Why do patients want medication free treatment for psychosis? An explorative study on reasons for applying to medication free programs.

BACKGROUND: A focus on patient's and service user's perspectives regarding long-term antipsychotic treatment led to a declaration from the Norwegian Ministry of Health in 2015 to offer treatment without psychotropic medication in mental health as a voluntary option in all four health care regions. In the northernmost region, a 6-bed inpatient ward unit was established, uniquely designed to give people with severe mental illness the possibility to choose such treatment. Only voluntary admissions were accepted. The aim of the present study was to explore the motivation for applying for medication free treatment among patients with several years of treatment history due to psychosis. METHOD: We performed nineteen semi-structured, in-depth interviews with persons having at least one admission at the medication free treatment ward during the period 01.01.17 - 17.10.2021. The interviews were recorded, transcribed and analysed using computer-assisted qualitative data analysis software (NVivo). Systematic Text Condensation was applied, with analysis of data from the first interview. Exploration of connections, similarities and nuances was performed through axial coding with continuous comparison of data and memo writing, followed by focused coding identifying core concepts. RESULTS: All participants had a diagnosis of severe mental illness and a history of use of antipsychotics throughout many years. The motivation to apply for medication free treatment was complex. Negative experiences with medication were described, but also positive. Many had tried to taper off before, but described this as a lonely and difficult process. Five core concepts were formed and developed from the participants' narratives: 1) Medication experiences, 2) Developing illness, 3) Treatment in general, 4) Social life and 4) Growing up. CONCLUSION: The concept of medication free treatment represents a salutogenetic hope for change, closely linked to self-efficacy and an experience of mastery. Potential conflicts concerning guidelines or evidence on medication does not come forward as important. Support from family and professionals is crucial, in contrast to the feeling of being alone when hoping for change. Motivational factors are closely linked to the concept of recovery, where interaction happens on both an individual and a structural level.

Beyond the diagnosis of drug-resistant Tuberculosis in Norway: patients' experiences before, during and after treatment.

BACKGROUND: This study aims to explore the varied experiences of patients with drug-resistant tuberculosis in Norway. The study emphasizes challenges and implications of being diagnosed with drug-resistant tuberculosis, including the impact on psychosocial health during the diagnosis, disease, treatment, isolation and recovery phases. Norway is a low endemic country of tuberculosis. Most patients are immigrants, and some of them have recently arrived in the country. Patients undergoing treatment for drug-resistant tuberculosis endure prolonged and demanding treatment that could affect their psychosocial health. METHODS: This qualitative study conducted 16 in-depth interviews with individuals aged 18 years and above who were diagnosed with drug-resistant tuberculosis. All participants completed the treatment between 2008 and 2020. Fourteen participants were immigrants, and eight of them had resided in Norway for less than four years before diagnosis. Data analysis followed the six-phase reflexive thematic analysis framework, focusing on identifying patterns in participants' experiences, thoughts, expectations and attitudes. RESULTS: The narratives of the participants highlighted the complexities of navigating the diagnosis of drug-resistant tuberculosis, treatment, side effects and life after treatment. Immigrants encountered additional challenges, including language barriers and adapting to new social environments. All participants reported experiencing physical health issues that additionally affected their mental health and social activity. Several participants had a delayed or prolonged diagnosis that complicated their disease trajectory. Participants with suspected or confirmed contagious pulmonary tuberculosis underwent hospital isolation for periods ranging from weeks to six months. The participants reported mental health issues, social isolation and stigma, however few were offered follow-up by a psychologist. Many participants had persistent problems at the time of the interviews. Three main themes emerged from the analysis: Delayed and prolonged diagnosis; Psychosocial impact of isolation during treatment; The life after tuberculosis. CONCLUSION: This study highlights the enduring impact of drug-resistant tuberculosis on patients and the significance of timely diagnosis, psychosocial support and post-treatment follow-up. The participants universally faced serious implications of the disease, including stigma and isolation. Participants who experienced delayed diagnosis, reflected on missed early intervention opportunities. We recommend further research in low endemic countries to evaluate the international and local recommendations on psychosocial support.

Association between cytokines and psychiatric symptoms in chronic fatigue syndrome and healthy controls.

PURPOSE: The reports regarding the status of the immune system in patients with chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) have been inconclusive. We approached this question by comparing a strictly defined group of CFS/ME outpatients to healthy control individuals, and thereafter studied cytokines in subgroups with various psychiatric symptoms. MATERIALS AND METHODS: Twenty patients diagnosed with CFS/ME according to the Fukuda criteria and 20 age- and sex-matched healthy controls were enrolled in the study. Plasma was analysed by ELISA for levels of the cytokines TNF-α, IL-4, IL-6 and IL-10. Participants also answered questionnaires regarding health in general, and psychiatric symptoms in detail. RESULTS: Increased plasma levels of TNF-α in CFS/ME patients almost reached significance compared to healthy controls (p = .056). When studying the CFS/ME and control groups separately, there was a significant correlation between TNF-α and The Hospital Anxiety and Depression Scale (HADS) depressive symptoms in controls only, not in the CFS/ME group. A correlation between IL-10 and psychoticism was found in both groups, whereas the correlation for somatisation was seen only in the CFS/ME group. When looking at the total population, there was a significant correlation between TNF-α and both the HADS depressive symptoms and the SCL-90-R cluster somatisation. Also, there was a significant association between IL-10 and the SCL-90-R cluster somatisation when analyzing the cohort (patients and controls together). CONCLUSIONS: These findings indicate that immune activity in CFS/ME patients deviates from that of healthy controls, which implies potential pathogenic mechanisms and possible therapeutic approaches to CFS/ME. More comprehensive studies should be carried out on defined CFS/ME subgroups.

Learning from clients: A qualitative investigation of psychotherapists' reactions to negative verbal feedback.

OBJECTIVE: To explore how therapists experience, react to, and learn from negative feedback from their clients. METHOD: Eighteen experienced therapists' written descriptions of episodes where they had received negative verbal feedback from clients were analyzed according to the Consensual Qualitative Research methodology. RESULTS: Receiving feedback was experienced as challenging, but educational. Learning was manifested in different ways: (a) Immediately Applied Learning-therapists improved the following therapy process by changing their behavior with the client, (b) Retrospectively Applied Learning-therapists made changes in their way of working with subsequent clients, and (c) Non-Applied Learning-new ideas generated by the experience had not been translated into behavior. We compared cases describing these manifestations of learning and found differences in the nature of the feedback and how therapists understood, reacted, and responded to it. CONCLUSIONS: The therapists benefitted from obtaining and being open to specific feedback from their clients, regulating their own emotional reactions, accommodating dissatisfied clients, and considering how they themselves contributed to negative therapy processes.

Religious convictions in patients with epilepsy-associated affective disorders: a controlled study from a psychiatric acute department.

Patients with epilepsy often have different mood symptoms and behavioral trait characteristics compared to the non-epileptic population. In the present prospective study, we aimed to assess differences in behavioral trait characteristics between acutely admitted, psychiatric in-patients with epilepsy-associated depressive symptoms and gender/age-matched patients with major depression. Patients with epilepsy-associated depression had significantly higher scores for "religious convictions," "philosophical and intellectual interests" and "sense of personal destiny." These behavioral trait characteristics at admission or in clinical history should alert the psychiatrist and lead to closer examination for a possible convulsive disorder.

Psychological distress and perceived health in inmates in Norwegian prisons.

BACKGROUND: Perceived health is a subjective measure of an individual's health based on self-reported, and self-knowledge about one's health status. It is related to one's functional status, morbidity, and mortality and serves as an important indicator in determining an individual's health status and health-related quality of life. The main purpose of this study is to explore (i) how a sample of adult inmates perceived their health and (ii) identify factors that may be associated with their perceived health. METHODS: This was a cross-sectional study, where data collection involved the use of a structured questionnaire. The study sites were six prisons. A total of 144 inmates, 13 women (14%) and 131 men (91%) took part in the study. RESULTS: The odds of having perceived good health were reduced by increasing age of the inmate (OR = 0.94, 95% CI = 0.90-0.98) and increased by high level of education (OR = 4.11, 95% CI = 1.09-15.50) and long time spent in prison (OR = 3.56, 95% CI = 1.09-15.50), adjusting for ethnicity and a previous history of murder/manslaughter (p > .02). In the same adjusted analysis, the odds of perceived good health were decreased with medium high and high depressive score (OR = 0.06, 95% CI = 0.02-0.17 and OR = 0.06, 95% CI = 0.00-0.48, respectively). CONCLUSIONS: Psychological distress, time spent in prison, level of education and age were independent predictors of perceived health. High levels of psychological distress predict poor perceived health. Low level of education predict poor perceived health, while time spent in prison and age predict good perceived health.

Therapeutic alliance in early schizophrenia spectrum disorders: a cross-sectional study.

BACKGROUND: The therapeutic alliance is related to better course and outcome of treatment in schizophrenia. This study explores predictors and characteristics of the therapeutic alliance in recent-onset schizophrenia spectrum disorders including the agreement between patient and therapist alliance ratings. METHODS: Forty-two patients were assessed with demographic, neurocognitive, and clinical measures including the Positive and Negative Syndrome Scale (PANSS). The therapeutic alliance was measured with the Working Alliance Inventory - Short Form (WAI-S). RESULTS: Patient WAI-S total scores were predicted by age and PANSS excitative symptoms. Therapist WAI-S total scores were predicted by PANSS insight. Patient and therapist WAI-S total scores were moderately associated. Neurocognition was not associated with working alliance. CONCLUSION: Working alliance is associated with specific demographic and symptom characteristics in patients with recent-onset schizophrenia spectrum disorders. There is moderate agreement between patients and therapists on the total quality of their working alliance. Findings highlight aspects that may increase therapists' specificity in the use of alliance-enhancing strategies.

Short-term prediction of threatening and violent behaviour in an Acute Psychiatric Intensive Care Unit based on patient and environment characteristics.

BACKGROUND: The aims of the present study were to investigate clinically relevant patient and environment-related predictive factors for threats and violent incidents the first three days in a PICU population based on evaluations done at admittance. METHODS: In 2000 and 2001 all 118 consecutive patients were assessed at admittance to a Psychiatric Intensive Care Unit (PICU). Patient-related conditions as actuarial data from present admission, global clinical evaluations by physician at admittance and clinical nurses first day, a single rating with an observer rated scale scoring behaviours that predict short-term violence in psychiatric inpatients (The Brøset Violence Checklist (BVC)) at admittance, and environment-related conditions as use of segregation or not were related to the outcome measure Staff Observation Aggression Scale-Revised (SOAS-R). A multiple logistic regression analysis with SOAS-R as outcome variable was performed. RESULTS: The global clinical evaluations and the BVC were effective and more suitable than actuarial data in predicting short-term aggression. The use of segregation reduced the number of SOAS-R incidents. CONCLUSIONS: In a naturalistic group of patients in a PICU segregation of patients lowers the number of aggressive and threatening incidents. Prediction should be based on clinical global judgment, and instruments designed to predict short-term aggression in psychiatric inpatients. TRIAL REGISTRATIONS: NCT00184119/NCT00184132.

Cognitive and clinical factors are associated with service engagement in early-phase schizophrenia spectrum disorders.

We examined how neurocognition contributes to adherence with treatment in early-phase schizophrenia spectrum disorders, in context with clinical symptoms. A total of 148 patients were assessed with a broad neurocognitive test battery and clinical assessments including the Positive and Negative Syndrome Scale (PANSS); service engagement was measured by the Service Engagement Scale (SES). Patients' ability to conceptualize (measure: Wechsler Abbreviated Scale of Intelligence similarities) substantially influenced service engagement. Verbal fluency scores (measure: Delis-Kaplan Executive Functioning System semantic set shift) were significantly different between patients with high and low SES scores. Positive and excitative symptoms (measure: PANSS) contributed significantly in explaining service engagement. In the SES availability subscore, 18% of the variance resulted from PANSS positive and PANSS excitative symptoms and Wechsler Abbreviated Scale of Intelligence conceptualizing ability. Some of the relationship between cognitive deficits and clinical outcome can be mediated by patients' ability to engage in arranging appointments, thereby benefiting from professional mental health care.

Acute Unstable Depressive Syndrome (AUDS) is associated more frequently with epilepsy than major depression.

BACKGROUND: Depressive disorders are frequent in epilepsy and associated with reduced seizure control. Almost 50% of interictal depressive disorders have to be classified as atypical depressions according to DSM-4 criteria. Research has mainly focused on depressive symptoms in defined populations with epilepsy (e.g., patients admitted to tertiary epilepsy centers). We have chosen the opposite approach. We hypothesized that it is possible to define by clinical means a subgroup of psychiatric patients with higher than expected prevalence of epilepsy and seizures. We hypothesized further that these patients present with an Acute Unstable Depressive Syndrome (AUDS) that does not meet DSM-IV criteria of a Major Depressive Episode (MDE). In a previous publication we have documented that AUDS patients indeed have more often a history of epileptic seizures and abnormal EEG recordings than MDE patients (Vaaler et al. 2009). This study aimed to further classify the differences of depressive symptoms at admittance and follow-up of patients with AUDS and MDE. METHODS: 16 AUDS patients and 16 age- and sex-matched MDE patients were assessed using the Symptomatic Organic Mental Disorder Assessment Scale (SOMAS), the Montgomery and Asberg Depression Rating Scale (MADRS), and the Mini-Mental State Test (MMST), at day 2, day 4-6, day 14-16 and 3 months after admittance to a psychiatric emergency unit. Life events were assessed with The Social Readjustment Rating Scale (SRRS) and The Life Experience Survey (LES). We also screened for medication serum levels and illicit drug metabolites in urine. RESULTS: AUDS patients had significantly higher SOMAS scores (average score at admission 6.6 +/- 0.8), reflecting increased symptom fluctuation and motor agitation, and decreased insight and concern compared to MDE patients (2.9 +/- 0.7; p < 0.001). Degree of mood depression, cognition, life events, drug abuse and medication did not differ between the two groups. CONCLUSIONS: AUDS patients present with rapidly fluctuating mood symptoms, motor agitation and relative lack of insight and concern. Seizures, epilepsy and EEG abnormalities are overrepresented in AUDS patients compared to MDE patients. We suggest that the study of AUDS patients may offer a new approach to better understanding epilepsy and its association with depressive disorders. TRIAL REGISTRATION: NCT00201474.

Patients' perspectives on care pathways and informed shared decision making in the transition between psychiatric hospitalization and the community.

RATIONALE, AIMS, AND OBJECTIVES: Patients with mental health problems experience numerous transitions into and out of hospital. This study explores former patients' views of pathways in transition between district psychiatric hospital centres (DPCs) and community mental health services. METHOD: A descriptive qualitative design was chosen. Three focus group interviews with a total of 10 informants from five different communities were conducted. Interviews were transcribed and analysed thematically where themes describe promoting or inhibitory factors to the transition phase. RESULTS: The informants shared their experiences on issues promoting and preventing successful care pathways in mental health. Four main paired themes were identified: (a) patient participation/activation/empowerment versus paternalism and institutionalization, (b) patient-centred care versus care interpreted as humiliation, (c) interprofessional collaboration or teamwork versus unsafe patient pathways in mental health services, and (d) sustainable integrated care versus fragmented, noncollaborative care. CONCLUSIONS: Shared decision making was reported more precisely as informed shared decision making. Shared information between all parties involved in care pathways is key.

Care pathways in the transition of patients between district psychiatric hospital centres (DPCs) and community mental health services.

RATIONALE AIMS AND OBJECTIVES: Patients with mental health problems experience numerous transitions into and out of hospital. Primary care providers have mixed success in identifying and managing patients' needs. This study explores health personnel's experience of care pathways in patient transition between inpatient and community mental health services. METHODS: A descriptive qualitative design was chosen. Four focus group interviews with 12 informants from 7 different communities were conducted. Interviews were analyzed thematically. RESULTS: Two main themes were identified: integrated care and patient activation. The participants shared their experiences on topics that can affect smooth care pathways in mental health. Six promoting factors were identified for successful patient transition: opportunities for information sharing, implementation of systematic plans, use of e-messages, around-the-clock care, designating one responsible health person in each system for each patient, and the involvement of patients and their families. The following barriers were all found to impede the patients' transition between levels of care: the lack of a single responsible person at each health care level, insufficient meetings, the absence of systematic plans, difficulties in identifying the right staff at different levels, delays in information sharing, and the complexity of welfare systems negatively affecting patient dignity. CONCLUSIONS: Systems and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathways of care. A single person should take charge of ensuring sufficient connection and communication between inpatient and community mental health services. Finally, both patient and staff in community services should be linked through a direct telephone number with around-the-clock availability.

Substance abuse and recovery in a Psychiatric Intensive Care Unit.

OBJECTIVES: The purpose of this study is to compare the development in symptoms, behaviors, function and treatment between patients with or without a substance use (SU) diagnose in a Psychiatric Intensive Care Unit (PICU). METHODS: A total of 118 admitted patients were assessed at admittance, day 3 and discharge from the PICU. Symptoms of psychopathology, therapeutic steps taken, violent episodes and length of patient stay were recorded. RESULTS: More males than females received an SU diagnosis. Substance use patients had less psychiatric symptoms at admittance and showed a faster symptom reduction, more favorable and faster improvement of function and a shorter length of stay. Except for symptom reduction and shorter length of stay, these differences were largely due to differences in sex and diagnoses in the two groups. CONCLUSION: In a naturalistic group of patients in a PICU, SU is associated with favorable outcomes compared to patients not using substances.

Incidence of violent behavior among patients in psychiatric intensive care units

Background and Objectives: Both psychiatric acute units and psychiatric intensive care units (PICUs) focus on acute treatment of behavioral disturbances such as violence and aggressive threats and acts. The aim of the present study is to describe the frequency of violent behavior; such as verbal or physical threats and physical attacks, among patients admitted to psychiatric intensive care unit (PICU). In addition the relationship between the episodes of threats and/or attacks in relation to time of the day, days of the week, and their seasonal variations was explored. Methods: All violent behavior was continuously assessed at the psychiatric emergency department. Data were collected during the period from May 2010 to May 2012. Results: Patients with only one hospitalization were less violent than those who have had two hospitalizations. There was a statistically significant difference in violence among patients without formal secondary education and those who have not formal education. Violent behavior showed two peaks during the day; the first occurring at 1 pm and the second at 8 pm. In regard to seasonality, summer had a higher incidence of violence. The most peaceful seasons of the year were spring and autumn. Conclusions: Violent behavior shows variation in daytime, days of the week and season in acute psychiatric intensive care. Daytime variation shows two peaks of violence at 1 pm and 8 pm, Sundays and Wednesdays being the quietest days regarding violence both in winter and summer. Patient`s level of education and hospitalization status partially explain the variation (AU)

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Differences in acute psychiatric admissions between asylum seekers and refugees.

The objective of the study was to examine differences between asylum seekers, living in asylum seekers' centres, and refugees, who officially have been granted asylum, when they were acutely admitted to a psychiatric hospital. All 53 asylum seekers and 45 refugees, acutely admitted to a Norwegian psychiatric hospital from 1995 to 2001 were included. The number of admissions by coercion, diagnosis, length of hospital stay and years residing in Norway at the time of the admissions were compared between the two groups. Post-traumatic stress disorder (PTSD) was more frequent among asylum seekers (43.4%) than among refugees (11%), while schizophrenia was more frequent among refugees (62.2%) than among asylum seekers (15%). The refugees (24.4%) were more often admitted by coercion than asylum seekers (11%). The high proportion of PTSD among asylum seekers compared to refugees may be explained by experiences in Norway after arrival into the country. The stresses of life in reception centres and the risk of being expelled from the country may contribute more to these admittances than experiences in the asylum seekers countries of origin.