Personality disorders of drivers killed in fatal motor vehicle accidents in Finland during 1990-2011.

OBJECTIVE: To examine the association of personality disorders (PDs) to deaths of drivers in fatal motor vehicle accidents (FMVAs) and analyze gender differences in lifetime psychiatric disorders and medico-legal findings at the time of accident. METHOD: The study sample consisted of 4810 Finnish drivers killed in FMVAs in Finland between 1990 and 2011. Doctor-diagnosed PD was found in 146 drivers (118 men and 28 women). The information of psychiatric morbidity was obtained from the Finnish Care Register for Health Care. RESULTS: The proportion of deceased drivers with PDs had increased significantly over the study period, particularly among females and those with PD not otherwise specified (NOS). Suicidality and use of medication affecting driving ability were more common among females with PD compared to males with PD. 88% of all deceased drivers with PD had comorbid psychiatric disorders. CONCLUSION: Our findings indicate that PDs may predispose drivers to FMVAs, particularly females. This study emphasizes the importance of evaluating the fitness-to-drive of subjects with PD and especially comorbid substance use disorders, which may relate to an increased risk of fatal motor accidents.

Comparing Effectiveness of Treatments for Borderline Personality Disorder in Communal Mental Health Care: The Oulu BPD Study.

The implementation of effective psychotherapies in community mental health care is challenging. This study aimed to create a well-structured and easily applicable treatment model for patients with severe borderline personality disorder (BPD). We integrated a schema therapy based psycho-educational group into an available individual therapy. Two groups were formed: (1) community treatment by experts (CTBE) patients (n = 24) receiving new treatment and (2) treatment as usual (TAU) patients (n = 47). Changes in symptoms were measured by Borderline Personality Disorder Severity Index-IV interview and quality of life by the 15D health-related quality of life questionnaire. After 1 year the CTBE patients showed a significant reduction in a wider range of BPD symptoms and better quality of life than TAU patients. The results of this study are encouraging. A well-structured treatment model was successfully implemented into community mental health care with improved patient adherence to treatment and superior treatment outcomes compared to TAU patients.

Body size at birth and psychiatric disorders among adolescents: a clinical study of 310 under-age inpatient adolescents in Northern Finland.

BACKGROUND: Deviant birth measure is a risk factor for later somatic illness but also for later psychiatric disorders of the offspring. Only a few studies have examined the association of birth measures to later psychiatric disorders among adolescents. Studies on sex differences in these associations are scarce as well. METHODS: The cases consisted of 508 adolescents (208 boys and 300 girls) aged 12-17 years, who were admitted to inpatient psychiatric hospitalization between 2001 and 2006. In addition, 478 healthy controls were derived from the Northern Finnish Birth Cohort 1986, born in approximately the same period and same area as the cases. Data of birth measures were collected from the National Birth Register for cases and from antenatal clinics for controls. Both cases and controls were interviewed using the Schedule for Affective Disorder and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) to assess psychiatric disorders. RESULTS: The adolescent patients were statistically significantly shorter and had higher ponderal index at birth compared to healthy controls. In addition, the age of the mothers at adolescent's birth was significantly younger in the patients than the controls. After controlling for various covariates, a 2.4-fold increased likelihood for internalizing disorders was seen among male adolescents with high ponderal index. CONCLUSIONS: The association of birth measures to psychiatric disorders was confirmed in our study, particularly among male adolescents suffering from internalizing disorders. Further studies in larger adolescent samples are needed to confirm our findings and clear up the association of high ponderal index to specific psychiatric disorders.

The characteristics and outcomes of hospitalised and outpatient-treated first-onset schizophrenia patients: a 5-year register linkage study.

AIM: We compared the course and outcome of schizophrenia in two groups: (i) hospitalised patients (HP) (n = 5980) who were identified based on their first hospital admission for schizophrenia and (ii) outpatient-treated patients (OTP) who received disability pension because of schizophrenia but who had no hospital admissions for schizophrenia or other psychotic disorder before having been granted a disability pension for schizophrenia (n = 1220). Outcomes were compared using data on mortality, psychiatric hospital utilisation, relapse rate and occupational functioning. METHODS: A nationwide register-based 5-year follow-up study of all first-onset schizophrenia cases between 1998 and 2003 in Finland. The data were linked with the register information of hospital admissions, disability pensions and National Causes of Death Registers. RESULTS: When outcome of treatment was evaluated using mortality rate, relapses, hospital treatment and involuntary admissions as outcome measures, results indicated that OTP group had got along better with their illnesses than HP group. The mortality rates, number of psychiatric treatment days and relapse rate during the 5-year follow up were significantly lower in OTP group. Within the OTP group, there was a notable subgroup of never HP (n = 737, 60.4%), who did not require any psychiatric hospitalisation during the 5-year follow up. CONCLUSIONS: Patients first identified as outpatients had better outcomes than patients first identified following a hospitalisation. Future studies are required to establish whether outpatient treatment is associated with more favourable prognosis, even after fully adjusting for severity of initial symptoms. The higher suicide mortality of hospital-treated patients suggests that hospital treatment of first-onset patients does not protect from suicide.

Overweight of adolescent girls is associated with self-mutilative behavior.

BACKGROUND: The purpose of the present study was to examine the association of overweight with suicide ideation, self-mutilative behavior (SMB) and suicide attempts among underage psychiatric inpatient adolescents. SAMPLING AND METHODS: Data were collected from 439 adolescents (age = 12-17 years) admitted to psychiatric hospitalization between April 2001 and March 2006. Information on adolescents' suicidal behavior and psychiatric DSM-IV diagnoses was obtained by using the Schedule for Affective Disorder and Schizophrenia for School-Age Children. An adolescent was defined as overweight if his/her BMI exceeded the 85th percentile BMI in the age- and sex-matched Finnish population. RESULTS: Compared to adolescents without overweight, a 2.5-fold likelihood for SMB was found among overweight girls, but not among boys. CONCLUSIONS: Low self-esteem, depression or dysfunctional emotion regulation may be possible mediating factors between overweight and SMB.

Smoking makes asthma expensive: a register-based study in Finland.

SETTING: Chronic bronchitis and chronic obstructive pulmonary disease (COPD)/emphysema occur frequently among middle-aged and elderly asthma patients who smoke. OBJECTIVE: To test how much this comorbidity increases the use and costs of health services in comparison with asthma alone. DESIGN: A sample of 6000 adults with a clinical diagnosis of asthma was extracted from a nationwide health insurance register for a postal inquiry. Comorbidity and the use of health services were measured using a questionnaire. Data on medication expenses were obtained from the national prescription register. RESULTS: Altogether 4956 individuals replied, of whom 3160 asthma patients aged > or =40 years (response rate 85%) were chosen for this investigation. Asthma patients with COPD/emphysema (12% of the series) accounted for 21% of all doctor consultations, 39% of the total number of hospital in-patient days and 27% of the total expenses, of which one third were medication costs. The mean annual gross expenditure on treatment services and anti-asthma medications was euro754 per patient for those with asthma alone and euro2107 for those with concurrent COPD/emphysema. Current smoking further increased costs among COPD patients. CONCLUSION: To prevent pulmonary comorbidity and the related high costs, cessation of smoking should be an integral part of the treatment provided for asthma patients.

Thought Disorder Index: a longitudinal study of severity levels and schizophrenia factors.

BACKGROUND: Thought disturbances are commonly associated with psychiatric disorders, especially schizophrenia. Our aim was to clarify whether thought disorders are only stable at certain severity levels and in the presence of certain schizophrenia factors of the Thought Disorder Index (TDI) scale. Furthermore, we also examined the significance of genetic status and the psychiatric disorder for the persistence of TDI severity levels and factors. METHODS: The thought disorders of 158 adoptees genetically at high-risk or low-risk for schizophrenia participating the Finnish Adoptive Family Study of Schizophrenia were evaluated twice at a mean interval of 11 years. Thought Disorder Index (TDI) was used to assess the severity levels and schizophrenia factors. TDI identifies 23 different items of thinking disturbances, which are weighted along a continuum of severity. RESULTS: Thought disorders at the 0.50 and 0.75 severity levels and idiosyncratic verbalization indicative of the schizophrenia factors turned out to be stable phenomena throughout the follow-up period. The adoptees' genetic or psychiatric status was not associated with the results. CONCLUSIONS: The study shows that the stability of TDI seems to be related to the most severe categories of thought disorders. However, of the specific schizophrenia factors, idiosyncratic verbalization, but not confusion and fluid thinking, showed stability over time. Although idiosyncratic verbalization does not necessarily represent the most severe type of thought disturbance, it turned out relatively stable and we can speculate that idiosyncratic verbalization have some predictive value, too.

Who is becoming personality disordered? A register-based follow-up study of 508 inpatient adolescents.

BACKGROUND: Our aim was to investigate which clinical and socio-demographic factors among adolescent psychiatric patient aged 13-17 are associated with a diagnosis of personality disorder (PD) in young adulthood after discharge from psychiatric hospitalization. METHODS: The study sample consisted of 508 adolescents (ages 13-17) admitted to acute psychiatric impatient care between April 2001 and March 2006. DSM IV-based psychiatric diagnoses were obtained from the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL). The information on hospital treatments either in out- or inpatient settings until the end of 2012 was extracted from the national Care Register for Health Care provided by the Finnish National Institute for Health and Welfare. The follow-up time was 9.2 years (mean, 95% CI 9.0-9.3 yrs). RESULTS: Altogether 57 (11.2%) of subjects were diagnosed PD in adulthood. Among girls with anxiety disorders in adolescence the risk for PD in adulthood increased to 4.39-fold (95% CI 2.02-9.53). Males with later PD were more likely to be admitted for hospital treatment from child welfare placements (OR 3.23, 95% CI 1.21-8.61). However, axis I disorders in adolescence was not associated with risk for PD among boys. CONCLUSIONS: The results indicate that risk of PD developing later in life is increased among girls with anxiety disorders. A child welfare placement associated with PD in males later in life. These associations in adolescents should be considered in clinical work.

Stability of Thought Disorder Index among high-risk and low-risk adoptees in the Finnish adoptive family study of schizophrenia.

The aim of the study was to evaluate whether thought disorders are stable, trait-like features specific to subjects who have a genetic liability to schizophrenia or a psychiatric disorder. The thought disorders of adoptees genetically at high risk (HR) or low risk (LR) for schizophrenia from the Finnish adoptive family study of schizophrenia were evaluated twice at a mean interval of 11 years, using the sum of the Thought Disorder Index (TDI) scores on the Rorschach (TD(R)). At the initial assessment, the mean TD(R) scores of women were significantly higher than those of men, while no association between genetic risk and psychiatric status or their interactions with the TD(R) scores at baseline were found. The main finding was that the initial TD(R) scores statistically significantly predicted the TD(R) scores at follow-up, thus indicating the stability of thought disorder over time. However, neither genetic or psychiatric status nor gender or any interaction between these variables associated with TD(R) at follow-up.

Seasonal variation in the occurrence of homicide in Finland.

OBJECTIVE: Although seasonal variation in impulsive aggression related to circannual rhythms of central serotonin neurotransmission is a topic of current interest, there is little firm knowledge on seasonality in the occurrence of homicide. Longitudinal studies on the seasonal rhythms of platelet imipramine binding and L-tryptophan levels have placed the circannual peaks around January and February and the nadirs around May and August. The aim of this study was to test the hypothesis that the number of homicides is the lowest during winter and the highest during spring and summer. A secondary hypothesis was that the seasonal variations in homicides and violent suicides are correlated. METHOD: The largest database on the monthly occurrence of homicide thus far (N = 4,553) was used in this study, in which the monthly occurrence of all murders and manslaughters in Finland during the years 1957-1995 was analyzed. RESULTS: During winter the homicide rate was 6% below the expected rate. Correspondingly, during summer there was a 6% elevation above the expected homicide rate, but no significant peak was observed in spring. There was a significant association between the monthly occurrence of homicides and violent suicides but not between homicides and nonviolent suicides. CONCLUSIONS: The results suggest that a seasonal variation in the occurrence of homicide exists. On the basis of current literature, it could be hypothesized that this seasonal variation and the correlation between the monthly occurrence of homicides and violent suicides are associated with the observed circannual rhythms of serotonin transmission.

Maternal smoking during pregnancy and risk of criminal behavior among adult male offspring in the Northern Finland 1966 Birth Cohort.

OBJECTIVE: The goal of this study was to test the hypothesis that maternal smoking during pregnancy is associated with greater risk for criminal behavior of the offspring in adulthood. METHOD: An unselected, general population cohort composed of 11,017 subjects (5,636 men, 5,381 women) was followed up prospectively from the sixth month of pregnancy to age 28 years. Interviews with the mother during the pregnancy, health records, and an assessment of the offspring at age 1 year provided information on risk factors. The Ministry of Justice provided information on criminal offenses for all subjects. RESULTS: Because of the low rate of criminal offenses among women, the present analyses are restricted to men (N = 5,636). Compared to the sons of mothers who did not smoke, the sons of mothers who smoked during pregnancy had more than a twofold risk of having committed a violent crime or having repeatedly committed crimes, even when other biopsychosocial risk factors were controlled. While maternal smoking during pregnancy alone explained 4% of the variance associated with violent offenses among male offspring, it was not significantly associated with nonviolent offenses among male offspring. When maternal smoking during pregnancy was combined with a maternal age of less than 20 years, a single-parent family, an unwanted pregnancy, and a developmental lag in walking or talking, the odds ratios for violent offenses increased up to ninefold and for persistent offenses up to 14-fold. CONCLUSIONS: Maternal smoking during pregnancy is associated with violent offenses and persistent offenses, but not with nonviolent offenses, among male offspring in adulthood.

Is a child's risk of early onset schizophrenia increased in the highest social class?

In a sample from the unselected, general population Northern Finland 1966 Birth Cohort, 11017 individuals alive at the age of 16 years were studied until the age of 27. The cumulative incidence of early onset schizophrenia until 23 years was higher (1.14%; 9/792) among young persons from the highest social class or class I (determined according to father's occupation) than among children from lower social classes (0.47%; 48/10225), the difference being statistically significant (p < 0.05). The incidence of schizophrenia in the highest social class was higher than expected among girls, firstborns, children of young mothers under 30 and urban residents (p < 0.05) compared with lower social classes. When cases from the highest and other social classes were compared, there was no clear difference in background factors or clinical course. Four alcoholics, one of them also schizophrenic, were found among nine social class I fathers. The results suggest that in some families in Northern Finland, a father's professional advancement, often linked to mental disorder, may be one determinant of an increased risk of schizophrenia in the child.

Early developmental differences between DSM-III-R schizophrenics treated with clozapine and typical neuroleptics.

Developmental deviance is known to be associated with schizophrenia. We tested the hypothesis that the most severe schizophrenia requiring treatment with clozapine would particularly show these effects. Therefore, associative factors from pregnancy, delivery, neonatal and socio-demographic characteristics were compared between the clozapine-treated schizophrenic cases (n = 17) and the remaining cases of schizophrenia treated with typical neuroleptics (n = 59) from an unselected, general population North Finland 1966 Birth Cohort, (n = 11,017). By the end of 1994, seventeen (22%) of a total 76 DSM-III-R schizophrenia patients, had received clozapine treatment. The mean length at birth was 52 cm in the clozapine group (in the non-clozapine group 50 cm) and correspondingly the mean one year weight 10.4 kg (9.8 kg), with the differences between the groups being statistically significant (P < 0.05). Other pregnancy, delivery, and socio-demographic characteristics were, however, similar in the clozapine-treated and the remaining cases with schizophrenia. There was no evidence that severe schizophrenia requiring treatment with clozapine was associated with impaired intrauterine or post-natal development. Indeed, during the first years of life the former group was larger in terms of weight and length than those treated with typical neuroleptics. These early developmental characteristics did not predict clinical severity of schizophrenia in adulthood.

The incidence and onset-age of hospitalized bipolar affective disorder in Finland.

BACKGROUND: Some studies have indicated that there are wide variations on incidence and prevalence of bipolar disorder in specific populations. METHODS: The occurrence of bipolar affective disorder and the age at onset was studied in both genders among the hospitalized Finnish population. RESULTS: The annual rate of all hospitalized patients with bipolar disorder was 0.03%. Of these, 2% were under 20 years, 14% under 30 years, 61% under 50 years and 81% under 60 years of age. The 1-year incidence was highest in the age group 50-59 years in males and 40-49 years in females. CONCLUSIONS: The low prevalence and incidence of bipolar disorder in Finland may be due to late onset-age. LIMITATION: The study is based on hospital-treated bipolar disorder patients. CLINICAL RELEVANCE: We have presented previously unreported differences between the age of onset of bipolar disorder in Finland compared with other countries.

Secular trends in the rates and seasonality of violent and nonviolent suicide occurrences in Finland during 1980-95.

BACKGROUND: Because secular trends in seasonality of different types of suicides has not been studied before, we utilized a novel statistical method to evaluate this phenomenon by using national Finnish suicide statistics during 1980-95. METHODS: Rates were analyzed with ordinary linear regression analysis. Secular trends were evaluated using ratio-statistic and its 95% confidence intervals. RESULTS: The rate of violent suicides increased before year 1990 and decreased since that. The nonviolent suicide rate increased continuously. The decreasing tendency of seasonality in nonviolent suicides and a slight decrease in violent suicides are seen within the three successive time periods studied. CONCLUSIONS: Trends in rates and in seasonality of suicides might be related to changes in the health politics in Finland. LIMITATIONS: The short time-series and lack of studying associations of suicides with socioeconomic, environmental or biological factors are limitations of our study. CLINICAL RELEVANCE: Studying the time-dependent changes in rates and in seasonality of suicides provide a novel perspective for the evaluation of the aetiology of suicidal behaviour.

Outcome of different types of long-term antidepressant treatments: a 3-year follow-up study of 14182 patients.

BACKGROUND: Antidepressant efficacy studies are rare in large populations for prolonged periods. METHODS: The efficacy of antidepressants was investigated by using disability pensions due to major affective disorders as the efficacy variable from a large Finnish population (n = 14182) during a 3-year follow-up. RESULTS: Of all males, 345 (6.0%) were receiving disability pension due to major affective disorder, and of all females, 498 (5.9%). A logistic regression analysis showed a significantly higher risk (age-adjusted ORs, 1.42-4.09) for disability pension in every antidepressant group except the amitriptyline group when compared with fluoxetine group. Those who used a combination of antidepressive agents (age-adjusted OR 4.09) or moclobemide (age-adjusted OR 2.18) had the highest risks. CONCLUSIONS: In the study population fluoxetine and amitriptyline were the most efficient antidepressants in the long-term treatment of depression.

Increasing homicide rate in Finland accompanied by decreasing seasonality over the period 1957-95.

Homicide is recognized as a global public health problem. Finland has the highest overall homicide rate of the Nordic countries in comparisons over short time periods. Using the 39-year time series of homicide incidents in Finland from 1957-95, we analyzed the trend in homicide rate. In addition, we explored for the first time over the time trend in the seasonal variation of homicide and compared seasonal statistics over eight successive time periods. The present study revealed that there has been steadily increasing trend in homicides in Finland since 1950s. At the same time, the seasonality of homicide has decreased markedly. The peaks in homicide rates occurred commonly during summer and the troughs during winter.

Community placement of long-stay psychiatric patients in northern Finland.

Rapid deinstitutionalization occurred in Finland in the 1990s, a decade later than in many other Western countries. A four-year follow-up study in northern Finland examined community placements of 253 long-stay psychiatric inpatients after deinstitutionalization in 1992 and at follow-up at the end of 1995. About 70 percent of the patients were discharged. Only 15 percent were able to live outside the hospital without continuous support. No patient was homeless at follow-up. Being unmarried, living in the city of Oulu, and having greater severity of illness were associated with hospitalization at follow-up. The results showed that long-stay patients are dependent on considerable support. Alternative residential facilities have made deinstitutionalization possible.

A portrait of the juvenile arsonist.

In this study we evaluated if juvenile arsonists (n = 34) differ from juvenile criminals of violence (n = 33) in regard to suicide and mental problems in forensic psychiatric examination. Both arsonists and violent offenders were mostly male, poorly educated, unskilled and unemployed at the times of committing their crimes; and 79% of the arsonists and 58% of the control group had used public health services for treatment of their mental symptoms before the crime. This difference was significant (p = 0.05). Suicide was more common among the arsonists than the control subjects (p = 0.02); 74% of the arsonists had suicidal thoughts and 44% had tried to commit suicide before setting a fire. In the forensic psychiatric examination the arsonists were more often relieved from responsibility than the comparison group (p = 0.02).

Sex differences in the contact rates and utilization of psychiatric services. A three-year follow-up study in northern Finland.

Sex differences in the use of psychiatric services were studied in the Oulu University Central Hospital in Finland during a three-year follow-up. A one-year treated incidence cohort of new patients was used. The total cohort comprised 537 patients (46.7% were males). The annual incidence rate was 6.7 per 1,000 members of the adult population for both males and females. Compared to females, males were younger, more often unemployed, unmarried and lived alone or with parents, and did not as often have an apartment of their own. Males predominated among organic psychoses, personality disorders and dependencies, females among neurotic disorders. Males more often had had previous inpatient care and inpatient care at index contact, and had more admissions, compulsory admissions and emergency outpatient contacts than females. However, there were no sex differences in the use of planned outpatient contacts, in the duration of hospital care and in the total consumption of psychiatric care. Male gender was an independent predictor of hospital admissions.