Predictors of family focused practice: organisation, profession, or the role as child responsible personnel?

BACKGROUND: Health professionals in Norway are required by law to help safeguard information and follow-up with children of parents with mental or physical illness, or who have substance abuse problems, to reduce their higher risk of psychosocial problems. Knowledge is lacking regarding whether organisation and/or worker-related factors can explain the differences in health professionals' ability to support the families when patients are parents. METHODS: Employing a translated, generic version of the Family Focused Mental Health Practice Questionnaire (FFPQ), this cross-sectional study examines family focused practice (FFP) differences in relation to health professionals' background and role (N = 280) along with exploring predictors of parent, child, and family support. RESULTS: While most health professions had begun to have conversations with parents on children's needs, under one-third have had conversations with children. There were significant differences between nurses, social workers, psychologists, physicians, and others on seven of the FFP subscales, with physicians scoring lowest on five subscales and psychologists providing the least family support. Controlling for confounders, there were significant differences between child responsible personnel (CRP) and other clinicians (C), with CRP scoring significantly higher on knowledge and skills, confidence, and referrals. Predictors of FFP varied between less complex practices (talking with parents) and more complex practices (family support and referrals). CONCLUSION: The type of profession was a key predictor of delivering family support, suggesting that social workers have more undergraduate training to support families, followed by nurses; alternately, the results could suggest that that social workers and nurses have been more willing or able than physicians and psychologists to follow the new legal requirements. The findings highlight the importance of multidisciplinary teams and of tailoring training strategies to health professionals' needs in order to strengthen their ability to better support children and families when a parent is ill.

Hospitals implementing changes in law to protect children of ill parents: a cross-sectional study.

BACKGROUND: Norway is one of the first countries to require all health professionals to play a part in prevention for children of parents with all kinds of illnesses (mental illness, drug addiction, or severe physical illness or injury) in order to mitigate their increased risk of psychosocial problems. Hospitals are required to have child responsible personnel (CRP) to promote and coordinate support given by health professionals to patients who are parents and to their children. METHODS: This study examined the extent to which the new law had been implemented as intended in Norwegian hospitals, using Fixsen's Active Implementation Framework. A stratified random sample of managers and child responsible personnel (n = 167) from five Hospitals filled in an adapted version of the Implementation Components Questionnaire (ICQ) about the implementation of policy changes. Additional information was collected from 21 hospital coordinators (H-CRP) from 16 other hospitals. RESULTS: Significant differences were found between the five hospitals, with lowest score from the smallest hopitals. Additional analysis, comparing the 21 hospitals, as reported by the H-CRP, suggests a clear pattern of smaller hospitals having less innovative resources to implement the policy changes. Leadership, resources and system intervention (strategies to work with other systems) were key predictors of a more successful implementation process. CONCLUSIONS: Legal changes are helpful, but quality improvements are needed to secure equal chances of protection and support for children of ill parents. TRIAL REGISTRATION: The study is approved by the Regional Committee on Medical and Health Research Etics South-East (reg.no. 2012/1176 ) and by the Privacy Ombudsmann.

Geographical accessibility and duration of untreated psychosis: distance as a determinant of treatment delay.

BACKGROUND: The duration of untreated psychosis is determined by both patient and service related factors. Few studies have considered the geographical accessibility of services in relation to treatment delay in early psychosis. To address this, we investigated whether treatment delay is co-determined by straight-line distance to hospital based specialist services in a mainly rural mental health context. METHODS: A naturalistic cross-sectional study was conducted among a sample of recent onset psychosis patients in northern Norway (n = 62). Data on patient and service related determinants were analysed. RESULTS: Half of the cohort had a treatment delay longer than 4.5 months. In a binary logistic regression model, straight-line distance was found to make an independent contribution to delay in which we controlled for other known risk factors. CONCLUSIONS: The determinants of treatment delay are complex. This study adds to previous studies on treatment delay by showing that the spatial location of services also makes an independent contribution. In addition, it may be that insidious onset is a more important factor in treatment delay in remote areas, as the logistical implications of specialist referral are much greater than for urban dwellers. The threshold for making a diagnosis in a remote location may therefore be higher. Strategies to reduce the duration of untreated psychosis in rural areas would benefit from improving appropriate referral by crisis services, and the detection of insidious onset of psychosis in community based specialist services.

The epidemiology of post-traumatic stress disorder in Norway: trauma characteristics and pre-existing psychiatric disorders.

PURPOSE: The prevalence of PTSD differs by gender. Pre-existing psychiatric disorders and different traumas experienced by men and women may explain this. The aims of this study were to assess (1) incidence and prevalence of exposure to traumatic events and PTSD, (2) the effect of pre-existing psychiatric disorders prior to trauma on the risk for PTSD, and (3) the effect the characteristics of trauma have on the risk for PTSD. All stratified by gender. METHOD: CIDI was used to obtain diagnoses at the interview stage and retrospectively for the general population N = 1634. RESULTS: The incidence for trauma was 466 and 641 per 100,000 PYs for women and men, respectively. The incidence of PTSD was 88 and 31 per 100,000 PYs. Twelve month and lifetime prevalence of PTSD was 1.7 and 4.3 %, respectively, for women, and 1.0 and 1.4 %, respectively, for men. Pre-existing psychiatric disorders were risk factors for PTSD, but only in women. Premeditated traumas were more harmful. CONCLUSION: Gender differences were observed regarding traumatic exposure and in the nature of traumas experienced and incidences of PTSD. Men experienced more traumas and less PTSD. Pre-existing psychiatric disorders were found to be risk factors for subsequent PTSD in women. However, while trauma happens to most, it only rarely leads to PTSD, and the most harmful traumas were premeditated ones. Primary prevention of PTSD is thus feasible, although secondary preventive efforts should be gender-specific.

"Lanthanic Presentation" in First-Episode Psychosis Predicts Long Service Delay: The Challenge of Detecting Masked Psychosis.

BACKGROUND/AIMS: Studies of pathways to care in first-episode psychosis have documented a substantial treatment delay occurring after patients enter mental health services. An initial presentation with neurotic rather than psychotic symptoms is common in first-episode psychosis. The term "lanthanic patient" has been used to refer to patients presenting with a reason for help-seeking that is unrelated to the underlying pathology. The aim of this study is to explore whether a lanthanic presentation is related to prolonged service delay. METHODS: The sample comprises 62 patients with recent-onset psychosis. Data on sociodemographic, clinical, help-seeking, and pathway indicators were collected using a comprehensive, semistructured-interview schedule. RESULTS: Service delay accounted for more than half of the overall treatment delay. An initially presenting complaint of neurotic symptoms was related to prolonged service delay. The effect remained after controlling for other potential risk factors of service delay. CONCLUSION: Anomalous experiences of pleasure, desire, or motivation are common in emerging psychosis. These difficulties are often misinterpreted as complaints of depression and anxiety by health professionals. The presence of such symptoms can introduce a focal vision on the part of health care professionals on the immediate presentation rather than the underlying psychopathology, leading to the underdetection of psychosis.

Prevalence and characteristics of suicide attempters and ideators among acutely admitted psychiatric hospital patients in northwest Russia and northern Norway.

BACKGROUND: More knowledge about suicidality and suicide risk profiles in acute psychiatric hospital patients (both first-time and chronic patients) is needed. While numerous factors are associated with suicidality in such populations, these may differ across cultures. Better understanding of factors underlying suicide risk can be informed by cross-cultural studies, and can aid development of therapeutic and preventive measures. METHODS: An explorative, cross-sectional cohort study was carried out. Acutely admitted patients at one psychiatric hospital in northwest Russia and two in northern Norway were included. At admission, demographic, clinical, and service use data were collected, in addition to an assessment of suicidal ideation and attempts, comprising five dichotomic questions. Data from 358 Norwegian and 465 Russian patients were analyzed with univariate and multivariate statistics. Within each cohort, attempters and ideators were compared with patients not reporting any suicidality. RESULTS: The observed prevalence of suicidal ideation and attempts was significantly higher in the Norwegian cohort than in the Russian cohort (χ(2) = 168.1, p < 0,001). Norwegian suicidal ideators and attempters had more depressed moods, more personality disorders, and greater problems with alcohol/drugs, but fewer psychotic disorders, cognitive problems or overactivity than non-suicidal patients. Russian suicidal ideators and attempters were younger, more often unemployed, had more depressed mood and adjustment disorders, but had fewer psychotic disorders and less alcohol/drug use than the non-suicidal patients. CONCLUSIONS: Rates of suicidal ideation and non-fatal attempts in Norwegian patients were intermediate between those previously reported for patients admitted for the first time and those typical of chronic patients. However, the significantly lower rates of suicidal ideation and non-fatal attempts in our Russian cohort as compared with the Norwegian, contrasted with what might be expected in a region with much higher suicide rates than in northern Norway. We suggest that suicide-related stigma in Russia may reduce both patient reporting and clinicians' recognition of suicidality. In both cohorts, overlapping risk profiles of ideators and attempters may indicate that ideators should be carefully evaluated and monitored, particularly those with depressed moods, alcohol/substance abuse disorders, and inadequate treatment continuity.

Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study.

BACKGROUND: Studies on the effect of organizational factors on the involuntary admission of psychiatric patients have been few and yielded inconclusive results. The objective was to examine the importance of type of service-system, level of care, length of inpatient stay, gender, age, and diagnosis on rates of involuntary admission, by comparing one deinstitutionalized and one locally institutionalized service-system, in a naturalistic experiment. METHODS: 5538 admissions to two specialist psychiatric service-areas in North Norway were studied, covering a four-year period (2003-2006). The importance of various predictors on involuntary admission were analyzed in a logistic regression model. RESULTS: Involuntary admission to the services was associated with the diagnosis of psychosis, male sex, being referred to inpatient treatment, as well as type of service-system. Patients from the deinstitutionalized system were more likely to be involuntarily admitted. CONCLUSIONS: Several factors predicted involuntary status, including male sex, the diagnosis of psychosis, and type of service-system. The results suggests that having psychiatric beds available locally may be more favourable than a traditional deinstitutionalized service system with local outpatient clinics and central mental hospitals, with respect to the use of involuntary admission.

Diagnosing comorbidity in psychiatric hospital: challenging the validity of administrative registers.

BACKGROUND: This study will explore the validity of psychiatric diagnoses in administrative registers with special emphasis on comorbid anxiety and substance use disorders. METHODS: All new patients admitted to psychiatric hospital in northern Norway during one year were asked to participate. Of 477 patients found eligible, 272 gave their informed consent. 250 patients (52%) with hospital diagnoses comprised the study sample. Expert diagnoses were given on the basis of a structured diagnostic interview (M.I.N.I.PLUS) together with retrospective checking of the records. The hospital diagnoses were blind to the expert. The agreement between the expert's and the clinicians' diagnoses was estimated using Cohen's kappa statistics. RESULTS: The expert gave a mean of 3.4 diagnoses per patient, the clinicians gave 1.4. The agreement ranged from poor to good (schizophrenia). For anxiety disorders (F40-41) the agreement is poor (kappa = 0.12). While the expert gave an anxiety disorder diagnosis to 122 patients, the clinicians only gave it to 17. The agreement is fair concerning substance use disorders (F10-19) (kappa = 0.27). Only two out of 76 patients with concurrent anxiety and substance use disorders were identified by the clinicians. CONCLUSIONS: The validity of administrative registers in psychiatry seems dubious for research purposes and even for administrative and clinical purposes. The diagnostic process in the clinic should be more structured and treatment guidelines should include comorbidity.

The factor structure and psychometric properties of the Clinical Outcomes in Routine Evaluation--Outcome Measure (CORE-OM) in Norwegian clinical and non-clinical samples.

BACKGROUND: The Clinical Outcomes in Routine Evaluation--Outcome Measure (CORE-OM) is a 34-item instrument developed to monitor clinically significant change in out-patients. The CORE-OM covers four domains: well-being, problems/symptoms, functioning and risk, and sums up in two total scores: the mean of All items, and the mean of All non-risk items. The aim of this study was to examine the psychometric properties of the Norwegian translation of the CORE-OM. METHODS: A clinical sample of 527 out-patients from North Norwegian specialist psychiatric services, and a non-clinical sample of 464 persons were obtained. The non-clinical sample was a convenience sample consisting of friends and family of health personnel, and of students of medicine and clinical psychology. Students also reported psychological stress. Exploratory factor analysis (EFA) was employed in half the clinical sample. Confirmatory (CFA) factor analyses modelling the theoretical sub-domains were performed in the remaining half of the clinical sample. Internal consistency, means, and gender and age differences were studied by comparing the clinical and non-clinical samples. Stability, effect of language (Norwegian versus English), and of psychological stress was studied in the sub-sample of students. Finally, cut-off scores were calculated, and distributions of scores were compared between clinical and non-clinical samples, and between students reporting stress or no stress. RESULTS: The results indicate that the CORE-OM both measures general (g) psychological distress and sub-domains, of which risk of harm separates most clearly from the g factor. Internal consistency, stability and cut-off scores compared well with the original English version. No, or only negligible, language effects were found. Gender differences were only found for the well-being domain in the non-clinical sample and for the risk domain in the clinical sample. Current patient status explained differences between clinical and non-clinical samples, also when gender and age were controlled for. Students reporting psychological distress during last week scored significantly higher than students reporting no stress. These results further validate the recommended cut-off point of 1 between clinical and non-clinical populations. CONCLUSIONS: The CORE-OM in Norwegian has psychometric properties at the same level as the English original, and could be recommended for general clinical use. A cut-off point of 1 is recommended for both genders.

Compulsory and voluntary admission in psychiatric hospitals in northern Norway 2009-2010. A national registry-based analysis.

BACKGROUND: During the last decade, Norwegian healthcare authorities have been concerned about the frequent use of coercive measures in psychiatric care. On this background, we aimed to explore the voluntary and compulsory admissions in psychiatric hospitals in northern Norway, the University Hospital of North Norway in Tromsø (UNN-T) and the Nordland Hospital in Bodø (NH-B). METHODS: All voluntary and compulsory admissions (2009-2010) among patients aged ≥18 years registered by the Norwegian Patient Registry (NPR) were analyzed retrospectively. Compulsory admission was registered according to the general practitioner's (GP's) decision and the patients were hospitalized in Bodø or Tromsø. A total of 12,237 admissions and 242,148 days in hospital were identified. The female/male ratio of admission and stay was 1.17 and 1.15, respectively. RESULTS: The admission rate (northern Norway =1.0) varied significantly from south to north (0.60-1.52). Whereas patients living close to the hospitals had the same admission rate as others, the mean hospital stay was significantly longer (ratio =1.32). Furthermore, the UNN-T had a higher re-admission rate (2% vs. 5%). Municipalities with District Psychiatric Centers (DPC) did not differ from others. A significant difference in the use of coercive measures was revealed between hospitals. Forced medication was the most frequent measure employed. CONCLUSIONS: The study documented a south-north gradient in admission rate and indicated differences in the use of coercion. Variation may partly be due to different reporting procedures. This finding and why patients living in the neighborhood of hospitals stay longer should be explored in future studies.

Classification of bipolar disorder in psychiatric hospital. A prospective cohort study.

BACKGROUND: This study has explored the classification of bipolar disorder in psychiatric hospital. A review of the literature reveals that there is a need for studies using stringent methodological approaches. METHODS: 480 first-time admitted patients to psychiatric hospital were found eligible and 271 of these gave written informed consent. The study sample was comprised of 250 patients (52%) with hospital diagnoses. For the study, expert diagnoses were given on the basis of a structured diagnostic interview (M.I.N.I.PLUS) and retrospective review of patient records. RESULTS: Agreement between the expert's and the clinicians' diagnoses was estimated using Cohen's kappa statistics. 76% of the primary diagnoses given by the expert were in the affective spectrum. Agreement concerning these disorders was moderate (kappa ranging from 0.41 to 0.47). Of 58 patients with bipolar disorder, only 17 received this diagnosis in the clinic. Almost all patients with a current manic episode were classified as currently manic by the clinicians. Forty percent diagnosed as bipolar by the expert, received a diagnosis of unipolar depression by the clinician. Fifteen patients (26%) were not given a diagnosis of affective disorder at all. CONCLUSIONS: Our results indicate a considerable misclassification of bipolar disorder in psychiatric hospital, mainly in patients currently depressed. The importance of correctly diagnosing bipolar disorder should be emphasized both for clinical, administrative and research purposes. The findings questions the validity of psychiatric case registers. There are potential benefits in structuring the diagnostic process better in the clinic.

Suicidality related to first-time admissions to psychiatric hospital.

BACKGROUND: The epidemiology of suicidality shows considerable variation across sites. However, one of the strongest predictors of suicide is a suicidal attempt. Knowledge of the epidemiology of suicidal ideas and attempts in the general population as well as in the health care system is of importance for designing preventive strategies. In this study, we will explore the role of the psychiatric hospital in suicide prevention by investigating treated incidence of suicidal ideation and attempt, and further, discern whether sociodemographic, clinical and service utilization factors differ between these two groups at admission. METHODS: The study was a prospective cohort study on treated incidence in a 1-year period and 12-month follow-up. The two psychiatric hospitals in northern Norway, serving a population of about 500,000 people, participated in the study. A total of 676 first-time admissions were retrospectively checked for suicidality at the time of admission. A study sample of 168 patients was found eligible for logistic regression analysis to elucidate the risk profiles of suicidal ideators versus suicidal attempters. GAF, HoNOS and SCL-90-R were used to assess symptomatology at baseline. RESULTS: 52.2% of all patients admitted had suicidal ideas at admission and 19.7% had attempted suicide. In the study sample, there were no differences in risk profile between the two groups with regard to sociodemographic and clinical factors. Males who had made a suicide attempt were less likely to have been in contact with an out-patient clinic before the attempt. The rating scales not measuring suicidality directly showed no differences in symptomatology. CONCLUSION: The findings provide evidence for the importance of the psychiatric hospital in suicide prevention. About half of the admissions were related to suicidality and the similar risk profiles found in suicidal ideators and suicidal attempters indicate that it is the ideators who mostly need treatment that get admitted to the hospital, and should be evaluated and treated with equal concern as those who have attempted suicide.

Factors of importance to involuntary admission.

BACKGROUND: Most countries allow for the use of involuntary admission of patients. While some countries have stable or declining rates of involuntary admission, this type of coercion is now on the increase in several European countries. AIMS: To increase understanding of the antecedents of involuntary admission. METHODS: The importance of various predictors of involuntary admission were analysed in univariate analyses and in a logistic regression model, involving approximately 2000 admissions to a Norwegian hospital. RESULTS: Involuntary admission was positively associated with the diagnostic category of psychosis and negatively associated with the category of anxiety. Emergency referrals were also more likely to be coerced. CONCLUSIONS: Diagnostic category seems to be a central factor with respect to involuntary admission. Patients that were admitted in an emergency were also more likely to be coerced. CLINICAL IMPLICATIONS: Certain groups of patients are more likely to be admitted involuntarily. Increasing attention to these groups could possibly also contribute to the reduction of coercion.

Qualified and Unqualified (N-R C) mental health nursing staff--minor differences in sources of stress and burnout. A European multi-centre study.

BACKGROUND: Unqualified/non-registered caregivers (N-R Cs) will continue to play important roles in the mental health services. This study compares levels of burnout and sources of stress among qualified and N-R Cs working in acute mental health care. METHODS: A total of 196 nursing staff --124 qualified staff (mainly nurses) and 72 N-R Cs with a variety of different educational backgrounds--working in acute wards or community mental teams from 5 European countries filled out the Maslach Burnout Inventory (MBI), the Mental Health Professional Scale (MHPSS) and the Psychosocial Work Environment and Stress Questionnaire (PWSQ). RESULTS: (a) The univariate differences were generally small and restricted to a few variables. Only Social relations (N-R Cs being less satisfied) at Work demands (nurses reporting higher demands) were different at the .05 level. (b) The absolute scores both groups was highest on variables that measured feelings of not being able to influence a work situation characterised by great demands and insufficient resources. Routines and educational programs for dealing with stress should be available on a routine basis. (c) Multivariate analyses identified three extreme groups: (i) a small group dominated by unqualified staff with high depersonalization, (ii) a large group that was low on depersonalisation and high on work demands with a majority of qualified staff, and (iii) a small N-R C-dominated group (low depersonalization, low work demands) with high scores on professional self-doubt. In contrast to (ii) the small and N-R C-dominated groups in (i) and (iii) reflected mainly centre-dependent problems. CONCLUSION: The differences in burnout and sources of stress between the two groups were generally small. With the exception of high work demands the main differences between the two groups appeared to be centre-dependent. High work demands characterized primarily qualified staff. The main implication of the study is that no special measures addressed towards N-R Cs in general with regard to stress and burnout seem necessary. The results also suggest that centre-specific problems may cause more stress among N-R Cs compared to the qualified staff (e.g. professional self-doubt).

Bed utilization in two differently organized community mental health services in Northern Norway: the VELO-project.

BACKGROUND: The literature on the dynamics between community- and hospital services concerning utilization of psychiatric beds is inconclusive. The Norwegian VELO-project provides an opportunity to study this in a natural experiment. Two service-systems are compared. The "central-bed system" have mainly outpatient- and day-hospital services locally, with psychiatric beds at a central mental hospital. The "local-bed system" have only one outpatient clinic, with beds at three local inpatient units. Also utilization of sheltered homes was studied. Hypotheses were predicted from Goldberg and Huxley's' stage theory and the Thornicroft and Tansella's' hydraulic model. MATERIALS AND METHODS: The case-registries of 2005 were linked across service levels by patients' 11-digit Social Security Number. From 1,865 single treatment episodes, 1,348 continuous courses by 1,253 individual patients were extracted. RESULTS: For overall utilization of psychiatric beds there was only a small difference, were the central-bed system utilized 10% less than the other. For utilization of emergency inpatient admissions and acute hospital beds, the rate was more than twice in the central-bed system compared to the other. For utilization of municipalities sheltered homes, the rate was three times higher in the local-bed system. DISCUSSION: There may be bedrock of need for psychiatric beds regardless of system-organization. Distance may in general be a minor issue for utilization of psychiatric beds, and may primarily interact with patient- or contextual characteristics associated with acute situations. Activity of day-hospital services rather than outpatient consultations may affect utilization of sheltered homes. The main theoretical models are conceptually useful, although more research is needed to specify mechanisms.

Negotiating the boundaries of psychosis: A qualitative study of the service provider perspective on treatment delay in community mental health.

AIM: Evidence shows that many patients are detected and treated late in their course of illness, and that substantial delay occurs even after entry to mental health services. Although several studies have examined the service user and carer perspectives on treatment delay, few have explored the issue from the service provider perspective. The aim of this study was to broaden our understanding of treatment delay by exploring the service provider perspective on reasons for treatment delay in community mental health services. METHODS: A qualitative study using data from focus group interviews with 33 healthcare professionals in community mental health care. Interview data were digitally recorded and transcribed verbatim, and analysed using a grounded theory approach. RESULTS: Service providers perceived divergent or conflicting perspectives as the main challenge in early psychosis. Clinical negotiation was chosen as the main term describing the interactions between patients and healthcare professionals: This was observed in 3 overlapping areas: (1) Negotiating the patients status as help-seeker; (2) Negotiating the place and conditions of treatment and (3) Negotiating the meaning of distressing experiences and the timing of treatment options. CONCLUSIONS: This study suggests that delay in initiation of treatment for psychosis in community mental health is related to clinical challenges of early disengagement from services and diagnostic uncertainty. Service providers found negotiating the therapeutic relationship and patient-centred flexibility more useful in ensuring engagement than an assertive outreach approach. Diagnostic uncertainty was resolved through watchful waiting using a distress-overload conceptualization in assessing changes in mental state and service needs.

Differences in implementation of family focused practice in hospitals: a cross-sectional study.

BACKGROUND: Changes in Norwegian law and health policy require all health professionals to help safeguard the provision of information and follow-up for the children of parents with mental or physical illness, or substance abuse problems, to decrease their risk of psychosocial problems. There is a lack of knowledge on how the national changes have been received by hospital-based health professionals, and if they have led to an increase in family focused practice. METHODS: This cross-sectional study examined the adherence of health professionals' (N = 280) in five hospitals to new guidelines for family focused practice, using a translated and generic version of Family Focused Mental Health Practice Questionnaire. RESULTS: Overall, health professionals scored high on knowledge and skills, and were confident in working with families and children, but reported moderate levels of family support and referrals. Comparison of the five hospitals showed significant differences in terms of workplace support, knowledge and skills and family support. The smallest hospital had less workplace support and less knowledge and skills but scored medium on family support. The two largest hospitals scored highest on family support, but with significant differences on parents refusing to have conversations with children. CONCLUSIONS: Differences in implementation of family focused practice highlight the need to tailor improvement strategies to specific barriers at the different hospitals. The use of implementation theories and improvement strategies could promote full implementation, where all families and children in need were identified and had access to family support.Trial registration The study is approved by the Regional Committee on Medical and Health Research Ethics South-East Q5 37 (reg. no. 2012/1176) and by the Privacy Ombudsman.

How mental health service systems are organized may affect the rate of acute admissions to specialized care: Report from a natural experiment involving 5338 admissions.

OBJECTIVES: Studies on the dynamics between service organization and acute admissions to psychiatric specialized care have given ambiguous results. We studied the effect of several variables, including service organization, coercion, and patient characteristics on the rate of acute admissions to psychiatric specialist services. In a natural experiment-like study in Norway, we compared a "deinstitutionalized" and a "locally institutionalized" model of mental health services. One had only community outpatient care and used beds at a large Central Mental Hospital; the other also had small bed-units at the local District Psychiatric Centre. METHODS: From the case registries, we identified a total of 5338 admissions, which represented all the admissions to the psychiatric specialist services from 2003 to 2006. The data were analyzed with chi-square tests and Z-tests. In order to control for possible confounders and interaction effects, a multivariate analysis was also performed, with a logistic regression model. RESULTS: The use of coercion emerged as the strongest predictor of acute admissions to specialist care (odds ratio = 7.377, 95% confidence interval = 4.131-13.174) followed by service organization (odds ratio = 3.247, 95% confidence interval = 2.582-4.083). Diagnoses of patients predicted acute admissions to a lesser extent. We found that having psychiatric beds available at small local institutions rather than beds at a Central Mental Hospital appeared to decrease the rate of acute admissions. CONCLUSION: While it is likely that the seriousness of the patients' condition is the most important factor in doctors' decisions to refer psychiatric patients acutely, other variables are likely to be important. This study suggests that the organization of mental health services is of importance to the rate of acute admissions to specialized psychiatric care. Systems with beds at local District Psychiatric Centers may reduce the rate of acute admissions to specialized care, compared to systems with local community outpatient services and beds at Central Mental Hospitals.

Predicting disability pension - depression as hazard: a 10 year population-based cohort study in Norway.

Disability pension (DP) is an escalating challenge to individuals and the welfare state, with mental health problems as imminent hazard. The objective of the present paper was to determine if a diagnosis of depression increased the risk of subsequent DP, and whether the risk differed by gender. A population cohort of 1230 persons were diagnostically interviewed (Composite International Diagnostic Interview, CIDI) in a population study examining mental health, linked to the DP registry and followed for 10 years. The risk for DP following depression was estimated using Cox regression. Life-time depression, as well as current depression, increased the risk of subsequent DP for both genders. The fully adjusted [baseline health, health behavior and socio-economic status (SES)] hazard ratios (HRs) for life-time depressed men and women were 2.9 [95% confidence interval (CI) 1.5-5.8] and 1.6 (95% CI 1.0-2.5) respectively. Men were significantly older at time of DP. There are reasons to believe that depression went under-recognized and under-treated. To augment knowledge in the field, without underestimating depression as risk for DP, a deeper understanding of the nature and effects of other distress is needed.

Local inpatient units may increase patients' utilization of outpatient services: a comparative cohort-study in Nordland County, Norway.

OBJECTIVES: In the last few decades, there has been a restructuring of the psychiatric services in many countries. The complexity of these systems may represent a challenge to patients that suffer from serious psychiatric disorders. We examined whether local integration of inpatient and outpatient services in contrast to centralized institutions strengthened continuity of care. METHODS: Two different service-systems were compared. Service-utilization over a 4-year period for 690 inpatients was extracted from the patient registries. The results were controlled for demographic variables, model of service-system, central inpatient admission or local inpatient admission, diagnoses, and duration of inpatient stays. RESULTS: The majority of inpatients in the area with local integration of inpatient and outpatient services used both types of care. In the area that did not have beds locally, many patients that had been hospitalized did not receive outpatient follow-up. Predictors of inpatients' use of outpatient psychiatric care were: Model of service-system (centralized vs decentralized), a diagnosis of affective disorder, central inpatient admission only, and duration of inpatient stays. CONCLUSION: Psychiatric centers with local inpatient units may positively affect continuity of care for patients with severe psychiatric disorders, probably because of a high functional integration of inpatient and outpatient care.