Epidemiology of psychotic depression - systematic review and meta-analysis.

Large amount of data have been published on non-psychotic depression (NPD), schizophrenia (SZ), and bipolar disorder, while psychotic depression (PD) as an own entity has received much smaller attention. We performed a systematic review and meta-analyses on epidemiology, especially incidence and prevalence, risk factors, and outcomes of PD. A systematic search to identify potentially relevant studies was conducted using four electronic databases and a manual search. The search identified 1764 unique potentially relevant articles, the final study included 99 articles. We found that the lifetime prevalence of PD varies between 0.35% and 1%, with higher rates in older age. Onset age of PD was earlier than that of NPD in younger samples, but later in older samples. There were no differences in gender distribution in PD v. NPD, but higher proportion of females was found in PD than in SZ or in psychotic bipolar disorder (PBD). Risk factors have rarely been studied, the main finding being that family history of psychosis and bipolar disorder increases the risk of PD. Outcomes of PD were mostly worse when compared with NPD, but better compared with SZ and schizoaffective disorder. The outcome compared with PBD was relatively similar, and somewhat varied depending on the measure of the outcome. Based on this review, the amount of research on PD is far from that of NPD, SZ, and bipolar disorder. Based on our findings, PD seems distinguishable from related disorders and needs more scientific attention.

Physical illnesses, developmental risk factors and psychiatric diagnoses among subjects at risk of psychosis.

BACKGROUND: Subjects with psychoses have significantly increased rates of physical illnesses, but the nature of the relationship remains largely unknown. MATERIAL AND METHODS: The present study is part of the European Prediction of Psychosis Study (EPOS). Data were collected from 245 help-seeking individuals from six European centers (age 16-35) who met criteria for ultra-high risk of psychosis criteria. This paper seeks to investigate self-reported physical ill health and its associations with psychiatric symptoms and disorders, risk factors, and onset of psychosis during 48 months of follow-up. RESULTS: In multivariate analysis, lifetime panic disorder (OR=2.43, 95%CI: 1.03-5.73), known complications during pregnancy and delivery (OR=2.81, 95%CI: 1.10-7.15), female gender (OR=2.88, 95%CI: 1.16-7.17), family history of psychosis (OR=3.08, 95%CI: 1.18-8.07), and having a relationship (OR=3.44, 95%CI: 1.33-8.94) were significantly associated with self-reported physician-diagnosed illness. In the Cox proportional hazard model we found no significant differences between those who had undergone a transition to psychosis and those who had not. CONCLUSIONS: The physical health of patients defined to be at ultra-high risk of psychosis seems to be commonly impaired and associated with female gender, marital status, complications during pregnancy and birth, lifetime panic disorder, and genetic risk of psychosis.

Early retirement from work among employees with a diagnosis of personality disorder compared to anxiety and depressive disorders.

OBJECTIVE: Risk of retirement from work before statutory retirement age among employees with personality disorders is unknown. METHOD: We used diagnoses of awarded medical rehabilitations and hospitalisations to select two clinical cohorts from a population of 151,618 employees: participants in rehabilitation (total N=1942, 233 personality disorder, 419 anxiety disorder and 1290 depression cases) and hospitalised patients (N=1333, 354, 126 and 853, respectively). Early retirement from work was tracked through national registers during a period of 5 years. Cox proportional hazard models were used to examine the association of diagnostic groups with risk of early retirement. RESULTS: In models adjusted for age, sex and socioeconomic position, the relative risk of early retirement for patients with personality disorders was 3.5-fold (95% CI 2.1 to 5.8) in the rehabilitation cohort and 2.3-fold (95% CI 1.6 to 3.5) in the hospital cohort compared with anxiety disorders. The corresponding hazard ratios of early retirement for personality disorders compared with depressive disorders were 1.1 (95% CI 0.8-1.5) and 1.7 (95% CI 1.4-2.1), respectively. CONCLUSIONS: Personality disorders increase the risk of early retirement at least to an equal extent as depression and more than twice that of anxiety disorders.

Attached to the web--harmful use of the Internet and its correlates.

BACKGROUND AND AIMS: The aim of this study was to test the validity of the Finnish version of the Internet Addiction Test and the correlates of harmful use of the Internet. METHODS: One thousand eight hundred and twenty-five students (45.5% men and 54.5% women, mean age 24.7 years, S.D.=5.7) filled in a web-based questionnaire including IAT, reasons for use of the Internet, distress, social support, and substance use. RESULTS: Men had a statistically significantly higher mean score on the IAT than women. Subjects with self-reported use of cannabis had higher mean score on the IAT compared to non-users (39.5 [11.3] vs 35.8 [10.8]). The total IAT score was associated with "adult entertainment" (OR=1.07, 95%CI: 1.06-1.08, P<0.001), "playing games" (OR=1.05, 95%CI: 1.04-1.06, P<0.001), "chatting" (OR=1.07, 95%CI: 1.06-1.08, P<0.001) and "discussion" (OR=1.08, 95%CI: 1.07-1.09, P<0.001) as reasons for Internet use. The IAT score had a significant negative correlation with social support (r=-0.24, P<0.001) and a significant positive correlation with the CAGE score (r=0.18, P<0.001). Using factor analysis, we found a single factor solution with a Cronbach's alpha of 0.92. CONCLUSIONS: The IAT seems to provide a valid measurement of harmful use of the Internet, as the score was significantly associated with variables tapping psychopathology.

Insulin resistance and lipid levels in adolescents with familial risk for psychosis.

OBJECTIVE: Type 2 diabetes and dyslipidemias co-occur frequently with schizophrenia. It is not known how common they are in adolescents with a familial risk for psychosis. METHOD: The Northern Finland 1986 Birth Cohort consists of 9432 children born alive in the two Northernmost provinces in Finland. At the age of 15/16 they participated in clinical examination including measurements of glucose, lipids and IR, and a questionnaire including items about their diet and physical activity. The Finnish Hospital Discharge Register was used to find out non-organic psychoses in parents during 1972-2000. This familial risk was found out in 54 boys and 68 girls. Their results were compared with other cohort members. RESULTS: No differences were observed in the cardiometabolic risk factors between the study groups. CONCLUSION: Our results suggest that familial risk for psychosis is not directly associated with disturbances of glucose and lipid metabolism among adolescents.

The use of harmful to others-criterion for involuntary treatment in Finland.

During the past decades the Western countries have paid attention to their Mental Health legislation, in particular, by making changes concerning involuntary treatment. In Western countries legislation allows involuntary treatment of the mentally ill. Involuntary psychiatric treatment is motivated by either potential harm to others (for the good of society) or by need for treatment and/or potential self-harm (for the good of the patient). The aims of this study were to describe to what extent the danger to others criterion is used as a motivation for involuntary hospitalization and detainment in Finland, and to what kind of patients this criterion is applied. The study involves a retrospective chart review of all the treatment periods of a six month admission sample in three Finnish university hospitals. We found that potential harm to others has been rarely used as a motivation for involuntary referral or detainment together with other motivations, and virtually never as the sole motivation. With the exception of gender, which was most often male, patients with potential harm to others did not differ significantly from other involuntarily treated patients. Coercion (defined as seclusion, the use of restraints, forced medication, physical restraint or restrictions in leaving the ward) was not used with these patients more regularly than with the patients motivated by the other criteria. Length of stay (LOS) in a psychiatric hospital did not differ between the patients determined harmful to others and the other involuntarily treated patients.

Involuntary medication in psychiatric inpatient treatment.

The aim of this study was to examine involuntary medication in psychiatric inpatient treatment. A retrospective chart review of 1543 consecutive admissions of working aged civil patients from well-defined catchment areas to three psychiatric centres were evaluated regarding events of involuntary medication. 8.2% of the admissions included involuntary medication episode(s). Involuntary medication was associated with a diagnosis of schizophrenia, involuntary legal status and having previously been committed. One of the studied centres used less involuntary medication than the other two, even if patients with schizophrenia were over-represented in that centre. Although involuntary medication mainly takes places in the treatment of patients who are conceptualised most ill and perhaps resist treatment most, treatment culture obviously also plays a role. In future, it is important to study the aspects of treatment culture to fully understand the use of involuntary medication in psychiatry.

PROD-screen--a screen for prodromal symptoms of psychosis.

The aim of this study was to describe the PROD-screen, an instrument for screening prodromal symptoms indicating risk for psychotic conversion in the near future. PROD-screen consists of 29 questions assessing performance and symptoms. Clinical construct validity was tested by comparing scores from the unselected general population (GP, n = 64) with those of general psychiatric patients from a community mental health centre (CMHC, n = 107). The concordant validity of PROD-screen for prodromal symptoms of psychosis was assessed in a large epidemiologically mixed sample of research subjects (n = 132) by comparing PROD-screen scores with the prodromal diagnosis made by Structured Interview for Prodromal Symptoms as a gold standard. Using the cut-off point of 2/12 specific symptoms, PROD-screen gave correct classification of prodromal status in 77% of cases, distinguishing prodromal from non-prodromal subjects with reasonable sensitivity (80%) and specificity (75%) in the epidemiologically mixed sample. According to subsample analysis PROD-screen functions well with first-degree relatives of schizophrenic patients and probably also with general population samples, but not with psychiatric outpatients. In conclusion, PROD-screen is a useful tool for screening prodromal symptoms of psychosis and selecting subjects for more extensive research interviews.

Living situation, subjective quality of life and social network among individuals with schizophrenia living in community settings.

OBJECTIVE: To investigate the relationships between characteristics of the living situation in the community and subjective quality of life and social network among community-based individuals with schizophrenia. METHOD: A total of 418 individuals with schizophrenia from 10 sites were interviewed with regard to quality of life, psychopathology, social network and needs for care. Characteristics of the living situation investigated were: living alone or not, living with family or not, and having an independent or a sheltered housing situation. RESULTS: An independent housing situation was related to a better quality of life concerning living situation and living with the family to a better quality of life concerning family relations. An independent housing situation was associated with a better social network regarding availability and adequacy of emotional relations. CONCLUSION: People with schizophrenia with an independent housing situation have a better quality of life associated with more favorable perceptions of independence, influence, and privacy. Their social network is better irrespective of whether they live alone or not, or with family or not.

Spinal anesthesia with hypobaric bupivacaine for knee arthroscopies: effect of posture on motor block.

BACKGROUND AND OBJECTIVES: The clinical impact of patient positioning on motor block during unilateral spinal anesthesia was the focus of our study. It was assumed that a 45 degrees rotation toward the prone position would minimize blocking the ventral motor roots compared with using the conventional lateral decubitus position. METHODS: Spinal anesthesia with 3.4 mL of hypobaric 0.18% bupivacaine via a 27-gauge Whitacre needle was administered to 70 patients undergoing knee arthroscopy. The patients were kept either in a lateral decubitus position (group I) or rotated approximately 45 degrees toward the prone position (group II). No prophylactic vasopressors or infusions were used. The intensity of motor block (modified Bromage scale) was assessed for both the operative and the contralateral side. RESULTS: The patients in group I had a slightly more pronounced motor block, but statistical significance could be shown only 20 minutes following the block. There was no statistical difference between the groups in the need of additional analgesics during the operation. None of the patients needed general anesthesia. The hemodynamics were stable and none of the patients developed postspinal headache or backache. CONCLUSIONS: The position of the patient affects the spread of the spinal anesthesia when clearly hypobaric agents are used. However, this small modification in positioning of the patient did not lead to a clinically meaningful difference in the spread of the motor block.

Coercion and restrictions in psychiatric inpatient treatment.

To find out to what extent coercion and restrictions are used in psychiatric inpatient treatment and with which patient characteristics the use of coercion is associated. To this end, the hospital records of 1,543 admissions (six-month admission samples) to the psychiatric clinics in three Finnish university towns were evaluated by retrospective chart review. The study clinics provide all psychiatric inpatient treatment for the working-age population in their catchment areas. Use of coercion and restrictions was recorded in a structured form. Coercion and restrictions were applied to 32% of the patients. Mechanical restraints were used on 10% of the patients, and forced medication on 8%. Compared to international statistics the figures in the current study are high.

Low-dose bupivacaine: a comparison of hypobaric and near isobaric solutions for arthroscopic surgery of the knee.

The results of studies on the effect of volume, concentration or total dose of local anaesthetic on the spread of spinal anaesthesia are inconclusive. Most support the assumption that the total dosage is more important than the volume. We compared low-dose bupivacaine (6 mg) in 0.5% and 0.18% solutions as sole anaesthetic to achieve predominantly unilateral spinal anaesthesia for knee arthroscopy. Sixty patients were randomly allocated to two groups to receive either 1.2 ml 0.5% bupivacaine (6 mg) (n = 30) or 3.4 ml 0.18% hypobaric bupivacaine (6.1 mg) (n = 30). Drugs were administered at the L3-4 interspace with the patient in the lateral position. Patients remained in this position for 20 min before being turned supine for the operation. Spinal block was assessed by pinprick and modified Bromage scale and compared between the operated and nonoperated sides. No significant changes were found in the spread or duration of sensory or motor block (p > 0.05). The haemodynamic changes were also similar between the groups. The same pinprick level of analgesia, degree of motor block and duration of spinal anaesthesia was obtained with bupivacaine (6 mg) in low (1.2 ml) or high (3.4 ml) volumes.

Restricted spinal anaesthesia for ambulatory surgery: a pilot study.

The increasing use of ambulatory surgery requires methods of anaesthesia that allow patients to be discharged soon after the operation is completed. Spinal anaesthesia is usually simple and quick, and the incidence of post-spinal headache has been reduced by using non-cutting small-gauge needles. Limiting the spread of spinal anaesthesia, as long as it still provides analgesia for surgery, should reduce the haemodynamic effects and speed recovery. Restricted spinal anaesthesia, intended to be unilateral using 0.18% hypobaric bupivacaine via a 25G or 27G Whitacre unidirectional needle, was compared with epidural anaesthesia (using a mixture of lignocaine and prilocaine) in 64 matched-pair patients undergoing ambulatory arthroscopy. Motor blockade, assessed for the specific myotomes L2 to S1, was significantly more unilateral in the spinal group. Two patients in the spinal group and nine patients in the epidural group were treated for hypotension (P < 0.05). One patient in the spinal group developed a post-spinal headache. One patient in the epidural group rated the anaesthesia poor.

Frequently hospitalised psychiatric patients: a study of predictive factors.

The purpose of this study was to investigate the factors predicting readmission and the interval between readmissions to psychiatric hospital during the early 1990s in Finland. Data were retrieved using the national register of all discharges from psychiatric hospitals during the early 1990s. Frequently admitted patients were an identifiable group. The factors associated with an increased risk of multiple readmissions were: previous admissions, long length of stay (LOS) and diagnosis of psychosis or personality disorder. Patients with psychosis or personality disorder were also readmitted more rapidly than patients with an organic disorder. There seemed to be a small proportion of psychiatric patients in need of frequent or lengthy hospital treatment. The expansion of community care did not as such seem to have diminished the need and use of psychiatric hospital care. However, the differences between the years 1990 and 1993 were less important than the other factors that predicted readmission, namely LOS and diagnosis.

Regional differences in the use of psychiatric hospital beds in Finland: a national case-register study.

We investigated the possible differences in the utilization of psychiatric hospital beds among five social security areas in Finland, and the association between the variables related to the psychiatric services and the use of hospital beds. The use of hospital beds varied quite distinctly among these areas, as did the total rate of in-patients, readmissions, and rates of in-patients with psychotic and affective disorders. The treatment practices appeared to vary as the length of stay (LOS) and the rate of committal differed regionally in a significant manner. There was a significant positive correlation between the total rate of in-patients and the rate of readmitted patients (r=0.92, P<0.001), and a significant negative correlation between the number of visits per worker in out-patient care and the rate of readmissions (r=-0.94, P<0.001).

Patterns of psychiatric hospital service use in Finland: a national register study of hospital discharges in the early 1990s.

We were interested in studying the possible concurrent changes in the psychiatric inpatient population during a rapid phase of deinstitutionalisation, and severe economic recession with a record level unemployment rate, and after the amendment of the mental health legislation. Although there were 4540 fewer beds in the psychiatric hospitals in 1993 compared to 1990, the rate of patient admissions remained the same. There was a significant increase in readmissions (P < 0.001) to the psychiatric hospitals, and particularly in multiple (three or more) readmissions among new inpatients (P < 0.001). The prevalence of inpatients with major depression increased by 0.2/1000 in the whole cohort and by 0.12/1000 among first-timers from 1990 to 1993 (P < 0.001). In addition, the rate of involuntary admissions decreased significantly (P < 0.001).

Readmitted nonpsychotic patients and their eventual diagnoses. A retrospective study on 64 first-timers of inpatient care in the Psychiatric Clinic of Turku, Finland.

This longitudinal study was performed to characterise frequently readmitted patients in a sample of 64 first-timers of inpatient care. Half of the 12 revolving door patients were psychotic at last discharge. The relative risk for diagnostic change in the Axis I group was nine times higher than in the personality disorder group.