Evaluation of health services and treatment alliance among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project.

BACKGROUND: Extensive psychiatric hospitalization due to repeated severe self-harm (SH), is a poorly researched area, but a challenge within health services (HS). Recent studies have demonstrated high levels of involuntary treatment among patients with severe personality disorder (PD) and complex comorbidity. Keeping focus on extensively hospitalized SH patients, this study aimed to investigate patients' and clinicians' evaluation of HS and treatment alliance. METHOD: A cross-sectional study with an inpatient sample (age >18 years) with frequent (>5) or long (>4 weeks) psychiatric hospital admissions last year due to SH or SA recruited from 12 hospitals across health regions (N = 42). Evaluation included patient and clinician report. RESULTS: A minority of the patients (14%) were satisfied with HS before the current admission, 45% (patients) and 20% (clinicians) found the current admission helpful, and 46% (patients) and 14% (clinicians) worried about discharge. Treatment complaints were received in 38% of the cases. Outpatient mental HS were available after discharge for 68% and a majority of clinicians indicated satisfactory contact across HS. More intensive or specialized formats were unusual (structured outpatient treatment 35%, day treatment 21%, ambulatory services 32%, planned inpatient services 31%). Mutual problem understanding, aims, and confidence in therapists during the hospital stay were limited (patient-rated satisfactory mutual problem understanding: 39%, aims of stay: 50%, confidence: 50%). Patient and therapist alliance-ratings were in concordance for the majority. CONCLUSION: The study highlights poor HS satisfaction, poor patient-therapist coherence, limited treatment alliance and limited follow-up in structured treatments addressing SH or intermediary supportive ambulatory/day/inpatient services.

Schizophrenia in Autistic People with Intellectual Disabilities. Treatment and Interventions.

Autistic people with intellectual disabilities appear to be at increased risk of schizophrenia. While current recommendations emphasize adapting interventions used for people with schizophrenia in general, few studies to date have investigated treatment of co-occurring schizophrenia in this specific population. To explore what interventions are provided to autistic people with intellectual disabilities and co-occurring schizophrenia in specialized mental health services, and to investigate whether changes in mental health symptoms and challenging behavior occurred during treatment. Using data from a longitudinal, national multicenter study, interventions provided to 26 autistic individuals with intellectual disabilities and co-occurring schizophrenia were explored. Symptoms were measured using the Psychopathology in Autism Checklist (PAC) and the Aberrant Behavior Checklist ABC) at referral (T1), at the end of treatment (T2), and at follow-up 12 months after T2 (T3). A broad range of interventions were provided to the participants, including inpatient admission, psychopharmacological treatment, various psychosocial interventions, and supportive interventions. Scores on the PAC and ABC were significantly lower at T2 than T1 for most scales, and no significant change was found from T2 to T3.Treatment of co-occurring schizophrenia appears feasible and effective in autistic people with intellectual disabilities.

Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project.

Background: Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited. Objectives: To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors. Method: A cross sectional study (period 2019-2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report. Results: The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life - greater impairment than the outpatient comparison sample. Conclusion: The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.

Schizophrenia in autistic people with intellectual disabilities: Symptom manifestations and identification.

BACKGROUND: The assessment of schizophrenia in autistic people with intellectual disabilities is challenging. This study aimed to explore the identification of schizophrenia in this population. METHODS: Using data from a clinical multi-centre study, reported symptoms in 26 autistic individuals with intellectual disabilities diagnosed with co-occurring schizophrenia were explored. Scores on two checklists (Psychopathology in Autism Checklist [PAC], Aberrant Behaviour Checklist [ABC]) were compared with two comparison groups: autistic individuals with intellectual disabilities and other mental disorders (94), or no mental disorder (63). RESULTS: Reported symptoms of schizophrenia in this population met the formal diagnostic criteria. For PAC/ABC scales, only PAC psychosis differed for the schizophrenia group. Among participants with schizophrenia, two were diagnosed with additional mental disorders. Elevated scores for anxiety and depression were common. CONCLUSIONS: Emphasising core symptoms seems necessary when assessing co-occurring schizophrenia in autistic people with intellectual disabilities. The PAC may serve as a helpful screening tool.

Exploring the predictive properties of the Hayes Ability Screening Index subtest background information in identifying individuals with MBID among in-patients with SUD.

Introduction: For individuals with substance use disorder (SUD), mild to borderline intellectual disability (MBID) goes undetected in treatment clinics. The Hayes Ability Screening Index (HASI) has been found to be a valid, time-saving screening instrument for MBID in SUD treatment. MBID can have significant implications for treatment planning and outcomes. Therefore, it is important to have methods for the early recognition of these comorbid conditions. Because of less sensitivity to recent or ongoing substance use, the HASI subtest background information may be particularly valuable as an early screening of MBID. The main aim was to investigate the convergent, predictive, and discriminant validity of the HASI subtest background information in identifying in-patients with SUD as MBID or non-MBID. Methods: Eighty-four in-patients with SUD aged 19-64 participated in this multicentre study. MBID was diagnosed according to the ICD-10 using WAIS-IV, Vineland II, and self-reported childhood learning difficulties. Results: The main finding was that, among the HASI subtests, background information was the strongest predictor. A HASI background information cut between 6 and 7 showed a sensitivity of 78% and a specificity of 72%. Conclusion: The HASI subtest background information has acceptable convergent, predictive, and discriminant validity as a screening for MBID among in-patients in SUD treatment.

Psychometric properties of the Psychopathology in Autism Checklist (PAC).

Psychiatric disorders in individuals with co-occurring autism spectrum disorders (ASD) and intellectual disability (ID) are common, but diagnosis presents many challenges. The Psychopathology in Autism checklist (PAC) is among the very few instruments specifically developed for this group of individuals. The psychometric properties of the PAC (i.e. criterion validity, specificity, sensitivity and predictive values) were explored by comparing scores with assessments on the Aberrant Behavior Checklist (ABC) and examining how well assessment by the PAC at referral predicts final clinical diagnoses. Results indicated a significant correlation with the ABC, further supporting the validity of the PAC. Sensitivity and Specificity for specific diagnoses were variable, although positive predictive value for "any diagnosis' was relatively high. The study confirms the potential value of the PAC as a screening checklist but highlights the need for clinical diagnosis to be based on a multimodal, multidisciplinary assessment.

"People just don't understand their role in it." Collaboration and coordination of care for service users with complex and severe mental health problems.

PURPOSE: To explore professionals' and service users' experiences and perceptions of interprofessional collaboration and coordination for service users with complex and severe mental health issues. DESIGN AND METHODS: A qualitative study involving semi-structured interviews of professionals and individual interviews of service users. Data were analyzed by thematic analysis. FINDINGS: Participants described challenges and suggested improvements concerning Distribution of roles, responsibilities, and tasks; Communication; and Knowledge and attitudes. PRACTICE IMPLICATIONS: Mental health nurses and other professional helpers should have a particular focus on common aims, clear division of roles, planning and timing of interventions, and communication with other professionals and service users.

Prevalence of drug use among adults with intellectual disabilities compared with drug use in the general population.

PURPOSE: Individuals with intellectual disabilities (IDs) have more health problems, a poorer general health, and a shorter life expectancy than individuals in general. High rates of drug use in IDs have been reported. Despite the increasing interest in health problems in individuals with IDs, little is known about their drug use. METHOD: Drug use in a community sample of adults with IDs (N = 593) was compared with dispensed drugs in a time-, age-, and region-matched comparison group of adults in Western Norway (N = 289 325). A logistic regression model was employed by using the main group effect to describe and analyze the differences between the ID sample and the comparison sample and by using the interaction term (group × age) to describe the rate change differences from the reference age (18-30 years) between the two groups. RESULTS: Total drug use in the ID sample was 62% compared with 50% in the reference sample (P = 0.0001). The high prevalence of drugs for the nervous system (ATC N) in the ID sample (50%) explained the difference. From age 51 and over, the increase in the drug use rate for the cardiovascular disease was significantly lower in the ID sample than in the reference sample (P value range: 0.002-0.019). CONCLUSIONS: Adults with IDs use more drugs than adults in general. However, the findings showed lower rates of drug use in the ID sample than in the general population for drugs targeting diseases that are the leading causes of death in individuals with IDs.

Screening for intellectual disabilities: a validation of the Hayes Ability Screening Index for in-patients with substance use disorder.

BACKGROUND: There is a reason to believe that many individuals with substance use disorder (SUD) in contact with services have an undiagnosed intellectual disability (ID). Assessing ID in persons with SUD can be challenging due to the influence of substances, time consumption, and specific requirements for the education of the assessor. On the other hand, an undiagnosed condition may lead to a lack of treatment adjustment and may result in drop-out from treatment or lack of treatment effect. There is a need for a time-saving, valid instrument to detect possible ID among people with SUD. AIMS: To validate the Hayes Ability Screening Index (HASI) as a screening instrument for identifying ID in a population of in-patients with SUD using all three ICD-10/DSM5 criteria in classifying ID as the validation criterion. METHODS: Eighty-four SUD in-patients aged 19-64 participated in this multicenter study. An ID was diagnosed according to the ICD-10 using WAIS-IV, Vineland II, and self-reported childhood learning difficulties. RESULTS: HASI correlated well with both the WAIS-IV and Vineland II. At the recommended cut-off score, the HASI had a sensitivity of 100% and a specificity of 65.4%. A large number of the false positives had IQ or both IQ and adaptive scores in the borderline range. CONCLUSIONS: The HASI has good convergent, discriminant, and overall construct validity in detecting ID in in-patients with SUD.

Intellectual Functioning in In-Patients with Substance Use Disorders: Preliminary Results from a Clinical Mediation Study of Factors Contributing to IQ Variance.

AIMS: To investigate the direct effect of different childhood difficulties on adult intelligence coefficient (IQ) and their possible indirect effect through the mediating pathways of education and severity substance use. PARTICIPANTS: Ninety in-patients aged 19-64. The participants had abstained from substance use for at least 6 weeks and had different substance use profiles. MEASUREMENTS: Substance use disorder (SUD) and psychiatric illnesses were diagnosed according to the International Classification of Diseases 10th edition criteria. IQ was measured with the Wechsler Adult Intelligence Scale, 4th edition. Childhood difficulties, severity of substance use and level of education were assessed through a self-report questionnaire. FINDINGS: Mean full scale IQ for the studied population was 87.3. Learning and attention deficit/hyperactivity difficulties in childhood were directly related to adult IQ. Education had a mediating effect between childhood learning difficulties/conduct problems and the verbal comprehension index. There was no significant difference in IQ due to the specific substance used or severity of substance use. CONCLUSION: IQ variance in in-treatment individuals with SUD was related to childhood functioning alone or through the mediator of education. Substance-related factors did not contribute to IQ variance. The results fit a normal theory of IQ development with commonly known risk factors and no disturbing effect of substance use.

Type and Intensity of Negative Life Events Are Associated With Depression in Adults With Intellectual Disabilities.

This study investigated the associations between types and intensity of life events and symptoms of depression among adults with intellectual disabilities. A community sample (N = 593) was screened for current depression and exposure to life events (i.e., loss, illness, change, and bullying) during the previous 12 months. Symptoms of depression were measured using the Psychopathology Checklists for Adults With Intellectual Disabilities. Exposure to three of the four types of life events studied (loss, illness, and bullying) and the intensity of the events were associated with depression, particularly in the cases of loss of relatives and bullying. Quality of care moderated the association between bullying and depression and may buffer the adverse consequences of bullying.

Parents' Prenatal Mental Health and Emotional, Behavioral and Social Development in Their Children.

This study examines the association between expectant parents' psychological distress and children's development at 36 months old. This is a prospective population study based on the Norwegian Mother and Child Cohort Study, N = 31,663. Logistic regression models were used to assess whether high scores (cutoff ≥ 2.00) on the symptom checklist-5 in parents predicted higher levels (cutoff ≥ 90 percentile) of developmental problems in their children. The risk of emotional and behavioral problems were significantly increased in children when both parents were affected by psychological distress during pregnancy, fully adjusted OR 2.35 (95% CI 1.36, 4.07) and OR 2.65 (96% CI 1.564.48), respectively. The risk was higher when mothers reported high level of psychological distress than when only the fathers did, but the risk of emotional difficulties in children was highest when both parents presented high levels of psychological distress, indicating an additive effect of parental psychological distress.

Does paternal mental health in pregnancy predict physically aggressive behavior in children?

The aim was to study the association between paternal mental health and physically aggressive behavior in children. This study is based on 19,580 father-child dyads from the Norwegian Mother and Child Cohort Study (MoBa). Fathers' mental health was assessed by self-report (Symptom Checklist-5, SCL-5) in week 17 or 18 of gestation. Children's behavior (hitting others) was obtained by mothers' reports. A multinomial logistic regression model was performed. Expectant fathers' high level of psychological distress was found to be a significant risk factor only for girls hitting, adjusted OR = 1.46 (1.01-2.12), p = 0.043, but not for boys. High levels of mental distress in fathers predict their daughters' hitting at 5 years of age.

Paternal mental health and socioemotional and behavioral development in their children.

OBJECTIVE: To examine the association between symptoms of psychological distress in expectant fathers and socioemotional and behavioral outcomes in their children at age 36 months. METHODS: The current study is based on data from the Norwegian Mother and Child Cohort Study on 31 663 children. Information about fathers' mental health was obtained by self-report (Hopkins Symptom Checklist) in week 17 or 18 of gestation. Information about mothers' pre- and postnatal mental health and children's socioemotional and behavioral development at 36 months of age was obtained from parent-report questionnaires. Linear multiple regression and logistic regression models were performed while controlling for demographics, lifestyle variables, and mothers' mental health. RESULTS: Three percent of the fathers had high levels of psychological distress. Using linear regression models, we found a small positive association between fathers' psychological distress and children's behavioral difficulties, B = 0.19 (95% confidence interval [CI] = 0.15-0.23); emotional difficulties, B = 0.22 (95% CI = 0.18-0.26); and social functioning, B = 0.12 (95% CI = 0.07-0.16). The associations did not change when adjusted for relevant confounders. Children whose fathers had high levels of psychological distress had higher levels of emotional and behavioral problems. CONCLUSIONS: This study suggests that some risk of future child emotional, behavioral, and social problems can be identified during pregnancy. The findings are of importance for clinicians and policy makers in their planning of health care in the perinatal period because this represents a significant opportunity for preventive intervention.

Quality of life among patients undergoing bariatric surgery: associations with mental health- A 1 year follow-up study of bariatric surgery patients.

BACKGROUND: Preoperative mental health seems to have useful predictive value for Health Related Quality of Life (HRQOL) after bariatric surgery. The aim of the present study was to assess pre- and postoperative psychiatric disorders and their associations with pre- and postoperative HRQOL. METHOD: Data were assessed before (n = 127) and one year after surgery (n = 87). Psychiatric disorders were assessed by Mini International Neuropsychiatric Interview (M.I.N.I.) and Structured Clinical Interview (SCID-II). HRQOL was assessed by the Short Form 36 (SF-36) questionnaire. RESULTS: Significant improvements were found in HRQOL from preoperative assessment to follow-up one year after surgery. For the total study population, the degree of improvement was statistically significant (p values < .001) for seven of the eight SF-36 subscales from preoperative assessment to follow-up one year after surgery. Patients without psychiatric disorders had no impairments in postoperative HRQOL, and patients with psychiatric disorders that resolved after surgery had small impairments on two of the eight SF-36 subscales compared to the population norm (all effect sizes < .5) at follow-up one year after surgery. Patients with psychiatric disorders that persisted after surgery had impaired HRQOL at follow-up one year after surgery compared to the population norm, with effect sizes for the differences from moderate to large (all effect sizes ≥ .6). CONCLUSION: This study reports the novel finding that patients without postoperative psychiatric disorders achieved a HRQOL comparable to the general population one year after bariatric surgery; while patients with postoperative psychiatric disorders did not reach the HRQOL level of the general population. Our results support monitoring patients with psychiatric disorders persisting after surgery for suboptimal improvements in quality of life after bariatric surgery. TRIAL REGISTRATION: The trial is registered at http://www.clinicaltrials.gov prior to patient inclusion (ProtocolID16280).

[A young man with acute, generalised oedema]. / En ung mann med akutte generaliserte ødemer.

BACKGROUND: Ménétrier disease is an uncommon, idiopathic disease characterized by development of chronic protein loss from marked gastric foveolar hyperplasia. A literature search identified several reports of self-limiting, cytomegalovirus-associated Ménétrier disease in children. Some cases have also been reported in adults. CASE REPORT: A formerly healthy man was admitted to hospital with a serum albumin level of 11 g/l and generalised oedema. Transabdominal ultrasound and endoscopy revealed a folded thickening of the (abdominal) ventricular wall; indications of Ménétrier disease. Histological examination of endoscopic biopsies showed moderate hyperplasia in foveolar epithelium, but also suggested an infectious cause. Intranucleal inclusion bodies, CMV-specific immunology, PCR and special stains all supported cytomegalovirus infection. The patient recovered quickly on antiviral treatment. CONCLUSION: Our case demonstrates that cytomegalovirus may cause severe, Ménétrier-like gastritis with protein loss in non-immune-compromised adults.

Developmental level and other factors associated with symptoms of mental disorders and problem behaviour in adults with intellectual disabilities living in the community.

BACKGROUND: Studies of the relationship between the level of intellectual disability and mental and behavioural disorders have reported divergent findings regarding the direction of the relationship and how it is related to different mental disorders. AIMS: To investigate the relationship between levels of intellectual disability and mental disorders and problem behaviour after adjusting for other relevant factors: age, gender, autism, genetic syndromes, the neurological conditions cerebral palsy and epilepsy, negative life events and quality of the social care provided. METHODS: A community sample of adults with intellectual disabilities (N = 593) were assessed using the Psychopathology Checklists for Adults with Intellectual Disability. A hierarchical regression model with forced entry was employed. RESULTS: Both linear and curvilinear relationships between intellectual disability and mental disorders were found after controlling for relevant factors that was independently associated with specific mental disorders. CONCLUSIONS: Psychopathology models for adults with intellectual disabilities should include the level of intellectual disability, either in a linear or a non-linear way. Future research on this issue should focus on people with borderline intellectual disability.

Psychometric properties of Psychopathology checklists for Adults with Intellectual Disability (P-AID) on a community sample of adults with intellectual disability.

The DC-LD is a new classification system providing operationalized diagnostic criteria in recognition of lacking applicability of standard psychiatric criteria for adults with intellectual disability. This study attempts to evaluate internal consistency, inter-rater reliability and factor structure of the Psychopathology Checklists for Adults with Intellectual Disability (P-AID), a set of checklists developed from the DC-LD. The P-AID checklists comprising 10 psychiatric diagnoses and 8 types of problem behaviors were filled in by staff at community based homes for adults with intellectual disability in Western Norway. A total of 593 were returned (66%) of which 83 had two sets of checklists. Intellectual disability was administratively defined. Alpha (alpha) values for the total P-AID checklists indicating high internal consistency. The inter-rater reliability measured by ICC showed values between 0.63 and 0.88 in 8 of 10 psychopathology Checklists. Factor analysis indicated four orthogonal units measured by the P-AID. Issues regarding sensitivity and specificity are discussed. This study is the first attempt to develop and evaluate Psychopathology Checklists based on the DC-LD. The results from this study indicate the P-AID can be used in identifying mental health needs at a detailed diagnostic level.