported poor to very poor self-rated health ( < 0.001, Cohen's = 1.11). Mediational analyses revealed no direct effect of having a chronic illness/physical disability on subjective well-being, but the indirect effects through higher levels of anxiety were significant. Functional impairment related to health conditions was both directly and indirectly (through higher levels of anxiety) associated with lower well-being. The co-occurrence of anxiety and physical disorders may confer a greater level of disability and lower levels of subjective well-being. Clinicians have to screen anxiety, even in a subthreshold level in patients with choric physical illness or with medically unexplained physical symptoms.
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http://dx.doi.org/10.3390/ijerph15081698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121583PMC
August 2018

Comorbidity of Physical and Anxiety Symptoms in Adolescent: Functional Impairment, Self-Rated Health and Subjective Well-Being.

Int J Environ Res Public Health 2018 08 9;15(8). Epub 2018 Aug 9.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, SE-171 77 Stockholm, Sweden.

Physical disorders and anxiety are frequently comorbid. This study investigates the characteristics of physical disorders, self-rated heath, subjective well-being and anxiety in adolescents. Data were drawn from the cohort study. From 11 countries 11,230 adolescents, aged 14⁻16 years were included. Zung Self-Rating Anxiety Scale (SAS), WHO-5 Well-Being Index and five questions prepared for this study to evaluate physical illnesses and self-rated heath were administered. Anxiety levels were significantly higher in adolescents who reported having physical disability ( < 0.001, Cohen's = 0.40), suffering from chronic illnesses ( < 0.001, Cohen's = 0.40), impairments associated to health conditions ( < 0.001, Cohen's = 0.61), or reported poor to very poor self-rated health ( < 0.001, Cohen's = 1.11). Mediational analyses revealed no direct effect of having a chronic illness/physical disability on subjective well-being, but the indirect effects through higher levels of anxiety were significant. Functional impairment related to health conditions was both directly and indirectly (through higher levels of anxiety) associated with lower well-being. The co-occurrence of anxiety and physical disorders may confer a greater level of disability and lower levels of subjective well-being. Clinicians have to screen anxiety, even in a subthreshold level in patients with choric physical illness or with medically unexplained physical symptoms.
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http://dx.doi.org/10.3390/ijerph15081698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121583PMC
August 2018

Correlates of sexual initiation among European adolescents.

PLoS One 2018 8;13(2):e0191451. Epub 2018 Feb 8.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.

Background: Sexuality is a physiological component of adolescent development, though early initiation is associated with reproductive health risk. This study aimed at identifying correlates and predictors of sexual initiation in a large multinational cohort of European adolescents.

Methods: A questionnaire addressing socio-demographics, behaviours, mental health and sexual activity, was delivered to 11,110 adolescents recruited from 168 randomly selected schools in 10 European countries between 2009 and 2011. A follow-up questionnaire was delivered after 12 months. The longitudinal association of baseline risk behaviors, psychological attributes and contextual vulnerabilities, with sexual initiation during follow-up was evaluated through simple and multivariable age/sex stratified logistic regression. Multinomial logistic regression measured the association between predictors and sexual initiation with or without coexisting reproductive risk factors, such as multiple partners or infrequent condom use.

Results: Baseline sexual experience was reported by 19.2% of 10,757 respondents (median age 15; IQR 14-15; females 59.6%). This was significantly more frequent among pupils older than 15 (41%) and males (20.8%). Of 7,111 pupils without previous experience who were available at follow-up (response rate 81.8%), 17% reported sexual initiation, without differences between females and males. Baseline smoking (age/sex adjusted odds ratio [aOR] 3.63), alcohol use (aOR 2.95), illegal drugs use (aOR 2.72), and poor sleep (aOR 1.71) predicted sexual initiation. Stratified analyses showed a particularly strong association in case of younger and female pupils, and, among girls, when initiation was reported together with multiple partners and/or infrequent condom use. Externalizing (i.e. conduct and hyperactivity) symptoms independently predicted sexual initiation. Internalizing difficulties (i.e. emotional and peer problems) were negatively associated with early and risky sexual initiation among boys. Significant predictors included also being bullied, fighting, truancy, and low parental involvement.

Conclusions: Adolescent sexual behaviours are related to non-sexual risk behaviours, psychological difficulties and contextual vulnerabilities. While gateway effects explain some associations, a comprehensive model is needed to understand adolescent sexual behaviours, their physical, mental, and social health outcomes, and their potential positive effects on wellbeing. Tailored interventions may need to consider younger girls as a particularly vulnerable group in view of a strong association between non-sexual and sexual behaviors.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191451PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805230PMC
March 2018

Interactions between youth and mental health professionals: The Youth Aware of Mental health (YAM) program experience.

PLoS One 2018 8;13(2):e0191843. Epub 2018 Feb 8.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden.

The Youth Aware Of Mental Health (yam) Experience: Youth stand at the core of much mental health promotion, yet little is written about their experiences of such efforts. We aimed to take this on by interviewing youth after they participated in Youth Aware of Mental Health (YAM), a universal mental health promotion program. YAM has a non-anticipatory methodology that provides youth with a safe space for reflection, role-play, and discussion. Addressing everyday mental health, YAM invites the experiences and issues relevant to the youth present to influence the program in a slightly different direction every time. The YAM instructor guides the participants but does not present the youth with given formulas on how to solve their problems. Like any mental health promotion, YAM appeals to some more than others in its intended audience and individuals engage with the program in many different ways. We set out to learn more about these experiences.

Conversations About Mental Health: Thirty-two semi-structured interviews were conducted with 15-17 year olds in Estonia, Italy, Romania and Spain. In these interviews, the researchers made an effort to discuss mental health in terms relevant to youth. Still, wide-ranging levels of motivation, ease with engaging in dialogue with mental health professionals, and comfort with the format and content of YAM were detected. The youth were clustered in five different groups relating to their positioning vis-à-vis the researcher during the interview. The following evocative labels were used: "interested", "foot in the door", "respect for authority", "careful", and "not my topic". Corresponding labels were devised for their YAM experience: "engaged", "initially hesitant", "cautious", "eager to please", or "disengaged". We also observed that the researchers brought their own expectations and employed a variety of approaches that led to anticipating answers, stating the obvious, or getting along better with some of the youth. These modes of interaction were categorized under: "favoritism", "familiarity", "frustration", "out of sync", and "insecurity". Similar power dynamics likely transpire in other encounters between youth and researchers, including interventions such as YAM.

Youth And Mental Health Professionals: Noticing The Dynamics At Play: As mental health professionals, we need to be aware of the professional habits and biases that sometimes obstruct us in understanding the experiences of youth. By initiating dialogue and listening closely to youth we can find a way to those experiences. Qualitative research can help bring the underlying interplay between mental health professionals and youth to the surface while also orienting the conversation towards topics that matter to youth. Some youth are more interested or feel more at ease in speaking openly with mental health professionals, while others find such exchanges less appealing or almost intolerable. Future mental health promotion initiatives would benefit from involving youth in the design of interventions to create an inclusive atmosphere and engage with topics that appeal to youth with diverse experiences of mental health.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191843PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805239PMC
March 2018

Interactions between youth and mental health professionals: The Youth Aware of Mental health (YAM) program experience.

PLoS One 2018 8;13(2):e0191843. Epub 2018 Feb 8.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden.

The Youth Aware Of Mental Health (yam) Experience: Youth stand at the core of much mental health promotion, yet little is written about their experiences of such efforts. We aimed to take this on by interviewing youth after they participated in Youth Aware of Mental Health (YAM), a universal mental health promotion program. YAM has a non-anticipatory methodology that provides youth with a safe space for reflection, role-play, and discussion. Addressing everyday mental health, YAM invites the experiences and issues relevant to the youth present to influence the program in a slightly different direction every time. The YAM instructor guides the participants but does not present the youth with given formulas on how to solve their problems. Like any mental health promotion, YAM appeals to some more than others in its intended audience and individuals engage with the program in many different ways. We set out to learn more about these experiences.

Conversations About Mental Health: Thirty-two semi-structured interviews were conducted with 15-17 year olds in Estonia, Italy, Romania and Spain. In these interviews, the researchers made an effort to discuss mental health in terms relevant to youth. Still, wide-ranging levels of motivation, ease with engaging in dialogue with mental health professionals, and comfort with the format and content of YAM were detected. The youth were clustered in five different groups relating to their positioning vis-à-vis the researcher during the interview. The following evocative labels were used: "interested", "foot in the door", "respect for authority", "careful", and "not my topic". Corresponding labels were devised for their YAM experience: "engaged", "initially hesitant", "cautious", "eager to please", or "disengaged". We also observed that the researchers brought their own expectations and employed a variety of approaches that led to anticipating answers, stating the obvious, or getting along better with some of the youth. These modes of interaction were categorized under: "favoritism", "familiarity", "frustration", "out of sync", and "insecurity". Similar power dynamics likely transpire in other encounters between youth and researchers, including interventions such as YAM.

Youth And Mental Health Professionals: Noticing The Dynamics At Play: As mental health professionals, we need to be aware of the professional habits and biases that sometimes obstruct us in understanding the experiences of youth. By initiating dialogue and listening closely to youth we can find a way to those experiences. Qualitative research can help bring the underlying interplay between mental health professionals and youth to the surface while also orienting the conversation towards topics that matter to youth. Some youth are more interested or feel more at ease in speaking openly with mental health professionals, while others find such exchanges less appealing or almost intolerable. Future mental health promotion initiatives would benefit from involving youth in the design of interventions to create an inclusive atmosphere and engage with topics that appeal to youth with diverse experiences of mental health.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191843PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805239PMC
March 2018

Attitudes within the general population towards seeking professional help in cases of mental distress.

Int J Soc Psychiatry 2017 Nov 10;63(7):614-621. Epub 2017 Aug 10.

4 Slovene Association for Suicide Prevention, POSVET, Ljubljana, Slovenia.

Background: Although effective treatment is available for a variety of mental disorders, the treatment and help-seeking gap remains high. One of the main obstacles to help-seeking behaviour is prevailing stigmatizing attitudes.

Aim: To examine attitudes within the general population towards seeking professional help in times of mental distress.

Methods: A representative general population survey ( N = 594) was conducted in Slovenia by means of an Internet-based questionnaire, covering data on demographic variables and attitudes towards help-seeking behaviour.

Results: More stigmatizing attitudes towards help-seeking behaviour were found in men, single persons, those of a younger age and lower educational achievement and in respondents coming from regions with a high suicide rate. Furthermore, 52.50% of the total sample have had an experience with psychological problems, yet only 41.50% of those have sought professional help. Experience with help-seeking behaviour in the past was associated with less stigmatizing attitudes.

Conclusion: Knowledge and understanding of mental health problems are necessary prerequisites to seeking help, but not the only ones. To improve help-seeking behaviour, it is also important to combat stigmatizing attitudes. Additionally, destigmatizing campaigns should also focus on social norms.
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http://dx.doi.org/10.1177/0020764017724819DOI Listing
November 2017

Attitudes within the general population towards seeking professional help in cases of mental distress.

Int J Soc Psychiatry 2017 Nov 10;63(7):614-621. Epub 2017 Aug 10.

4 Slovene Association for Suicide Prevention, POSVET, Ljubljana, Slovenia.

Background: Although effective treatment is available for a variety of mental disorders, the treatment and help-seeking gap remains high. One of the main obstacles to help-seeking behaviour is prevailing stigmatizing attitudes.

Aim: To examine attitudes within the general population towards seeking professional help in times of mental distress.

Methods: A representative general population survey ( N = 594) was conducted in Slovenia by means of an Internet-based questionnaire, covering data on demographic variables and attitudes towards help-seeking behaviour.

Results: More stigmatizing attitudes towards help-seeking behaviour were found in men, single persons, those of a younger age and lower educational achievement and in respondents coming from regions with a high suicide rate. Furthermore, 52.50% of the total sample have had an experience with psychological problems, yet only 41.50% of those have sought professional help. Experience with help-seeking behaviour in the past was associated with less stigmatizing attitudes.

Conclusion: Knowledge and understanding of mental health problems are necessary prerequisites to seeking help, but not the only ones. To improve help-seeking behaviour, it is also important to combat stigmatizing attitudes. Additionally, destigmatizing campaigns should also focus on social norms.
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http://dx.doi.org/10.1177/0020764017724819DOI Listing
November 2017

Attitudes within the general population towards seeking professional help in cases of mental distress.

Int J Soc Psychiatry 2017 Nov 10;63(7):614-621. Epub 2017 Aug 10.

4 Slovene Association for Suicide Prevention, POSVET, Ljubljana, Slovenia.

Background: Although effective treatment is available for a variety of mental disorders, the treatment and help-seeking gap remains high. One of the main obstacles to help-seeking behaviour is prevailing stigmatizing attitudes.

Aim: To examine attitudes within the general population towards seeking professional help in times of mental distress.

Methods: A representative general population survey ( N = 594) was conducted in Slovenia by means of an Internet-based questionnaire, covering data on demographic variables and attitudes towards help-seeking behaviour.

Results: More stigmatizing attitudes towards help-seeking behaviour were found in men, single persons, those of a younger age and lower educational achievement and in respondents coming from regions with a high suicide rate. Furthermore, 52.50% of the total sample have had an experience with psychological problems, yet only 41.50% of those have sought professional help. Experience with help-seeking behaviour in the past was associated with less stigmatizing attitudes.

Conclusion: Knowledge and understanding of mental health problems are necessary prerequisites to seeking help, but not the only ones. To improve help-seeking behaviour, it is also important to combat stigmatizing attitudes. Additionally, destigmatizing campaigns should also focus on social norms.
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http://dx.doi.org/10.1177/0020764017724819DOI Listing
November 2017

Attitudes within the general population towards seeking professional help in cases of mental distress.

Int J Soc Psychiatry 2017 Nov 10;63(7):614-621. Epub 2017 Aug 10.

4 Slovene Association for Suicide Prevention, POSVET, Ljubljana, Slovenia.

Background: Although effective treatment is available for a variety of mental disorders, the treatment and help-seeking gap remains high. One of the main obstacles to help-seeking behaviour is prevailing stigmatizing attitudes.

Aim: To examine attitudes within the general population towards seeking professional help in times of mental distress.

Methods: A representative general population survey ( N = 594) was conducted in Slovenia by means of an Internet-based questionnaire, covering data on demographic variables and attitudes towards help-seeking behaviour.

Results: More stigmatizing attitudes towards help-seeking behaviour were found in men, single persons, those of a younger age and lower educational achievement and in respondents coming from regions with a high suicide rate. Furthermore, 52.50% of the total sample have had an experience with psychological problems, yet only 41.50% of those have sought professional help. Experience with help-seeking behaviour in the past was associated with less stigmatizing attitudes.

Conclusion: Knowledge and understanding of mental health problems are necessary prerequisites to seeking help, but not the only ones. To improve help-seeking behaviour, it is also important to combat stigmatizing attitudes. Additionally, destigmatizing campaigns should also focus on social norms.
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http://dx.doi.org/10.1177/0020764017724819DOI Listing
November 2017

Attitudes within the general population towards seeking professional help in cases of mental distress.

Int J Soc Psychiatry 2017 Nov 10;63(7):614-621. Epub 2017 Aug 10.

4 Slovene Association for Suicide Prevention, POSVET, Ljubljana, Slovenia.

Background: Although effective treatment is available for a variety of mental disorders, the treatment and help-seeking gap remains high. One of the main obstacles to help-seeking behaviour is prevailing stigmatizing attitudes.

Aim: To examine attitudes within the general population towards seeking professional help in times of mental distress.

Methods: A representative general population survey ( N = 594) was conducted in Slovenia by means of an Internet-based questionnaire, covering data on demographic variables and attitudes towards help-seeking behaviour.

Results: More stigmatizing attitudes towards help-seeking behaviour were found in men, single persons, those of a younger age and lower educational achievement and in respondents coming from regions with a high suicide rate. Furthermore, 52.50% of the total sample have had an experience with psychological problems, yet only 41.50% of those have sought professional help. Experience with help-seeking behaviour in the past was associated with less stigmatizing attitudes.

Conclusion: Knowledge and understanding of mental health problems are necessary prerequisites to seeking help, but not the only ones. To improve help-seeking behaviour, it is also important to combat stigmatizing attitudes. Additionally, destigmatizing campaigns should also focus on social norms.
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http://dx.doi.org/10.1177/0020764017724819DOI Listing
November 2017

Attitudes within the general population towards seeking professional help in cases of mental distress.

Int J Soc Psychiatry 2017 Nov 10;63(7):614-621. Epub 2017 Aug 10.

4 Slovene Association for Suicide Prevention, POSVET, Ljubljana, Slovenia.

Background: Although effective treatment is available for a variety of mental disorders, the treatment and help-seeking gap remains high. One of the main obstacles to help-seeking behaviour is prevailing stigmatizing attitudes.

Aim: To examine attitudes within the general population towards seeking professional help in times of mental distress.

Methods: A representative general population survey ( N = 594) was conducted in Slovenia by means of an Internet-based questionnaire, covering data on demographic variables and attitudes towards help-seeking behaviour.

Results: More stigmatizing attitudes towards help-seeking behaviour were found in men, single persons, those of a younger age and lower educational achievement and in respondents coming from regions with a high suicide rate. Furthermore, 52.50% of the total sample have had an experience with psychological problems, yet only 41.50% of those have sought professional help. Experience with help-seeking behaviour in the past was associated with less stigmatizing attitudes.

Conclusion: Knowledge and understanding of mental health problems are necessary prerequisites to seeking help, but not the only ones. To improve help-seeking behaviour, it is also important to combat stigmatizing attitudes. Additionally, destigmatizing campaigns should also focus on social norms.
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http://dx.doi.org/10.1177/0020764017724819DOI Listing
November 2017

Physical activity in European adolescents and associations with anxiety, depression and well-being.

Eur Child Adolesc Psychiatry 2017 Jan 9;26(1):111-122. Epub 2016 Jun 9.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden.

In this cross-sectional study, physical activity, sport participation and associations with well-being, anxiety and depressive symptoms were examined in a large representative sample of European adolescents. A school-based survey was completed by 11,110 adolescents from ten European countries who took part in the SEYLE (Saving and Empowering Young Lives in Europe) study. The questionnaire included items assessing physical activity, sport participation and validated instruments assessing well-being (WHO-5), depressive symptoms (BDI-II) and anxiety (SAS). Multi-level mixed effects linear regression was used to examine associations between physical activity/sport participation and mental health measures. A minority of the sample (17.9 % of boys and 10.7 % of girls; p < 0.0005) reported sufficient activity based on WHO guidelines (60 min + daily). The mean number of days of at least 60 min of moderate-to-vigorous activity in the past 2 weeks was 7.5 ± 4.4 among boys and 5.9 days ± 4.3 among girls. Frequency of activity was positively correlated with well-being and negatively correlated with both anxiety and depressive symptoms, up to a threshold of moderate frequency of activity. In a multi-level mixed effects model more frequent physical activity and participation in sport were both found to independently contribute to greater well-being and lower levels of anxiety and depressive symptoms in both sexes. Increasing activity levels and sports participation among the least active young people should be a target of community and school-based interventions to promote well-being. There does not appear to be an additional benefit to mental health associated with meeting the WHO-recommended levels of activity.
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http://dx.doi.org/10.1007/s00787-016-0875-9DOI Listing
January 2017

Pathological Internet Use and Risk-Behaviors among European Adolescents.

Int J Environ Res Public Health 2016 Mar 8;13(3). Epub 2016 Mar 8.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institutet, Stockholm SE-17177, Sweden.

Risk-behaviors are a major contributor to the leading causes of morbidity among adolescents and young people; however, their association with pathological Internet use (PIU) is relatively unexplored, particularly within the European context. The main objective of this study is to investigate the association between risk-behaviors and PIU in European adolescents. This cross-sectional study was conducted within the framework of the FP7 European Union project: Saving and Empowering Young Lives in Europe (SEYLE). Data on adolescents were collected from randomized schools within study sites across eleven European countries. PIU was measured using Young's Diagnostic Questionnaire (YDQ). Risk-behaviors were assessed using questions procured from the Global School-Based Student Health Survey (GSHS). A total of 11,931 adolescents were included in the analyses: 43.4% male and 56.6% female (M/F: 5179/6752), with a mean age of 14.89 ± 0.87 years. Adolescents reporting poor sleeping habits and risk-taking actions showed the strongest associations with PIU, followed by tobacco use, poor nutrition and physical inactivity. Among adolescents in the PIU group, 89.9% were characterized as having multiple risk-behaviors. The significant association observed between PIU and risk-behaviors, combined with a high rate of co-occurrence, underlines the importance of considering PIU when screening, treating or preventing high-risk behaviors among adolescents.
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http://dx.doi.org/10.3390/ijerph13030294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4808957PMC
March 2016

Pathological Internet Use and Risk-Behaviors among European Adolescents.

Int J Environ Res Public Health 2016 Mar 8;13(3). Epub 2016 Mar 8.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institutet, Stockholm SE-17177, Sweden.

Risk-behaviors are a major contributor to the leading causes of morbidity among adolescents and young people; however, their association with pathological Internet use (PIU) is relatively unexplored, particularly within the European context. The main objective of this study is to investigate the association between risk-behaviors and PIU in European adolescents. This cross-sectional study was conducted within the framework of the FP7 European Union project: Saving and Empowering Young Lives in Europe (SEYLE). Data on adolescents were collected from randomized schools within study sites across eleven European countries. PIU was measured using Young's Diagnostic Questionnaire (YDQ). Risk-behaviors were assessed using questions procured from the Global School-Based Student Health Survey (GSHS). A total of 11,931 adolescents were included in the analyses: 43.4% male and 56.6% female (M/F: 5179/6752), with a mean age of 14.89 ± 0.87 years. Adolescents reporting poor sleeping habits and risk-taking actions showed the strongest associations with PIU, followed by tobacco use, poor nutrition and physical inactivity. Among adolescents in the PIU group, 89.9% were characterized as having multiple risk-behaviors. The significant association observed between PIU and risk-behaviors, combined with a high rate of co-occurrence, underlines the importance of considering PIU when screening, treating or preventing high-risk behaviors among adolescents.
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http://dx.doi.org/10.3390/ijerph13030294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4808957PMC
March 2016

Pathological Internet Use and Risk-Behaviors among European Adolescents.

Int J Environ Res Public Health 2016 Mar 8;13(3). Epub 2016 Mar 8.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institutet, Stockholm SE-17177, Sweden.

Risk-behaviors are a major contributor to the leading causes of morbidity among adolescents and young people; however, their association with pathological Internet use (PIU) is relatively unexplored, particularly within the European context. The main objective of this study is to investigate the association between risk-behaviors and PIU in European adolescents. This cross-sectional study was conducted within the framework of the FP7 European Union project: Saving and Empowering Young Lives in Europe (SEYLE). Data on adolescents were collected from randomized schools within study sites across eleven European countries. PIU was measured using Young's Diagnostic Questionnaire (YDQ). Risk-behaviors were assessed using questions procured from the Global School-Based Student Health Survey (GSHS). A total of 11,931 adolescents were included in the analyses: 43.4% male and 56.6% female (M/F: 5179/6752), with a mean age of 14.89 ± 0.87 years. Adolescents reporting poor sleeping habits and risk-taking actions showed the strongest associations with PIU, followed by tobacco use, poor nutrition and physical inactivity. Among adolescents in the PIU group, 89.9% were characterized as having multiple risk-behaviors. The significant association observed between PIU and risk-behaviors, combined with a high rate of co-occurrence, underlines the importance of considering PIU when screening, treating or preventing high-risk behaviors among adolescents.
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http://dx.doi.org/10.3390/ijerph13030294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4808957PMC
March 2016

Pathological Internet Use and Risk-Behaviors among European Adolescents.

Int J Environ Res Public Health 2016 Mar 8;13(3). Epub 2016 Mar 8.

National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institutet, Stockholm SE-17177, Sweden.

Risk-behaviors are a major contributor to the leading causes of morbidity among adolescents and young people; however, their association with pathological Internet use (PIU) is relatively unexplored, particularly within the European context. The main objective of this study is to investigate the association between risk-behaviors and PIU in European adolescents. This cross-sectional study was conducted within the framework of the FP7 European Union project: Saving and Empowering Young Lives in Europe (SEYLE). Data on adolescents were collected from randomized schools within study sites across eleven European countries. PIU was measured using Young's Diagnostic Questionnaire (YDQ). Risk-behaviors were assessed using questions procured from the Global School-Based Student Health Survey (GSHS). A total of 11,931 adolescents were included in the analyses: 43.4% male and 56.6% female (M/F: 5179/6752), with a mean age of 14.89 ± 0.87 years. Adolescents reporting poor sleeping habits and risk-taking actions showed the strongest associations with PIU, followed by tobacco use, poor nutrition and physical inactivity. Among adolescents in the PIU group, 89.9% were characterized as having multiple risk-behaviors. The significant association observed between PIU and risk-behaviors, combined with a high rate of co-occurrence, underlines the importance of considering PIU when screening, treating or preventing high-risk behaviors among adolescents.
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http://dx.doi.org/10.3390/ijerph13030294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4808957PMC
March 2016
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