Experiences of clinicians and managers in the implementation of a family focused model in child and adult psychiatry.

Introduction: This paper describes the process of implementing a family focused model, The Family Model, in child and adolescent and adult mental health services in Sweden. Additionally, it describes a service development project carried out in both services within a defined geographical area of Region Stockholm. The Family Model is a communication tool designed to assist clinicians in both services to have family focused conversations with their patients and relatives. Internationally, the needs of individuals experiencing mental health challenges (parents, children and young people) and their close relatives are now well recognized, but barriers to family focused practice nevertheless persist. The aim of this study was to better understand clinicians` experiences in implementing The Family Model in both services. Methods: Three preplanned focus group interviews were carried out with 14 clinicians and managers across both services and the data were analyzed in accordance with methods of Naturalistic inquiry. Result: Findings suggest that The Family Model has utility in both services. The Naturalistic inquiry analyses revealed three main themes: individual, relational and organizational aspects with a total of 10 sub-themes of how the models influence the participants. Furthermore, analyses on a meta understanding level explored that participants underwent a developmental journey in learning about and using The Family Model in practice which was expressed through three themes: "Useful for burdened families", "Influencing prevention", and "To integrate this would be fantastic". Conclusions: The Family Model, when adapted for the Swedish context, is a useful tool for assisting experienced clinicians to engage in family focused practice in both child and adolescent and adult mental health services. The Family Model highlights different aspects in everyday clinical services that were of special interest for clinicians, families, and the system. Future research could explore families' perspectives of the utility of the model.

Burdens experienced and perceived needs of relatives of persons with SMI - a systematic meta-synthesis.

Background: Close relatives of people with severe mental illness (SMI) experience problems known as family burdens. In addition, they may have their own needs for support, something often overlooked by the healthcare system. Meta-syntheses in this area may help explore the meaning of the experience of living with someone who has a SMI.Aim: Our aim was to describe the burdens experienced and needs perceived on a daily basis by relatives to someone who has a SMI.Methods: The databases PubMed, CINAHL, and PsychInfo were searched using a systematic search strategy. Studies were screened for relevance and quality was appraised. A meta-synthesis of nine qualitative studies was then conducted.Results: The nine studies discerned the following themes. Burden themes; Forced to carry a sometimes unbearable burden; Burdened by own ill-health and disrupted relationships; Distressed and stigmatized by society. Needs themes; strengthening protective factors; Skills and practical support greatly appreciated.Conclusions: The burdens and needs of relatives of persons with SMI strongly influence their lives. They require relief from both practical and emotional burdens. Family interventions and other programs to support relatives should be encouraged with this knowledge in mind.

A Mismatch of Paradigms Disrupts the Introduction of Psycho-Educative Interventions for Families of Persons with SMI: An Interview Study with Staff from Community Services.

Treatment and support of people diagnosed with severe mental illness in Sweden takes place in out-patient psychiatric services or municipality services. Most of the responsibility for support in daily life are provided by the close family. One crucial matter is how to support these families. This research project aimed to investigate the Swedish construction with shared responsibility between county psychiatric care and municipality social care for consumers with severe mental illness affects actions in municipalities in relation to family support. Ten representatives from five municipality settings were interviewed. Five semi-structured interviews were analysed using a thematic analysis. The following themes emerged; One overarching theme, "a mismatch of paradigms", and sub-themes: (a) "accentuating differences", (b) "doubts about including the entire family in the same session" and (c) "lack of a uniform family support policy". We conclude that a shared mandate needs a dialogue between psychiatric and municipality services concerning this mismatch.

Sex-related illness perception and self-management of a Thai type 2 diabetes population: a cross-sectional descriptive design.

BACKGROUND: Increased knowledge concerning the differences in the illness perception and self-management among sexes is needed for planning proper support programs for patients with diabetes. The aim of this study was to investigate the illness perception and self-management among Thai women and Thai men with type 2 diabetes and to investigate the psychometric properties of the translated instruments used. METHODS: In a suburban province of Thailand, 220 women and men with type 2 diabetes participated in a cross-sectional descriptive study. The participants were selected using a multistage sampling method. Data were collected through structured interviews and were analyzed using group comparisons, and psychometric properties were tested. RESULTS: Women and men with type 2 diabetes demonstrated very similar experiences regarding their illness perception and no differences in self-management. Women perceived more negative consequences of the disease and more fluctuation in the symptoms than men, whereas men felt more confident about the treatment effectiveness than women. Furthermore, the translated instruments used in this study showed acceptable validity and reliability. CONCLUSIONS: The Thai sociocultural context may influence people's perceptions and affect the self-care activities of Thai individuals, both women and men, with type 2 diabetes, causing differences from those found in the Western environment. Intervention programs that aim to improve the effectiveness of the self-management of Thai people with diabetes might consider a holistic and sex-related approach as well as incorporating Buddhist beliefs.

Parents in adult psychiatric care and their children: a call for more interagency collaboration with social services and child and adolescent psychiatry.

BACKGROUND: A parental mental illness affects all family members and should warrant a need for support. AIM: To investigate the extent to which psychiatric patients with underage children are the recipients of child-focused interventions and involved in interagency collaboration. METHODS: Data were retrieved from a psychiatric services medical record database consisting of data regarding 29,972 individuals in southern Sweden and indicating the patients' main diagnoses, comorbidity, children below the age of 18, and child-focused interventions. RESULTS: Among the patients surveyed, 12.9% had registered underage children. One-fourth of the patients received child-focused interventions from adult psychiatry, and out of these 30.7% were involved in interagency collaboration as compared to 7.7% without child-focused interventions. Overall, collaboration with child and adolescent psychiatric services was low for all main diagnoses. If a patient received child-focused interventions from psychiatric services, the likelihood of being involved in interagency collaboration was five times greater as compared to patients receiving no child-focused intervention when controlled for gender, main diagnosis, and inpatient care. CONCLUSIONS: Psychiatric services play a significant role in identifying the need for and initiating child-focused interventions in families with a parental mental illness, and need to develop and support strategies to enhance interagency collaboration with other welfare services.

Professional views of supporting relatives of mental health clients with severe mental illness.

BACKGROUND: Supporting families where one person suffers from long-term severe mental illness (SMI) is essential, but seems hard to reach. The aim of this study was to examine professionals' views of supporting relatives of persons with SMI. MATERIAL: Individual interviews mirroring personal narratives and group interviews reflecting group-processed answers were conducted among 23 professionals and analyzed thematically. RESULTS: Three themes emerged: (a) information and group interaction reduces stigma and increases well-being, (b) professionals need to feel secure and confident about how the support structure works and (c) collaboration is difficult but required on several levels. CONCLUSION: Trusting relationships with families were considered important, although seldom achieved; professionals wished to feel secure in their role toward relatives of a person with SMI; and professionals wanted to feel confident when working together with other services to support families.

Personality factors and depression as predictors of hospital-based health care utilization following acute myocardial infarction.

BACKGROUND: Whether personality factors and depressive traits affect patients' utilization of health care following an acute myocardial infarction is relatively unknown. The aim of this study was to examine whether hospital-based health care utilization after a myocardial infarction was correlated with patients' personality factors and depressive symptoms. METHODS: We studied 366 myocardial infarction patients admitted to Malmö University Hospital between 2002 and 2005 who subsequently participated in a cardiac rehabilitation programme. The patients were followed for two years after their index event. We investigated whether personality factors and depressive traits were correlated with the participants' health care utilization, defined as a) out-patient Cardiology visits and phone calls to a physician, nurse or a social worker, and b) acute visits or admissions to the Emergency or Cardiology Departments, using negative binominal regression analysis. RESULTS: In unadjusted comparisons neuroticism predicted more out-patient contacts. This significance remained after adjusting for age, sex, smoking, alcohol consumption and size of the myocardial infarction (measured as max level on troponin-I and left ventricular ejection fraction). There were no significant correlations between other personality factors or depression and out-patient contacts. None of the personality factors or depression predicted acute admissions. CONCLUSION: Apart from neuroticism, personality factors did not explain utilization of health care in terms of Cardiology out-patient contacts or acute admissions in myocardial infarction patients participating in a cardiac rehabilitation programme. Neither did depressive symptoms predict more health care utilization. This might indicate a robust cardiac rehabilitation programme offered to the study subjects, minimizing the need for additional health care contacts.

Emotional, physical, and sexual abuse and the association with symptoms of depression and posttraumatic stress in a multi-ethnic pregnant population in southern Sweden.

OBJECTIVES: This study aims to describe the prevalence of emotional, physical, and sexual abuse and analyze associations with symptoms of depression and posttraumatic stress (PTS) in pregnancy, by ethnic background. STUDY DESIGN: This is a cross-sectional study of the Swedish data from the Bidens cohort study. Ethnicity was categorized as native and non-native Swedish-speakers. Women completed a questionnaire while attending routine antenatal care. The NorVold Abuse Questionnaire (NorAQ) assessed a history of emotional, physical or sexual abuse. The Edinburgh Depression Scale-5 measured symptoms of depression. Symptoms of Posttraumatic Stress (PTS) included intrusion, avoidance and numbness. RESULTS: Of 1003 women, 78.6% were native and 21.4% were non-native Swedish-speakers. Native and non-native Swedish-speakers experienced a similar proportion of lifetime abuse. Moderate emotional and physical abuse in childhood was significantly more common among non-native Swedish-speakers. Sexual abuse in adulthood was significantly more prevalent among native Swedish-speakers. Emotional and sexual abuse were significantly associated with symptoms of depression for both natives and non-natives. Physical abuse was significantly associated with symptoms of depression for non-natives only. All types of abuse were significantly associated with symptoms of PTS for both native and non-native Swedish-speakers. Adding ethnicity to the multiple binary regression analyses did not really alter the association between the different types of abuse and symptoms of depression and PTS. CONCLUSION: The prevalence of lifetime abuse did not differ significantly for native and non-native Swedish-speakers but there were significant differences on a more detailed level. Abuse was associated with symptoms of depression and PTS. Being a non-native Swedish-speaker did not influence the association much.

Living with Diabetes: Experiences of Inner and Outer Sources of Beliefs in Women with Low Socioeconomic Status.

The purpose of this study was to examine the life experiences of nineteen Thai women of low socioeconomic status who were living with type 2 diabetes. A qualitative research design was conducted, and the women were identified by the snowball technique. Data was collected through semi-structured interviews, and processes of induction and abstraction were used for data analysis. The theme "keeping equilibrium of one's mind" involved two sub-themes: experiencing an unpredictable future and being empowered by emerged beliefs. The first sub-theme encompassed worries concerning health and fears of being a burden to one's family. The second sub-theme comprised the experiences of continuing life without being conquered by the disease and believing in the natural law described in Buddhist teachings. These findings revealed that participants could maintain a balance among their concerns through empowerment by inner and outer sources of beliefs, particularly in Buddhist teachings. Despite the vulnerable situations caused by diabetes and low socioeconomic status, the women remained calm, with a consciousness to continue their lives with the disease. The Buddhist views on life, specifically natural law, assisted them to consider life with diabetes as simply a natural course. Buddhism served as a spiritual refuge and helped the women to cope with their psychological burden from diabetes. These findings may reflect the need for health care professionals to provide more holistic care that would assist patients to live with their disease. Buddhist beliefs can be used as a tool to assist Thai patients to empower themselves successfully.

Smoking Cessation After Acute Myocardial Infarction in Relation to Depression and Personality Factors.

BACKGROUND: Smoking is an important cardiovascular risk factor and smoking cessation should be a primary target in secondary prevention after a myocardial infarction (MI). PURPOSE: The purpose of this study was to examine whether personality, coping and depression were related to smoking cessation after an MI. METHOD: MI patients ≤70 years (n = 323, 73 % men, 58.7 ± 8.3 years), participating in the Secondary Prevention and Compliance following Acute Myocardial Infarction study in Malmö, Sweden, between 2002 and 2005, were interviewed by a psychologist to assess coping strategies and completed Beck Depression and NEO Personality Inventories, in close proximity to the acute event. Correlation between smoking status (current, former and never), personality factors, coping and depression was assessed at baseline and 24 months after the MI using logistic regression and in a multivariate analysis, adjusting for age and sex. RESULTS: Of the participating patients, 46 % were current smokers. Two years after the event, 44 % of these were still smoking. At baseline, current smokers scored higher on the depression and neuroticism scales and had lower agreeableness scores. Patients who continued to smoke after 2 years had higher scores on being confrontational (i.e. confrontative coping style) compared to those who had managed to quit. Patients who continued to smoke had significantly lower agreeableness and were more often living alone. CONCLUSION: Personality, coping strategies and psychosocial circumstances are associated with smoking cessation rates in patients with MI. Considering personality factors and coping strategies to better individualise smoking cessation programs in MI patients might be of importance.

Women of low socioeconomic status living with diabetes: Becoming adept at handling a disease.

OBJECTIVE: The objective of this study was to explore how Thai women of low socioeconomic status handle their type 2 diabetes. METHODS: A qualitative interpretative method was used to study 19 women with type 2 diabetes in a suburban community in Thailand. Data were collected via semi-structured interviews and were analysed using inductive and constructive processes. RESULTS: Participants' lives underwent many changes between their initial diagnoses and later stages when they became adept at handling diabetes. Two themes emerged, which involved (1) the transition to handling diabetes and (2) the influences of the social environment. The first theme encompassed confronting the disease, reaching a turning point in the process of adaptation and developing expertise in handling diabetes. The second theme involved threats of loss of status and empowerment by families. These findings showed that becoming adept at handling diabetes required significant changes in women's behaviours and required taking advantage of influences from the social environment. CONCLUSION: The process of developing expertise in handling diabetes was influenced by both inner and outer factors that required adjustment to learn to live with diabetes. Furthermore, the reductions found in women's social statuses when they become patients in the healthcare system might pose a barrier to women of low socioeconomic status becoming adept at handling diabetes. However, the experiences of empowerment received from the women's families acted as a powerful strategy to strengthen their handling of the disease. To develop accessible and sensitive health care for this population, it is important to pay attention to these findings.

Low satisfaction with sex life among people with severe mental illness living in a community.

Research on the sex lives of people with severe mental illness (SMI) most often focuses on dysfunction and the side-effects of medication. We wished to determine how people with SMI experience sex and assess satisfaction with it in a broader evaluation of quality of life. Data were gathered using mixed methods, including a reliable psychometric quality of life instrument, and in-depth interviews. Sex life showed the lowest rating of all quality of life domains, with men indicating lower satisfaction in this area than women. Low satisfaction also correlated with lower scores on the total quality of life index. Sexuality and intimate relations were generally experienced as out of reach or something of secondary importance that had to be controlled, according to many of those suffering from SMI. Programs such as patient disorder-specific or partner assisted interventions, to increase the possibility of sustaining a sex life might need to be added to existing recommendations for people with SMI living in a community.

People living in community with a severe mental illness: utilization and satisfaction with care and support.

The object of this paper was to investigate the experiences of patients with severe mental illness (SMI) living in a community, including their utilization of care and treatment services. Psychiatric care and social services staff members were asked to make an inventory of those they served in two districts of Malmö, Sweden. Participants had to be over 18 years of age and unable to manage their daily lives without help from others. Almost all of the 80 participants (95 %) were under psychiatric care. A majority (86 %) was receiving dental treatment, and 61 % were supported by social services. Fifty-four percent of the participants received somatic care on an ongoing basis. Although the majority reported the care given as sufficient, one-third of this SMI population considered the care and support they received to be insufficient. Satisfying those who are dissatisfied with the care they are being given would be a significant challenge for service providers, since the unsatisfied are shown to have more difficult lives.

"Young women": the meaning of a collaborative program supporting young women's rehabilitation and reintegration into the labor market.

Women are at a higher risk for long-term sick leaves and mental ill health. The aim of this study was to explore a supportive program's meaning for women with anxiety/stress/depression problems that are unemployed and/or on a sick leave, and for the personnel involved. Seven women and the personnel (n = 5) were interviewed individually pre- and post-intervention. Data was analyzed using content analysis. The program appeared to provide participants with tools to handle their physical and mental health, and occupational support, improving their social situation. Collaboration between organizations appears to be beneficial for all parties involved.

Obstacles to the prevention of overweight and obesity in the context of child health care in Sweden.

BACKGROUND: Overweight and obesity in younger children could better be brought in focus through a deeper understanding of how Child Health Care nurses (CHC-nurses) perceive their work with the problems of overweight at the CHC Centers. The aim of this study was to elucidate the CHC-nurses conceptions of their preventive work with childhood overweight and obesity in Child Health Care. METHOD: A qualitative study, based on open-ended interviews, involving 18 CHC-nurses strategically selected from 17 CHC Centres in the southern part of Sweden using a phenomenographic approach. RESULTS: Two categories of description emerged from the data: (i) Internal obstacles to the CHC- nurses' work with overweight in children and (ii) External obstacles to the management of overweight in children. The CHC-nurses conceived their work with overweight in Child Health Care to be complicated and constrained by several obstacles depending on the nurses' personal priorities, knowledge, responsibility and the absence of resources and cooperation, as well as the lack of uniform guidelines for preventing and managing childhood overweight and further a deficient management organisation. CONCLUSION: Nurses' attention to monitoring overweight in children, and their initiative for prevention, is based on their conceptions of the obstacles that hinder them in their efforts. An increased awareness of the CHC-nurses conceptions of the priorities, their sense of responsibility and prevention practices is warranted. If measures in this direction are not taken there is a growing risk that overweight children will pass through the CHC without any formal recognition of their situation. There is an indication that the present level of the CHC-nurses' preventive work with childhood overweight has room for improvement in several areas. It is suggested that the specialist education of these health care professionals should be supplemented and that organisation of the management of childhood overweight should be also revised at the primary health care level.

Schizophrenia and relationships: the effect of mental illness on sexuality.

This paper seeks to investigate the impact of mental illness on the sexuality of patients with a schizophrenic disorder who live in the community in a long-term relationship with a partner. We conducted qualitative, in-depth interviews with five such patients who were in treatment at a psychiatric outpatient clinic, and three of their partners. The data were analyzed by thematic analysis and identified the following areas of concern: relationships outweigh sexuality; uncertainties about one's sexual capacity; the dwindling of sexual fantasies, feelings of desire, and satisfaction; and, a lack of communication and support in sexual matters. Both patients and partners reported feeling overlooked by psychiatric services as sexual beings. They also expressed dissatisfaction with a patient-therapist treatment model that excluded their partners. Our findings indicate that dysfunctional sexuality affects both patients suffering from severe mental illness and their partners. Patients and partners deplore the lack of opportunity to discuss questions related to their sexuality and long-term relationships with psychiatric clinicians. Sexual problems arising from, or exacerbated by, schizophrenia require supportive services, whether in the form of general, psychiatric, or couples therapy.

Central venous oxygen saturation during cardiopulmonary bypass predicts 3-year survival.

OBJECTIVES: Long-term survival after cardiac surgery is determined by a number of different risk factors. Central venous oxygen saturation (S(v)O(2)) measures the balance between oxygen delivery and demand. S(v)O(2) levels in the intensive care situation are reported to be associated with patient outcome. The present report explores the connection between S(v)O(2) during cardiopulmonary bypass (CPB) and survival after cardiac surgery. METHODS: Retrospective analysis of one thousand consecutive cardiac surgical patients was undertaken. S(v)O(2) during CPB was monitored online. Registry data combining specific risk factors with S(v)O(2) were selected for Kaplan-Meier and Cox regression analysis to examine the influence on 30-day and 3-year survivals. RESULTS: Nine-hundred and thirty-two patient records were eligible for analysis. S(v)O(2) below 75% during CPB was associated with significantly shorter 30-day and 3-year survivals. Based on Kaplan-Meier statistics, the survival rate decreased by 3.1% (98.1-95.0), P = 0.011 and 6.1% (92.7-86.6), P = 0.003, respectively. The influence of S(v)O(2) on 3-year survival remained statistically significant after controlling for a series of risk factors in the Cox regression analysis. Patients with S(v)O(2) <75% carried a 2-fold (odds ratio 2.1) increased relative risk of shortened 3-year survival (P = 0.003). Other risk factors statistically significantly associated with 3-year survival were age, gender, duration of CPB, blood temperature, hypertension, haematocrit and type of surgical procedure. CONCLUSIONS: We report decreased 30-day and 3-year survival expectancy for patients experiencing S(v)O(2) lower than 75% during CPB.

Mental health status in pregnancy among native and non-native Swedish-speaking women: a Bidens study.

OBJECTIVES: To describe mental health status in native and non-native Swedish-speaking pregnant women and explore risk factors of depression and posttraumatic stress (PTS) symptoms. DESIGN AND SETTING: A cross-sectional questionnaire study was conducted at midwife-based antenatal clinics in Southern Sweden. SAMPLE: A non-selected group of women in mid-pregnancy. METHODS: Participants completed a questionnaire covering background characteristics, social support, life events, mental health variables and the short Edinburgh Depression Scale. MAIN OUTCOME MEASURES: Depressive symptoms during the past week and PTS symptoms during the past year. RESULTS: Out of 1003 women, 21.4% reported another language than Swedish as their mother tongue and were defined as non-native. These women were more likely to be younger, have fewer years of education, potential financial problems, and lack of social support. More non-native speakers self-reported depressive, PTS, anxiety and, psychosomatic symptoms, and fewer had had consultations with a psychiatrist or psychologist. Of all women, 13.8% had depressive symptoms defined by Edinburgh Depression Scale 7 or above. Non-native status was associated with statistically increased risks of depressive symptoms and having ≥1 PTS symptom compared with native-speaking women. Multivariate modeling including all selected factors resulted in adjusted odds ratios for depressive symptoms of 1.75 (95% confidence interval: 1.11-2.76) and of 1.56 (95% confidence interval: 1.10-2.34) for PTS symptoms in non-native Swedish speakers. CONCLUSION: Non-native Swedish-speaking women had a more unfavorable mental health status than native speakers. In spite of this, non-native speaking women had sought less mental health care.

Swedish Child Health Care nurses conceptions of overweight in children: a qualitative study.

BACKGROUND: Registered Sick Children's Nurses and District Nurses employed at Child Health Care centres are in a position to help prevent childhood overweight and obesity. Prevention of this challenging public health threat could be improved through having a better understanding of how this group of nurses perceives childhood obesity. The aim of this study was to elucidate the conceptions of childhood overweight, including obesity, among nurses working in Child Health Care. METHOD: A qualitative study using a phenomenographic approach, based on open-ended interviews with 18 Child Health Care nurses (CHC-nurses) strategically selected from 17 Child Health Care Centres in the southern part of Sweden. RESULTS: Four categories of description emerged from the data: Perception of childhood overweight changes, Overweight in younger children a neglected concern, Overweight a delicate issue and Importance of family lifestyle. The participating CHC-nurses conceived overweight in children, primarily obesity in children to be an extensive and serious problem which affects children, families and the surrounding society. Overweight in children was further perceived as a consequence of their parent's lifestyle and their awareness of the problem, which was considered by the CHC-nurses as a sensitive and a provoking issue. It was also perceived that overweight in children is not taken seriously during the pre-school period and that concerns regarding overweight in younger children were mainly about the appearance and not the health of the child. The CHC-nurses perceived that the proportion of overweight children has increased, which Swedish society and the CHC-nurses have adapted to. This adaptation makes it difficult for CHC-nurses to define those children who are overweight. CONCLUSION: CHC-nurses provide a comprehensive and complex picture of childhood overweight, which includes several difficulties dealing with this issue. Attention to CHC-nurse's conceptions of overweight in children is important since it can affect the parent-nurse relationship and thereby the nurse's, as well as the parent's efforts to influence the children's weight. It is suggested that CHC- nurses should work with person centered counseling and empowerment concerning parent to child relations in cases involving overweight.

Lost in interpretation: the use of interpreters in research on mental ill health.

BACKGROUND: The literature concerning interpretation in research primarily concentrates on rigorous techniques to eliminate bias. This article analyses other significant issues that arise when interpreters participate in research. MATERIAL: Empirical examples are drawn from a research project concerning mental ill health in a multicultural neighbourhood. DISCUSSION: Interpreters influence interview data in ways commonly unnoticed by researchers. One often-overlooked factor is that languages are dynamic and interpreters are not instruments. CONCLUSION: Research conducted with an interpreter is a complex undertaking. Solely relying on checklists to improve methodological rigour can result in a false sense of the material's validity.