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  • 1. Clason van de Leur, Jakob
    et al.
    Buhrman, Monica
    Wallby, Kajsa
    Karlström, Amanda
    Johansson, Fred
    Sophiahemmet University.
    Associations between improvements in psychological variables and subsequent sick leave among persons receiving a multimodal intervention for exhaustion disorder2023In: BMC Public Health, E-ISSN 1471-2458, Vol. 23, article id 1976Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The incidence of sick leave due to stress-related disorders such as exhaustion disorder (ED) is high in many economically developed countries. Meanwhile, knowledge about facilitating return to work during clinical interventions for ED patients is still limited. The current study aimed to investigate if improvements in exhaustion symptoms, insomnia, perfectionistic behaviors, psychological flexibility, and perceived work ability during treatment of ED were associated with subsequent sick leave in the year following treatment.

    METHODS: Using a cohort of 880 ED patients who had participated in a multimodal intervention based on Cognitive Behavior Therapy, we estimated the association between one standard deviation (SD) improvement in treatment-related variables and the rate of net days of sick leave one-year following treatment.

    RESULTS: Our results showed that improvements in all treatment-related variables were associated with lower sick leave rates one year following treatment. Improvements in exhaustion symptoms (rate ratio (RR): 0.70 [95% CI 0.66; 0.75]) and self-perceived work ability (RR 0.56 [95% CI 0.50; 0.63]) showed the strongest associations to subsequent sick leave.

    CONCLUSIONS: These findings suggest that interventions focusing on exhaustion symptoms, insomnia, perfectionistic behaviors, psychological flexibility, and perceived work ability can have a meaningful impact on ED patients' subsequent sick leave.

    TRIAL REGISTRATION: Clinicaltrials.gov (Identifier: NCT03360136).

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  • 2. Clason van de Leur, Jakob
    et al.
    Johansson, Fred
    Sophiahemmet University.
    McCracken, Lance M
    Åhs, Fredrik
    Brodda Jansen, Gunilla
    Buhrman, Monica
    Mediators during a multimodal intervention for stress-induced exhaustion disorder2023In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316Article in journal (Refereed)
    Abstract [en]

    Our understanding of the underlying psychological processes of development, maintenance, and treatments for stress-induced exhaustion disorder (ED) remains limited. Therefore, the current study aimed to explore whether sleep concerns, pathological worry, perfectionistic concerns, and psychological flexibility mediate change in exhaustion symptoms during a Multimodal intervention for ED based on Cognitive behavioral therapy principles. Participants (N = 913) were assessed at three time points, and mediation was explored using a two-criteria analytical model with linear mixed-effects models (criterion one) and random intercepts cross-lagged panel modeling (criterion 2). Criterion one for mediation was successfully met, as the findings indicated significant associations between time in treatment, with all suggested mediators, and exhaustion symptoms (significant ab-products). However, criterion two was not satisfied as changes in the mediators did not precede changes in exhaustion symptoms. Therefore, mediation could not be established. Instead, changes in the suggested mediators appeared to result from changes in exhaustion symptoms. Consequently, sleep concerns, pathological worry, perfectionistic concerns, and psychological flexibility appear to improve in conjunction with exhaustion symptoms during treatment, where improvement in exhaustion is indicated as the main driving factor, based on this exploratory analysis. The implications of these findings are contextualized within a broader framework of process-based therapy.

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  • 3. Clason van de Leur, Jakob
    et al.
    Johansson, Fred
    Sophiahemmet University.
    McCracken, Lance M
    Åhs, Fredrik
    Brodda Jansen, Gunilla
    Buhrman, Monica
    Predictors and sub-groups in the treatment of stress-induced exhaustion disorder2023In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 52, no 4, p. 397-418Article in journal (Refereed)
    Abstract [en]

    Little is known about psychological interventions for stress-induced Exhaustion disorder (ED), and there is a need for more research to improve the outcomes obtained in treatments. The present study examines predictors of improvement, including sub-group responses, in a large sample of ED patients receiving a Multimodal intervention (MMI) based on Cognitive Behavior Therapy (N = 915). In step one, available variables were explored separately as predictors of improvement in ED symptoms. In step two, sub-groups were explored through Latent Class Analysis to reduce the heterogeneity observed in the larger group and to investigate whether combining the variables from step one predicted symptom improvement. Younger age, no previous sick leave due to ED, and scoring high on anxiety, depression, insomnia, perfectionism, and treatment credibility emerged as separate predictors of improvement. In the sub-group analyses, a sub-group including participants who were single and had a lower income showed less improvement. Overall, people with ED participating in MMI report symptom improvement regardless of characteristics before treatment. However, the present findings do have the potential to inform future treatments for ED, as they highlight perfectionism as a predictor of improvement and the importance of assessing treatment credibility during treatment.

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  • 4.
    Edlund, Klara
    et al.
    Sophiahemmet University.
    Johansson, Fred
    Sophiahemmet University.
    Lindroth, Rebecca
    Bergman, Louise
    Sundberg, Tobias
    Sophiahemmet University.
    Skillgate, Eva
    Sophiahemmet University.
    Body image and compulsive exercise: Are there associations with depression among university students?2022In: Eating and Weight Disorders, ISSN 1124-4909, E-ISSN 1590-1262, Vol. 27, no 7, p. 2397-2405Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Mental health problems among university students have been reported to be significantly increasing and suggested to be associated with college drop-out. Body dissatisfaction and compulsive exercise are both constructs relevant for mental health problems in general and eating disorders in particular. This study examined associations between body dissatisfaction, compulsive exercise and self-reported symptoms of depression among Swedish university students.

    METHODS: Participants (n = 4262) are students in an ongoing cohort study, and data from the baseline assessment were used. Four linear regression models were built to explore the associations between body dissatisfaction, compulsive weight control exercise and depressive symptoms.

    RESULTS: Our findings showed that females reported higher levels of body dissatisfaction than males. Body dissatisfaction and compulsive exercise were associated with self-reported symptoms of depression in this non-clinical population. Results showed that compulsive exercise was negatively associated with reported symptoms of depression, while body dissatisfaction was positively associated with symptoms of depression.

    CONCLUSION: In line with previous research, there was a gender difference in body dissatisfaction where females displayed higher levels of dissatisfaction than males.  Body dissatisfaction was  positively associated with reported symptoms of depression, suggesting support of previous research indicating body dissatisfaction to increase mental health problems. Compulsive exercise was negatively associated with symptoms of depression suggesting a behavior negatively reinforced, supporting both constructs to be of interest for reported symptoms of depression in a non-clinical population of Swedish university students.

    LEVEL OF EVIDENCE: III, cohort study.

    TRIAL REGISTRATION: http://clinicaltrials.gov/ID : NCT04465435.

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  • 5.
    Edlund, Klara
    et al.
    Sophiahemmet University.
    Sundberg, Tobias
    Sophiahemmet University.
    Johansson, Fred
    Sophiahemmet University.
    Onell, Clara
    Sophiahemmet University.
    Rudman, Ann
    Holm, Lena W
    Sophiahemmet University.
    Grotle, Margreth
    Jensen, Irene
    Côté, Pierre
    Skillgate, Eva
    Sophiahemmet University.
    Sustainable UNiversity Life (SUN) study: Protocol for a prospective cohort study of modifiable risk and prognostic factors for mental health problems and musculoskeletal pain among university students2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 4, article id e056489Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Mental health problems and musculoskeletal pain are common health problems among young adults including students. Little is known about the aetiology and prognosis of these problems in university students. We aim to determine the role of personal, sociodemographic, academic and environmental factors for risk and prognosis of symptoms of depression, anxiety and stress as well as musculoskeletal pain in university students. The constructs that will be studied are based on the biopsychosocial model and psychopathology associated with disabling pain. This model acknowledges illness to consist of interrelated mechanisms categorised into biological, psychological, environmental and social cues.

    METHODS AND ANALYSIS: This cohort study aims to recruit around 5000 Swedish full-time students. Data will be collected using five online surveys during one academic year. A subgroup (n=1851) of the cohort, recruited before the COVID-19 pandemic, receive weekly text messages with three short questions assessing mood, worry and pain, sent through the web-based platform SMS-track . Statistical analyses will include Kaplan-Meier estimates, Cox regression analyses, multinomial logistic regression analyses and generalised estimating equations. We will assess effect measure modification when relevant and conduct sensitivity analyses to assess the impact of lost to follow-up.

    PROTOCOL AMENDMENTS: Due to opportunity and timing of the study, with relevance to the outbreak of the COVID-19 pandemic, this study further aims to address mental health problems, musculoskeletal pain and lifestyle in university students before and during the pandemic.

    ETHICS AND DISSEMINATION: The Sustainable UNiversity Life study was approved by the Swedish ethics authority (2019-03276; 2020-01449). Results will be disseminated through peer-reviewed research papers, reports, research conferences, student theses and stakeholder communications.

    TRIAL REGISTRATION NUMBER: NCT04465435.

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  • 6.
    Johansson, Fred
    Sophiahemmet University.
    Aspects of the aetiology of mental health problems among university students2023Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Mental disorders are among the leading causes of years lost due to disability in young people globally. Students are no exception, both mental disorders and mental health problems are common among university students with dramatic increases reported in recent years. The aetiology of mental disorders and mental health problems is generally assumed to be multicausal, with factors at different levels contributing to their development. Given the complexity of the causal network underlying mental health problems, it has been argued that a clear causal framework is needed when studying the aetiology of mental health problems. This thesis aimed to investigate some aspects of the potential aetiology of mental health problems among university students. Specifically, it focuses on four exposures at the psychosocial level presented in four studies: 1) the coronavirus disease (COVID-19) pandemic, 2) poor sleep quality, 3) procrastination and 4) sexual harassment and sexual violence. In addition to the discussion provided in each respective paper, this thesis discusses limitations and possible interpretations of our results from a modern causal inference perspective.

    The four studies of this thesis are based on The Sustainable University Life (SUN) cohort. The SUN cohort followed 4262 university students from eight universities in and around Stockholm, Sweden, with web-surveys at five time-points over one year.

    In Study I, we aimed to determine the mean trajectories of depression, anxiety, and stress symptoms among university students in Stockholm before and during the first months of the COVID-19 pandemic. For this, we included a subsample of 1836 university students that entered the SUN cohort before the outbreak of the COVID-19 pandemic, and were followed during the months before the pandemic, during the first wave of the pandemic and in the summer, months following the first wave of the pandemic. We found that mean depression, anxiety, and stress symptom levels were largely stable during the first wave compared to the months before the pandemic and decreased slightly during the following summer months. Our results indicate that mean levels of mental health symptoms did not change much during the early phase of the pandemic compared to before the pandemic.

    In Study II, we aimed to determine whether sleep quality statistically interacts cross-sectionally with loneliness, risky alcohol use, perfectionistic concerns and/or physical inactivity in relation to depressive symptoms in university students. We conducted a cross-sectional study using baseline-data from all 4262 participants in the SUN cohort. We found that while all factors were associated with depressive symptoms, only perfectionistic concerns interacted with sleep quality in its relation to depression. This interaction was quite weak and explainedonly a small proportion of the variance in depressive symptoms. Overall, we did not find support for our hypothesis that poor sleep quality could interact with several different potential risk factors for depressive symptoms.

    In Study III, we aimed to evaluate the associations between procrastination and sixteen subsequent health outcomes (including mental health symptoms, disabling pain, lifestyle behaviours and psychosocial health factors), measured 9 months later, among university students. We used data from all participants responding to the first follow-up in the SUN cohort (n=3525) and found that procrastination was related to several subsequent health outcomes, including symptoms of depression, anxiety and stress, while controlling for multiple potential confounders. Although we cannot rule out non-causal explanations for these associations, the results indicate that procrastination could have an effect on health outcomes among students, but that it is likely to be rather small for any specific health outcome.

    In Study IV, we investigated the impact of recent exposure to different forms of sexual harassment and sexual violence; 1) unwanted sexual attention, 2) offensive sexual remarks, 3) presentation or distribution of sexist material, 4) uncomfortable touching, 5) being offered benefits for sex and 6) sex against ones will, along with a wide definition of sexual harassment: sexual harassment (wide subjective definition) on levels of depression and anxiety symptoms three, six and nine months later, for women and men, respectively. We conducted a cohort study using data from all women and men responding to the first follow-up in the SUNcohort (n= 3503). Our results showed that women recently exposed to 1) sexual harassment (wide definition), 2) unwanted sexual attention and 3) sex against ones will showed higher subsequent levels of depression and/or anxiety symptoms. The general trend was that all exposures were related to higher symptom levels at three months, but that this difference between exposed and unexposed diminished over time, although these trends are uncertain with wide confidence intervals. The exception was exposure to sex against ones will, where exposed showed elevated symptom levels throughout the follow-up period. For men, the estimates were uncertain overall, and we refrain from interpreting these results. Our results indicate that recent exposure to different forms of sexual harassment and sexual violence may impact later depression and anxiety symptoms among women, and that there could be differences in the strength and long-term impact on mental health between different forms of sexual harassment and sexual violence. Again, we cannot, with certainty rule out non-causal reasons for these associations.

    Interpreting any of these results as causal effects rests on multiple assumptions, which are discussed in the thesis. Determination of causal effects preferably relies on triangulation of results from different studies with different methodology. Overall, however, I believe that this thesis has strengthened the evidence that procrastination and sexual harassment and sexual violence may be causes of mental health problems among university students. An equally important finding, is that mental health seemed rather stable during COVID-19 pandemic, indicating that the pandemic may not have caused increased mental health problems on the group level.

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  • 7.
    Johansson, Fred
    et al.
    Sophiahemmet University.
    Billquist, Jessica
    Andreasson, Hanna
    Jensen, Irene
    Onell, Clara
    Sophiahemmet University.
    Berman, Anne H
    Skillgate, Eva
    Sophiahemmet University.
    Study environment and the incidence of mental health problems and activity-limiting musculoskeletal problems among university students: The SUN cohort study2023In: BMJ Open, E-ISSN 2044-6055, Vol. 13, no 9, article id e072178Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To determine the association between different aspects of study environment and the incidence of mental health problems and activity-limiting musculoskeletal problems.

    DESIGN, SETTING AND PARTICIPANTS: We recruited a cohort of 4262 Swedish university students of whom 2503 (59%) were without moderate or worse mental health problems and 2871 (67%) without activity-limiting musculoskeletal problems at baseline. The participants were followed at five time points over 1 year using web surveys.

    EXPOSURES: Self-rated discrimination, high study pace, low social cohesion and poor physical environment measured at baseline.

    OUTCOMES: Self-rated mental health problems defined as scoring above cut-off on any of the subscales of the Depression, Anxiety and Stress Scale. Self-rated activity-limiting musculoskeletal problems in any body location assessed by the Nordic Musculoskeletal Questionnaire.

    STATISTICAL ANALYSIS: Discrete survival-time analysis was used to estimate the hazard rate ratio (HR) of each exposure-outcome combination while adjusting for gender, age, living situation, education type, year of studies, place of birth and parental education as potential confounders.

    RESULTS: For discrimination, adjusted HRs were 1.75 (95% CI 1.40 to 2.19) for mental health problems and 1.39 (95% CI 1.12 to 1.72) for activity-limiting musculoskeletal problems. For high study pace, adjusted HRs were 1.70 (95% CI 1.48 to 1.94) for mental health problems and 1.25 (95% CI 1.09 to 1.43) for activity-limiting musculoskeletal problems. For low social cohesion, adjusted HRs were 1.51 (95% CI 1.29 to 1.77) for mental health problems and 1.08 (95% CI 0.93 to 1.25) for activity-limiting musculoskeletal problems. For perceived poor physical study environment, adjusted HRs were 1.20 (95% CI 0.99 to 1.45) for mental health problems and 1.20 (95% CI 1.01 to 1.43) for activity-limiting musculoskeletal problems.

    CONCLUSIONS: Several aspects of the study environment were associated with the incidence of mental health problems and activity-limiting musculoskeletal problems in this sample of Swedish university students.

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  • 8.
    Johansson, Fred
    et al.
    Sophiahemmet University.
    Côté, Pierre
    Hogg-Johnson, Sheilah
    Rudman, Ann
    Holm, Lena W
    Grotle, Margreth
    Jensen, Irene
    Sundberg, Tobias
    Sophiahemmet University.
    Edlund, Klara
    Sophiahemmet University.
    Skillgate, Eva
    Sophiahemmet University.
    Depression, anxiety and stress among Swedish university students before and during six months of the COVID-19 pandemic: A cohort study2021In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 49, no 7, p. 741-749, article id 14034948211015814Article in journal (Refereed)
    Abstract [en]

    AIMS: The COVID-19 pandemic has had a profound effect on societies and citizens worldwide, raising concerns about potential mental health impacts. We aimed to describe trajectories of depression, anxiety and stress symptoms during the COVID-19 outbreak compared to before the outbreak, and to determine if trajectories were modified by pre-pandemic loneliness, poor sleep quality and mental health problems.

    METHODS: We conducted a cohort study with 1836 Swedish university students entering the study before 13 March 2020, the onset of the pandemic, with follow-ups within three (FU1) and six months (FU2) of the outbreak. Generalized Estimating Equations were used to estimate mean differences in symptom levels over time-periods, and to estimate potential effect modifications.

    RESULTS: We found small differences in mean levels of the depression, anxiety and stress scale (DASS-21) over time. Compared to before the pandemic, depression increased by 0.25 points of 21 (95% CI: 0.04 to -0.45) at FU1 and decreased by 0.75/21 (95% CI:-0.97 to -0.53) at FU2. Anxiety decreased from baseline to FU1 by 0.09/21 (95% CI: -0.24 to -0.07) and by 0.77/21 (95% CI: -0.93 to -0.61) to FU2. Stress decreased from baseline to FU1 by 0.30/21 (95% CI: -0.52 to -0.09) and by 1.32/21 (95% CI: -1.55 to -1.09) to FU2. Students with pre-pandemic loneliness, poor sleep quality or pre-pandemic mental health problems did not have worse trajectories of mean mental health symptoms.

    CONCLUSIONS: Symptom levels were relatively stable during the first three months of the pandemic, while there was a slight decrease during the summer months, probably due to seasonality effects.

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  • 9.
    Johansson, Fred
    et al.
    Sophiahemmet University.
    Côté, Pierre
    Hogg-Johnson, Sheilah
    Skillgate, Eva
    Sophiahemmet University.
    Depression, anxiety and stress among Swedish university students during the second and third waves of COVID-19: A cohort study2021In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 49, no 7, p. 750-754, article id 14034948211031402Article in journal (Refereed)
    Abstract [en]

    AIMS: This study aims to describe the mean trajectories of depression, anxiety and stress symptoms among Swedish university students before and during the second and third waves of the COVID-19 pandemic.

    METHODS: We recruited 1835 participants in September 2020, of whom 81% provided follow-ups in December 2020-January 2021 and 77% provided follow-ups in March-April 2021. The short-form Depression, Anxiety and Stress Scale was used to measure mental health symptoms. Generalized estimating equations were used to estimate the mean differences in symptom levels over the three time periods.

    RESULTS: Compared with September, mean depression was 0.91 points of 21 higher (95% confidence interval (CI) 0.70-1.13) in December 2020-January 2021 and 0.66 points higher (95% CI 0.43-.88) in March-April 2021. Anxiety levels were 0.20 points higher (95% CI 0.05-0.34) in December 2020-January 2021 and 0.17 points higher (95% CI 0.02-0.33) in March-April 2021. Stress levels were 0.21 points higher (95% CI 0.00-0.41) in December 2020-January 2021 and 0.16 points lower (95% CI -0.38 to 0.05) in March-April 2021.

    CONCLUSIONS: Our results indicate relatively stable levels of mental health among Swedish university students during the second and third waves of COVID-19 compared with before the second wave. Mean depression symptom scores increased slightly, but the importance of this small increase is uncertain.

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  • 10.
    Johansson, Fred
    et al.
    Sophiahemmet University.
    Côté, Pierre
    Onell, Clara
    Sophiahemmet University.
    Källberg, Henrik
    Sophiahemmet University.
    Sundberg, Tobias
    Sophiahemmet University.
    Edlund, Klara
    Sophiahemmet University.
    Skillgate, Eva
    Sophiahemmet University.
    Strengths of associations between depressive symptoms and loneliness, perfectionistic concerns, risky alcohol use and physical activity across levels of sleep quality in Swedish university students: A cross-sectional study2023In: Journal of Sleep Research, ISSN 0962-1105, E-ISSN 1365-2869, Vol. 32, no 2, article id e13745Article in journal (Refereed)
    Abstract [en]

    Previous research shows that sleep quality may interact with some other predictors of depression, such that poor sleep could strengthen the association between these factors and depression. We aimed to determine the presence of statistical interactions between sleep quality and loneliness, risky alcohol use, perfectionistic concerns and/or physical inactivity in relation to depressive symptoms. Further, we aimed to describe the functional form of the statistical interactions and associations. We used a cross-sectional design and included 4262 Swedish university students. All measures were self-reported, sleep quality was measured with the Pittsburgh Sleep Quality Index, and depressive symptoms with the short-form Depression, Anxiety and Stress Scale. Regression models of increasing complexity (linear and non-linear, with and without interactions) were compared to determine the presence of associations and statistical interactions, and to explore the best functional form for these associations and interactions. Out-of-sample R2 from repeated cross-validation was used to select the final models. We found that sleep quality was associated with depressive symptoms in all final models. Sleep quality showed a linear interaction with perfectionistic concerns in relation to depressive symptoms, such that perfectionistic concerns were more strongly associated with depressive symptoms when sleep quality was poor. Loneliness, risky alcohol use and physical inactivity were non-linearly associated with depressive symptoms but did not interact with sleep quality. We concluded that out of the four examined variables, only perfectionistic concerns interacted with sleep quality in relation to depressive symptoms. This interaction was weak and explained little of the overall variance in depressive symptoms.

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  • 11.
    Johansson, Fred
    et al.
    Sophiahemmet University.
    Edlund, Klara
    Sophiahemmet University.
    Sundgot-Borgen, J
    Björklund, C
    Côté, P
    Onell, Clara
    Sophiahemmet University.
    Sundberg, Tobias
    Sophiahemmet University.
    Skillgate, Eva
    Sophiahemmet University.
    Sexual harassment, sexual violence and subsequent depression and anxiety symptoms among Swedish university students: A cohort studyManuscript (preprint) (Other academic)
  • 12.
    Johansson, Fred
    et al.
    Sophiahemmet University.
    Rozental, Alexander
    Edlund, Klara
    Sophiahemmet University.
    Côté, Pierre
    Sundberg, Tobias
    Sophiahemmet University.
    Onell, Clara
    Sophiahemmet University.
    Rudman, Ann
    Skillgate, Eva
    Sophiahemmet University.
    Associations between procrastination and subsequent health outcomes among university students in Sweden2023In: JAMA Network Open, E-ISSN 2574-3805, Vol. 6, no 1, p. e2249346-, article id e2249346Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE: Procrastination is prevalent among university students and is hypothesized to lead to adverse health outcomes. Previous cross-sectional research suggests that procrastination is associated with mental and physical health outcomes, but longitudinal evidence is currently scarce.

    OBJECTIVE: To evaluate the association between procrastination and subsequent health outcomes among university students in Sweden.

    DESIGN, SETTING, AND PARTICIPANTS: This cohort study was based on the Sustainable University Life study, conducted between August 19, 2019, and December 15, 2021, in which university students recruited from 8 universities in the greater Stockholm area and Örebro were followed up at 5 time points over 1 year. The present study used data on 3525 students from 3 time points to assess whether procrastination was associated with worse health outcomes 9 months later.

    EXPOSURE: Self-reported procrastination, measured using 5 items from the Swedish version of the Pure Procrastination Scale rated on a Likert scale from 1 ("very rarely or does not represent me") to 5 ("very often or always represents me") and summed to give a total procrastination score ranging from 5 to 25.

    MAIN OUTCOMES AND MEASURES: Sixteen self-reported health outcomes were assessed at the 9-month follow-up. These included mental health problems (symptoms of depression, anxiety, and stress), disabling pain (neck and/or upper back, lower back, upper extremities, and lower extremities), unhealthy lifestyle behaviors (poor sleep quality, physical inactivity, tobacco use, cannabis use, alcohol use, and breakfast skipping), psychosocial health factors (loneliness and economic difficulties), and general health.

    RESULTS: The study included 3525 participants (2229 women [63%]; mean [SD] age, 24.8 [6.2] years), with a follow-up rate of 73% (n = 2587) 9 months later. The mean (SD) procrastination score at baseline was 12.9 (5.4). An increase of 1 SD in procrastination was associated with higher mean symptom levels of depression (β, 0.13; 95% CI, 0.09-0.17), anxiety (β, 0.08; 95% CI, 0.04-0.12), and stress (β, 0.11; 95% CI, 0.08-0.15), and having disabling pain in the upper extremities (risk ratio [RR], 1.27; 95% CI, 1.14-1.42), poor sleep quality (RR, 1.09, 95% CI, 1.05-1.14), physical inactivity (RR, 1.07; 95% CI, 1.04-1.11), loneliness (RR, 1.07; 95% CI, 1.02-1.12), and economic difficulties (RR, 1.15, 95% CI, 1.02-1.30) at the 9-month follow-up, after controlling for a large set of potential confounders.

    CONCLUSIONS AND RELEVANCE: This cohort study of Swedish university students suggests that procrastination is associated with subsequent mental health problems, disabling pain, unhealthy lifestyle behaviors, and worse psychosocial health factors. Considering that procrastination is prevalent among university students, these findings may be of importance to enhance the understanding of students' health.

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  • 13.
    Johansson, Fred
    et al.
    Sophiahemmet University.
    Tranaeus, Ulrika
    Asker, Martin
    Sophiahemmet University.
    Skillgate, Eva
    Sophiahemmet University.
    Johansson, Fredrik
    Sophiahemmet University.
    Athletic identity and shoulder overuse injury in competitive adolescent tennis players: The Smash cohort study2022In: Frontiers in Sports and Active Living, E-ISSN 2624-9367, Vol. 4, article id 940934Article in journal (Refereed)
    Abstract [en]

    Objectives: Our primary aim was to determine if athletic identity is prospectively associated with shoulder overuse injuries. Secondly, we aimed to determine if athletic identity is prospectively associated with playing through pain and to describe how athletic identity relates to sex, age, playing level, weekly training load, and match volume.

    Methods: A cohort of 269 adolescent tennis players were followed over a period of 52 weeks. Cox regression was used to estimate the hazard rate ratio (HRR) of first-time shoulder overuse injury associated with every 10-unit increase on the Athletic Identity Measurement Scale (AIMS).

    Results: The adjusted HRR of shoulder overuse injury was 0.89 (95% CI: 0.36-2.20) and the odds ratio of playing through pain was 2.41 (95% CI: 0.74-8.96) for every 10 unit increase on AIMS. The level of athletic identity was higher among players at the national level than among players at the regional level and was weakly correlated to weekly hours of tennis matches, tennis training, and fitness training.

    Conclusions: Our results indicate that higher levels of athletic identity may be associated with a lower incidence of shoulder overuse injuries, and potentially with playing through pain, although these results are inconclusive due to wide confidence intervals.

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  • 14. Wickberg, Frida
    et al.
    Lenhard, Fabian
    Aspvall, Kristina
    Serlachius, Eva
    Andrén, Per
    Johansson, Fred
    Sophiahemmet University.
    Silverberg-Mörse, Maria
    Mataix-Cols, David
    Feasibility of internet-delivered cognitive-behavior therapy for obsessive-compulsive disorder in youth with autism spectrum disorder: A clinical benchmark study2022In: Internet interventions, ISSN 2214-7829, Vol. 28, article id 100520Article in journal (Refereed)
    Abstract [en]

    Obsessive-compulsive disorder (OCD) is a treatable condition that often requires specialist care, particularly when comorbid with autism spectrum disorder (ASD). However, specialist clinics are few and typically located in large medical centers. To increase availability of evidence-based treatment for OCD in individuals with ASD, we adapted an internet-delivered cognitive behavior therapy (ICBT) protocol to suit the needs of these individuals and conducted a feasibility study (N = 22). The primary outcome was the clinician-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), administered at pre- and post-treatment as well as 3 months after treatment. ICBT was deemed acceptable and was associated with clinically significant improvements in CY-BOCS scores, corresponding to a large within-group effect size (Cohen's d = 1.33). Similarly, significant improvements were observed in most of the secondary parent- and self-rated measures. Approximately 60% of the participants were classed as treatment responders and 50% were in remission from their OCD at the 3-month follow-up. To provide a meaningful benchmark, we also analyzed data from a specialist clinic that regularly treats individuals with comorbid OCD and ASD (N = 52). These analyses indicated that specialized in-person CBT produced significantly larger effects (d = 2.69) while being markedly more resource demanding, compared to ICBT. To conclude, ICBT can be successfully adapted to treat OCD in youth with ASD and may be a viable alternative for those who do not have direct access to highly specialized treatment. Further improvements of the treatment protocol based on participant and therapist feedback are warranted, as is a formal test of its efficacy and cost-effectiveness in a randomized controlled trial.

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