[Vocational rehabilitation in mental disorders]. / Ammatillinen kuntoutus mielenterveyshäiriöissä.

Supporting the working careers of patients having mental disorders is in the best interest of the individual, the community and the society. In mental disorders, recovery to be able to work is more challenging than in other disease groups. Vocational rehabilitation yields the best results when implemented early enough and in close association with work. Work trial and preparation for work are among the most common means of rehabilitation supporting mental patients' return to work. Collaboration with the workplace is needed when the work and working hours are adapted to the needs of the rehabilitee. Supported employment helps even the severely ill to be able to return to work.

Attempted suicide in mental disorders in young adulthood.

BACKGROUND: Nationwide general population study establishes the prevalence of suicide attempts in different mental disorders among young adults and their sociodemographic correlates. Current psychiatric symptoms are also examined. METHODS: A random sample of 1,894 young Finnish adults aged 20-34 years were approached to participate in a questionnaire containing several screens for mental health interviews. All screen positives and random sample of screen negatives were invited to an SCID interview. Altogether 546 subjects participated in the interview. Diagnostic assessment and lifetime history of suicide attempts were based on all available systematically evaluated information from the questionnaire, the interview and/or case records. RESULTS: The lifetime prevalence of suicide attempts was 5.6% in men and 6.9% in women. Both mental disorders and poor educational and occupational functioning were associated with lifetime suicide attempts. Lifetime history of suicide attempts was associated with current psychological distress, problems related to substance use and other psychiatric symptoms, even after taking current Axis I disorder into account. Suicide attempts were most common in persons with psychotic disorders (41%). CONCLUSIONS: These results suggest that continued efforts are needed to outreach and treat effectively young adults with serious mental disorders. Young people who make a suicide attempt should be offered treatment. It seems also important to prevent psychosocial alienation of young people by providing them with adequate education and work possibilities.

Paternal age and mortality in nonaffective psychosis.

INTRODUCTION: Advanced paternal age (APA) is associated with an increased mortality in the general population, and is a risk factor for schizophrenia. We aimed to test if APA is associated with increased mortality in people with nonaffective psychosis. METHODS: Subjects with nonaffective psychosis who were born in Helsinki, Finland, between 1951 and 1960 (n=529) were followed until June 2006 (age 46 to 55). Hazard ratios were calculated, adjusting for subject age, age of the other parent, and gender. RESULTS: In females but not males, there was a significant increase in all-causes mortality (HR=7.04, 95% CI 1.60-31.04, p=0.01) and natural deaths (HR=7.64, 95% CI 1.20-48.66, p=0.03) in offspring of fathers age > or =40, after adjustment for potential confounders. In males but not females, there was a significant decrease in suicides (HR=0.89, 95% CI 0.81-0.97, p=0.01) with increasing maternal age (as a continuous variable). In the entire sample, there was also a trend for decreased all-cause mortality (HR=0.96, 95% CI 0.92-1.01, p=0.08) with increasing maternal age (as a continuous variable). DISCUSSION: Both paternal and maternal age may affect mortality risk in offspring with psychosis. The specific disorders and pathway(s) associated with the increase in natural cause mortality remain to be determined.

The validity of schizophrenia diagnosis in the Finnish Hospital Discharge Register: findings from a 10-year birth cohort sample.

The purpose of this study was to investigate the diagnostic validity of schizophrenia in the Finnish Hospital Discharge Register (FHDR) with a large, epidemiologically representative sample using a multidiagnostic approach (DSM-III-R, DSM-IV, ICD-10), and to find additional criteria that could be used to improve the validity of schizophrenia diagnosis in future register-based research that utilizes the FHDR. The study population consisted of all individuals (n=877) who were born in Helsinki, Finland, between 1 January 1951 and 31 December 1960, and who had had at least one diagnosis of schizophrenia, schizophreniform disorder or schizoaffective disorder in the FHDR. All their available hospital case notes were collected. The total number of subjects for whom case notes were obtained was 806. We used the OPCRIT system (version 3.4) to produce diagnoses according to ICD-10, DSM-III-R and DSM-IV criteria based on the information extracted from the hospital case notes. We examined the distribution of the DSM-III-R, DSM-IV and ICD-10 diagnoses generated by the OPCRIT and calculated the proportion of individuals who received the same diagnosis in the FHDR and in the OPCRIT assessment. The proportion of subjects who received a core schizophrenia spectrum diagnosis (schizophrenia, schizoaffective disorder or schizophreniform disorder) in both the FHDR and OPCRIT assessment varied between 75% (DSM-III-R criteria) and 78% (ICD-10 criteria). Of the subjects with a narrow schizophrenia diagnosis in the FHDR, between 74% (DSM-IV) and 78% (ICD-10) received a diagnosis of schizophrenia in the reassessment depending on the diagnostic criteria applied. Eighty per cent of those who had received a core schizophrenia spectrum FHDR diagnosis after 1982 (vs. 56% of those who had received their last schizophrenia diagnosis in 1982 or before) received a DSM-IV diagnosis of core schizophrenia spectrum disorder. Of the 58 subjects in the sample who had been given at various times diagnoses of both core schizophrenia diagnosis and bipolar I diagnosis in FHDR, 43% received a core schizophrenia spectrum diagnosis according to DSM-IV criteria. The validity of the FHDR schizophrenia diagnosis is acceptable for large-scale register studies and comparable with that of other Nordic registers. Diagnostic validity can be further improved by selecting subjects who have core schizophrenia spectrum disorder as the latest diagnosis, by omitting cases diagnosed before 1982, and by excluding cases with a register diagnoses of both a core schizophrenia spectrum and bipolar I disorder.

One-year course and predictors of outcome of adolescent depression: a case-control study in Finland.

BACKGROUND: Clinical studies on the outcome of adolescent depression beyond treatment trials are scarce. OBJECTIVE: To investigate the impact of characteristics of the depressive episode and current comorbidity on the 1-year outcome of depression. METHOD: A sample of 174 consecutive adolescent psychiatric outpatients (aged 13 through 19 years) and 17 school-derived matched controls, all with unipolar depressive disorders at baseline, were reinterviewed for DSM-IV Axis I and Axis II disorders at 12 months. The study was conducted between January 1998 and May 2002. RESULTS: The outpatients had equal recovery rate and episode duration but shorter time to recurrence than the controls. Among the outpatients, Axis II comorbidity predicted shorter time to recurrence (p = .02). Longer time to recovery was predicted by earlier lifetime age at onset for depression (p = .02), poor psychosocial functioning (p = .003), depressive disorder diagnosis (p

Reductions in postdischarge suicide after deinstitutionalization and decentralization: a nationwide register study in Finland.

OBJECTIVE: This study analyzed trends in suicides occurring after a psychiatric hospitalization during more than a decade of significant structural changes in mental health services in Finland-that is, deinstitutionalization, downsizing of inpatient care, and decentralization. METHODS: Retrospective register data on completed suicides and psychiatric inpatient treatments were collected for the periods 1985-1991 and 1995-2001, representing service provision before and after significant structural changes. The data were used to produce an estimate for a change in postdischarge suicide risk. RESULTS: In both periods, a fifth of suicide victims had been psychiatrically hospitalized within the preceding year. Among persons hospitalized, the risk of suicide was greater in 1985-1991 than in 1995-2001 for both one week after discharge (risk ratio [RR]=1.50, 95% confidence interval [CI]=1.38-1.62) and one year after discharge (RR=1.25, CI=1.19-1.30). When types of disorders were analyzed separately, the relative risk of suicide one year postdischarge for those hospitalized in the earlier period was greater for patients with schizophrenia (RR=1.26, CI=1.17-1.36) and patients with affective disorders (RR=1.60, CI=1.48-1.73). In parallel with general development of inpatient psychiatric services, in 1995-2001 the inpatient treatment periods preceding suicides were significantly shorter (a mean+/-SD of 45+/-340 days in 1995-2001, compared with a mean of 98+/-558 days in 1985-1991), the number of individual patients treated in the hospital for schizophrenia spectrum disorders was lower (26% compared with 36%), and the number treated for affective disorders was higher (45% compared with 35%). CONCLUSIONS: The restructuring and downsizing of mental health services was not associated with any increase in suicides immediately (one week) or one year postdischarge. Instead, the risk of these suicides decreased significantly between the two time periods among several diagnostic categories. Although the role of psychiatric hospitalization in general may have changed over time, patients who are hospitalized now may be less suicidal after discharge. Our results indicate, in terms of postdischarge suicides, that the downsizing of psychiatric hospitals has been a success. However, there is still a substantial need for better recognition of suicidal risk among psychiatric patients.

Differences in the clinical characteristics of adolescent depressive disorders.

Our objective was to analyze differences in clinical characteristics and comorbidity between different types of adolescent depressive disorders. A sample of 218 consecutive adolescent (ages 13-19 years) psychiatric outpatients with depressive disorders was interviewed for DSM-IV Axis I and Axis II diagnoses. We obtained data by interviewing the adolescents themselves and collecting additional background information from the clinical records. Lifetime age of onset for depression, current episode duration, frequency of suicidal behavior, psychosocial impairment, and the number of current comorbid psychiatric disorders varied between adolescent depressive disorder categories. The type of co-occurring disorder was mainly consistent across depressive disorders. Minor depression and dysthymia (DY) presented as milder depressions, whereas bipolar depression (BPD) and double depression [DD; i.e., DY with superimposed major depressive disorder (MDD)] appeared as especially severe conditions. Only earlier lifetime onset distinguished recurrent MDD from first-episode MDD, and newly emergent MDD appeared to be as impairing as recurrent MDD. Adolescent depressive disorder categories differ in many clinically relevant aspects, with most differences reflecting a continuum of depression severity. Identification of bipolarity and the subgroup with DD seems especially warranted. First episode MDD should be considered as severe a disorder as recurring MDD.

Current comorbidity among consecutive adolescent psychiatric outpatients with DSM-IV mood disorders.

OBJECTIVE: To compare selected characteristics (age, sex, age of onset for depression, impairment, severity of depression, somatic comorbidity, and treatment status) of adolescents with currently comorbid and non-comorbid depression. METHOD: A sample of 218 consecutive adolescent (13-19 years) psychiatric outpatients with depressive disorders, and 200 age- and sex-matched school-attending controls were interviewed for DSM-IV Axis I and Axis II diagnoses. RESULTS: Current comorbidity, most commonly with anxiety disorders, was equally frequent (>70%) in outpatients and depressed controls. Younger age (OR 0.20; 95% CI 0.08, 0.51) and male gender (OR 0.02; 95% CI 0.09, 0.55) were associated with concurrent disruptive disorders. Current comorbidity with substance use disorders (SUD) was independent of age (OR 1.13; 95% CI 0.51, 2.49) and sex (OR 0.51; 95% CI 0.22, 1.17). Personality disorders associated with older age (OR 2.06; 95% CI 1.10, 3.86). In multivariable logistic regression analysis, impairment (GAF

Psychometric properties of the defense style questionnaire (DSQ-40) in adolescents.

This study examined the psychometric properties of the Defense Style Questionnaire (DSQ-40) in adolescents. Internal consistency, factor structure, and discriminant and concurrent validity of the DSQ-40 were studied in 211 adolescent psychiatric outpatients aged 13 to 19 years and 199 age-matched and sex-matched controls. Principal components analysis yielded four internally consistent components: mature, neurotic, image-distorting, and immature defense styles. The outpatients reported more immature, image-distorting, and neurotic styles and less mature style than did the controls, suggesting adequate discriminant validity. As a demonstration of convergent and concurrent validity, the severity of psychiatric symptoms assessed by the General Health Questionnaire and psychosocial adjustment assessed by the Global Assessment of Functioning Scale correlated theoretically meaningfully with the different defense styles. The DSQ-40 appears to be a reliable and valid instrument for adolescents.

Mortality among patients with schizophrenia and reduced psychiatric hospital care.

BACKGROUND: There are suggestions that mortality, especially that due to suicide, increases among schizophrenia patients during a period of declining psychiatric beds. We investigated the mortality of schizophrenia patients in the general population of Finland during the reduction of psychiatric beds during 1980-1996. METHOD: Patients hospitalized for schizophrenia before 31 December 1996, and alive on 1 January 1980 (n = 58761) were identified via the National Hospital Discharge Register. General population data came from the National Population Register, and mortality data from the National Causes of Death Register. We calculated relative risks (RR) for total mortality, mortality due to natural causes (cancer, ischaemic heart disease, respiratory disease), unnatural causes (accident, homicide, suicide), and suicide. RESULTS: Patients with schizophrenia had an increased mortality both from natural causes (RR 2.59, 95% CI 2.55-2.63) and from suicide (RR 9.9, 95% CI 9.43-10.30). The RR for both natural and unnatural deaths was highest among patients with < 5 years since onset of schizophrenia. Among them all-cause mortality rose in the 1990s, but decreased among patients with > 10 years from onset. Otherwise no major changes or linear trends were found in mortality during deinstitutionalization. CONCLUSIONS: Reduction of psychiatric beds did not generally increase the mortality of patients with schizophrenia. However, patients in their early years of illness experienced increased mortality after the steepest bed reduction. Improved recognition and treatment of somatic illness would benefit patients with schizophrenia.

Psychometric properties and clinical utility of the Scale for Suicidal Ideation (SSI) in adolescents.

BACKGROUND: Accurate assessment of suicidality is of major importance in both clinical and research settings. The Scale for Suicidal Ideation (SSI) is a well-established clinician-rating scale but its suitability to adolescents has not been studied. The aim of this study was to evaluate the reliability and validity, and to test an appropriate cutoff threshold for the SSI in a depressed adolescent outpatient population and controls. METHODS: 218 adolescent psychiatric outpatient clinic patients suffering from depressive disorders and 200 age- and sex-matched school-attending controls were evaluated by the SSI for presence and severity of suicidal ideation. Internal consistency, discriminative-, concurrent-, and construct validity as well as the screening properties of the SSI were evaluated. RESULTS: Cronbach's alpha for the whole SSI was 0.95. The SSI total score differentiated patients and controls, and increased statistically significantly in classes with increasing severity of suicidality derived from the suicidality items of the K-SADS-PL diagnostic interview. Varimax-rotated principal component analysis of the SSI items yielded three theoretically coherent factors suggesting construct validity. Area under the receiver operating characteristic (ROC) curve was 0.84 for the whole sample and 0.80 for the patient sample. The optimal cutoff threshold for the SSI total score was 3/4 yielding sensitivity of 75% and specificity of 88.9% in this population. CONCLUSIONS: SSI appears to be a reliable and a valid measure of suicidal ideation for depressed adolescents.

Estimating suicidality as an outcome measure in clinical trials of suicide in schizophrenia.

A Suicide Monitoring Board (SMB) evaluated putative events of suicidal behavior to determine whether they should be counted as outcome data (endpoints) in the International Suicide Prevention Trial (InterSePT) study. The InterSePT study compared clozapine and olanzapine prospectively, on reduction of suicidality in schizophrenia and schizoaffective disorder. SMB members, blinded to patient identification, evaluated packages of clinical information and the forms used to summarize the putative events and their context. The SMB members met regularly by international teleconference to discuss ratings they found problematic and to achieve consensus. Exactly 243 of the 980 patients enrolled (24.8%) were considered to have experienced 577 suicidal events. Of these events, 483 (83.7%) were confirmed by the SMB as real or valid endpoints. Before the consensus discussions, acceptable levels of agreement (K = 0.52) were reached among the SMB members regarding ratings considered as valid suicidal events; agreement increased (K = 0.64) when consensus ratings and those of on-site psychiatrists also blinded to treatment were also included. This article discusses our experience of evaluating schizophrenia patients for suicidality in general and in particular from reviewing chart information. The process of making clinical judgments regarding the seriousness of suicidal behavior in schizophrenia patients and their suicidal risk warrants further study.

Nursing home suicides-a psychological autopsy study.

OBJECTIVE: Older adults comprise a fifth of all suicides. Elders are the fastest growing part of the population, thus the number of persons needing nursing home care will increase dramatically in the near future. Little information has been available about suicides in nursing homes. The present study described all suicides among older adults in nursing homes in Finland during a 12-month period emphasizing the factors that have been found to be associated with suicide in the general elderly population. METHODS: Drawing on data from a psychological autopsy study of all suicides (n=1397) in Finland during one year, all suicides committed by patients in nursing homes were identified. Retrospective DSM-IV consensus diagnoses were assigned. RESULTS: Twelve elderly (aged 60 years or more) nursing home residents who died by suicide, 0.9% of all suicides, were identified. The primary finding of the present study was that nursing home residents who died by suicide had suffered from highly comorbid somatopsychiatric disorders. One or more diagnoses on Axis I were made for all who died by suicide in nursing home. Depressive syndrome was diagnosed in three-quarters of subjects. Only a third of these were identified to have suffered from depressive symptoms before their death. CONCLUSIONS: Early recognition and adequate treatment of both somatic diseases and mental disorders, particularly depression, as well as early recognition of suicide risk among nursing home residents, are needed in order to prevent suicide.

General hospital suicides--a psychological autopsy study in Finland.

Although both severe medical disorders and mental disorders are established risk factors for suicide, it is not known if patients who commit suicide in general hospitals differ from others. This study investigated current mental disorders and other clinical characteristics among general hospital suicide victims and compared them with other suicide victims in an unselected nationwide population. Drawing on data from a psychological autopsy study of all suicides (N = 1397) in Finland during one year, all suicides committed by patients in a general hospital setting were identified. Retrospective DSM-III-R consensus diagnoses were assigned and general hospital suicide victims were compared with other suicide completers in terms of clinical characteristics. Twenty-six general hospital suicide victims, 1.9% of all suicides, were identified. Subjects who completed suicide during general hospital treatment were older and used more violent suicide methods than other suicide victims. One or more diagnoses of psychiatric (Axis I) disorders were assigned for 88% of the general hospital suicide victims. Overall, the most prevalent disorder was major depression, which was more common among the general hospital suicide victims, even when age was controlled for. The findings of this study suggest that most people who commit suicide during a spell of general hospital treatment suffer from current mental disorder, as do suicide victims in general. The recognition and treatment of major depression in particular should be improved in order to prevent suicide in general hospitals.