Temporal patterns in adolescent psychiatric treatment and outcomes: a nationwide register-based cohort follow-up.

The rise in mental health problems among adolescents in high-income countries presents a challenge to service systems. For the development of services, there is a need for better insight into temporal psychiatric treatment-trends and outcomes. This study aims to analyze time-trends in both psychiatric treatment patterns and outcomes, utilizing a national sample of all adolescents receiving psychiatric treatment in Finland from 2003 to 2013. For time-trend-analysis, the sample was divided into two cohorts, using the onset year of 2008 as a cutoff. For each case, information on psychiatric treatment was gathered from registers within a five-year follow-up period from the onset of treatment or to death. The association between the inclusion year and outcome variables was studied via weighted generalized linear models. Adolescents in the latter cohort had a greater proportion (p < 0.001) of mood and anxiety diagnoses, a lower likelihood of hospitalization, a higher average of outpatient visits, and greater usage of psychotropics (excluding benzodiazepines). Those whose treatment began after 2008 were more likely to be alive (baseline characteristic adjusted Odds Ratio (aOR): 0.7, 95%CI: 0.6-0.8) and still in treatment contact (aOR: 1.4, 95%CI: 1.3-1.4) after four years from the onset. There was no difference in the long-term disability ratio. The results indicate favorable developments towards outpatient care in mental health services for adolescents with a significant decrease in mortality. Approaches to further developing cost-effective, personalized mental health services are discussed.

Open Dialogue services around the world: a scoping survey exploring organizational characteristics in the implementation of the Open Dialogue approach in mental health services.

Objective: This cross-sectional study investigates the characteristics and practices of mental health care services implementing Open Dialogue (OD) globally. Methods: A structured questionnaire including a self-assessment scale to measure teams' adherence to Open Dialogue principles was developed. Data were collected from OD teams in various countries. Confirmatory Composite Analysis was employed to assess the validity and reliability of the OD self-assessment measurement. Partial Least Square multiple regression analysis was used to explore characteristics and practices which represent facilitating and hindering factors in OD implementation. Results: The survey revealed steady growth in the number of OD services worldwide, with 142 teams across 24 countries by 2022, primarily located in Europe. Referrals predominantly came from general practitioners, hospitals, and self-referrals. A wide range of diagnostic profiles was treated with OD, with psychotic disorders being the most common. OD teams comprised professionals from diverse backgrounds with varying levels of OD training. Factors positively associated with OD self-assessment included a high percentage of staff with OD training, periodic supervisions, research capacity, multi-professional teams, self-referrals, outpatient services, younger client groups, and the involvement of experts by experience in periodic supervision. Conclusion: The findings provide valuable insights into the characteristics and practices of OD teams globally, highlighting the need for increased training opportunities, supervision, and research engagement. Future research should follow the development of OD implementation over time, complement self-assessment with rigorous observations and external evaluations, focus on involving different stakeholders in the OD-self-assessment and investigate the long-term outcomes of OD in different contexts.

Out-of-home interventions for adolescents who were treated according to the Open Dialogue model for mental health care.

BACKGROUND: The Open Dialogue approach (OD) emphasizes community-based psychiatric treatment for adolescents, but its success in achieving this is poorly documented. OBJECTIVE: To analyse out-of-home intervention usage in a national sample of adolescent psychiatric patients and determine if OD is linked to increased time until out-of-home intervention. PARTICIPANTS AND SETTING: The register-based cohort study included all adolescents aged 13-20 who received psychiatric treatment in Finland between 2003 and 2008. The research group (n = 780) included adolescents whose treatment was initiated in the Western Lapland catchment area, where OD covered the entire psychiatric service. The comparison group (n = 44,088) included the rest of Finland. National register data encompassed the period from treatment onset until the end of the 10-year follow-up or death. The primary outcomes of interest were the times to the first and second out-of-home intervention, including foster care, supportive housing, and hospitalization. The secondary outcomes included the clinical/demographic characteristics of adolescents treated out-of-home. METHODS: The hypothesis was tested via an inverse probability of treatment-weighted Cox hazard model, plus within- and between-group comparisons to analyse the secondary outcome. RESULTS: OD was associated with increased time to the first (adjusted hazard ratio [aHR]: 0.61, 95%CI: 0.52-0.72) and second (aHR: 0.75, 95%CI: 0.58-0.96) out-of-home interventions. In both service types, there was a subgroup of adolescents with repeated out-of-home interventions, who also demonstrated poorer long-term outcomes. CONCLUSION: OD-based psychiatric services for adolescents are associated with fewer out-of-home interventions. The clinical significance of the findings warrants further research.

A 5-Year Suicide Rate of Adolescents Who Enrolled to an Open Dialogue-Based Services: A Nationwide Longitudinal Register-Based Comparison.

In the Open Dialogue (OD) based psychiatric services adolescent patients receive less medication and are more often treated within an outpatient setting as compared to standard services. An evaluation of the possible risks of implementing OD are required. The aim of this longitudinal register-based study was to evaluate how treatment under OD is associated with the probability of suicide as compared standard psychiatric care. Study included all 13- to 20-year-old adolescents who enrolled to a psychiatric service in Finland in 2003-2013. The OD-group included adolescents whose treatment commenced in the Western Lapland area (n = 2107), this being the only region where OD covered all psychiatric services. The comparison group (CG) included rest of Finland (n = 121,658). Information was gathered from onset of treatment to the end of the 5-year follow-up or death. In a multivariate Cox regression there were no statistically significant differences in 5-year suicide hazard ratios between OD and CG.

The Association of Antipsychotic Postponement With 5-Year Outcomes of Adolescent First-Episode Psychosis.

Background and Hypothesis: Based on the need-adapted approach, delaying antipsychotics could help identify first-episode psychosis (FEP) adolescents who might not require them. However, some individuals might need antipsychotics, and postponing could harm their prognosis. This nationwide register-based follow-up aimed to test these two hypotheses. Study Design: All adolescents aged 13-20 with a psychotic disorder (ICD-10 codes: F20-F29) in Finland between 2003 and 2013 were identified (n = 6354) from national registers. For each case, a fixed 1825-day follow-up period was established from the onset of psychosis or until death. The outcome was considered "good" if adolescents did not die and had not received psychiatric treatment and/or disability allowances during the final year of follow-up. Testing the first hypothesis involved all antipsychotic treatment-naïve adolescents with FEP (n = 3714). The second hypothesis was tested with a sub-sample of only those who had received antipsychotics during follow-up (n = 3258). To account for baseline confounders, hypotheses were tested via a stabilized inverse probability of treatment weighted generalized linear models with logit link function. Study Results: Immediate antipsychotic treatment after the onset of psychosis was associated with poor 5-year outcome (adjusted odds ratio [aOR]: 1.8, 95% CI: 1.6-2.1). There was no statistically significant association between antipsychotic postponement and treatment outcome in those who eventually received antipsychotic treatment (aOR: 1.02, 95% CI: 0.7-1.2, P: .8), thus not providing support for second hypothesis. Conclusions: There is a significant subgroup of adolescent with psychosis who do not require immediate antipsychotic treatment. A more robust design is needed to evaluate the causality of the observed association.

The 10-year treatment outcome of open dialogue-based psychiatric services for adolescents: A nationwide longitudinal register-based study.

AIM: To evaluate the 10-year treatment outcomes and cost-effectiveness of adolescents' mental health treatment initiated under the social network-oriented open dialogue (OD) approach. METHODS: This longitudinal register-based study included all persons who, for the first time, received psychiatric treatment in Finland during the period 1 January 2003-31 December 2008, and who were aged 13-20 at onset (n = 44 868). The OD group included all persons whose treatment commenced in the Western Lapland catchment area (n = 780), this being the only region in Finland where OD covered the entire mental healthcare service at the time of inclusion. The comparison group (CG) included the rest of Finland (n = 44 088). The primary outcome variables were psychiatric treatment and/or disability allowances at the end of the 10-year follow-up, or death. The secondary outcome variables were treatment and disability expenses. Generalized linear models weighted by inverse probability of treatment were used to study the association between OD and the primary outcomes. Population proportions were used to evaluate the cost-effectiveness of the approaches. RESULTS: Treatment that commenced outside OD was associated with higher odds of continuing to receive treatment (adjusted odds ratio [aOR] 1.4; 95%CI 1.2-1.6) and disability allowances (aOR 1.6; 95%CI 1.2-2.1) at the end of the 10-year follow-up. No significant difference in the mortality ratio emerged. The cumulative 10-year expenses per capita were lower under OD. CONCLUSIONS: OD associated with favourable long-term outcomes, but due the observational design and possible residual confounding, further studies with a more robust research design are required.

Retrospective Experiences of First-Episode Psychosis Treatment Under Open Dialogue-Based Services: A Qualitative Study.

Open Dialogue (OD) is an integrated approach to mental health care, which has demonstrated promising outcomes in the treatment of first-episode psychosis (FEP) in Finnish Western Lapland region. However, little is known how treatment under OD is retrospectively experienced by the service users themselves. To address this, twenty participants from the original Western Lapland research cohort diagnosed with psychosis (F20-F29) were asked about their treatment of FEP, initiated under OD 10-23 years previously. Thematic analysis was used to explore how the treatment was experienced. Most participants viewed network treatment meetings as an important part of their treatment, as they enabled interactions with other people and the chance to go through difficult experiences. A minority of the participants had mixed experiences regarding family involvement and immediate home visits. OD may have the potential to promote therapeutic relationships, but replications from other catchment areas are needed.

Dialogue as a Response to the Psychiatrization of Society? Potentials of the Open Dialogue Approach.

In recent decades, the use of psychosocial and psychiatric care systems has increased worldwide. A recent article proposed the concept of psychiatrization as an explanatory framework, describing multiple processes responsible for the spread of psychiatric concepts and forms of treatment. This article aims to explore the potentials of the Open Dialogue (OD) approach for engaging in less psychiatrizing forms of psychosocial support. While OD may not be an all-encompassing solution to de-psychiatrization, this paper refers to previous research showing that OD has the potential to 1) limit the use of neuroleptics, 2), reduce the incidences of mental health problems and 3) decrease the use of psychiatric services. It substantiates these potentials to de-psychiatrize psychosocial support by exploring the OD's internal logic, its use of language, its processes of meaning-making, its notion of professionalism, its promotion of dialogue and how OD is set up structurally. The conclusion touches upon the dangers of co-optation, formalization and universalization of the OD approach and stresses the need for more societal, layperson competencies in dealing with psychosocial crises.

Open Dialogue as a Human Rights-Aligned Approach.

Throughout the last 20 years, the human rights perspective has increasingly developed into a paradigm against which to appraise and evaluate mental health care. This article investigates to what extent the Finnish open dialogue (OD) approach both aligns with human rights and may be qualified to strengthen compliance with human rights perspectives in global mental health care. Being a conceptual paper, the structural and therapeutic principles of OD are theoretically discussed against the background of human rights, as framed by the Universal Declaration of Human Rights, the UN Convention on the Rights of People with Disabilities, and the two recent annual reports of the Human Rights Council. It is shown that OD aligns well with discourses on human rights, being a largely non-institutional and non-medicalizing approach that both depends on and fosters local and context-bound forms of knowledge and practice. Its fundamental network perspective facilitates a contextual and relational understanding of mental well-being, as postulated by contemporary human rights approaches. OD opens the space for anyone to speak (out), for mutual respect and equality, for autonomy, and to address power differentials, making it well suited to preventing coercion and other forms of human rights violation. It is concluded that OD can be understood as a human rights-aligned approach.

The family-oriented open dialogue approach in the treatment of first-episode psychosis: Nineteen-year outcomes.

Open Dialogue (OD) is a family-oriented early intervention approach which has demonstrated good outcomes in the treatment of first-episode psychosis (FEP). Nevertheless, more evidence is needed. In this register-based cohort study the long-term outcomes of OD were evaluated through a comparison with a control group over a period of approximately 19 years. We examined the mortality, the need for psychiatric treatment, and the granting of disability allowances. Data were obtained from Finnish national registers regarding all OD patients whose treatment for FEP commenced within the time of the original interventions (total N = 108). The control group consisted of all Finnish FEP patients who had a follow-up of 19-20 years and who were guided to other Finnish specialized mental healthcare facilities (N = 1763). No difference between the samples was found regarding the annual incidence of FEP, the diagnosis, and suicide rates. Over the entire follow-up, the figures for durations of hospital treatment, disability allowances, and the need for neuroleptics remained significantly lower with OD group. Findings indicated that many positive outcomes of OD are sustained over a long time period. Due to the observational nature of the study, randomized trials are still needed to provide more information on effectiveness of approach.