Patient complaints in Finland 2000-2004: a retrospective register study.

Today, monitoring of patient complaints in healthcare services is being used as a tool for quality assurance systems and in the future development of services. This nationwide register study describes the number of all complaints processed, number of complaints between different state provinces, healthcare services and healthcare professionals, and outcomes of complaints in Finland during the period 2000-2004. All complaints processed at the State Provincial Offices and the National Authority for Medicolegal Affairs were analysed by statistical methods. Complaints about mental healthcare were explored in greater detail. The analysis showed that the number of patient complaints increased considerably during the study period. There were changes in the number of complaints between study years in different provinces. Out of different healthcare services, an especially marked increase was seen in private healthcare. Nearly all complaints were lodged against physicians, and over half of the complaints were made because of medical error. In mental health care, patients more often complained about unsatisfactory certificates and statements and the use of compulsory hospital care. An analysis of the outcomes revealed that in mental health care complaints more seldom led to consequences. The results need to be utilised when planning interventions for advanced supervision, prevention of adverse events and patient safety in healthcare, and especially in mental health care. From the patients' perspective, it is important to create a culture where most problem situations are handled where the treatment was provided, thus avoiding a complex complaints process.

Priority criteria tool for elective specialist level adolescent psychiatric care predicts treatment received.

BACKGROUND: Little validation data has so far been published on scoring systems and the literature on prioritization in psychiatry is especially meagre. OBJECTIVE: To explore if the priority criteria score for elective specialist level adolescent psychiatric care in Finland is associated with treatment received and whether the association between the priority criteria scores and treatment given is similar among different subgroups. METHODS: Adolescents currently in treatment contact in three adolescent psychiatric outpatient clinics (n = 450) were rated according to the criteria of the priority rating tool for specialist level adolescent psychiatric care and information about adolescent's age, sex, diagnosis, and treatments was gathered using a structured form. RESULTS: When sex, age and psychiatric diagnosis were controlled for, the likelihood of receiving specific therapies and medications was significantly associated with the highest priority scores. Except for very frequent individual therapy, there were no differences in the probability of receiving any psychosocial treatment or medication between the sexes. Receiving individual therapy, lengthy treatment contacts and medications were more frequent among older adolescents. The rating tool worked best among adolescents with affective or anxious disorders and worst among those with conduct disorders. CONCLUSION: The present study indicates that the structured tool used in Finland, originally modified from a Canadian priority rating tool for child and adolescent psychiatry, is able to identify adolescents requiring specified, multiple and lengthy treatments, indicating a need for specialist level services. The scoring system tested is a good candidate for a transparent prioritization tool for European adolescent psychiatric services.

Serious delinquency and later schizophrenia: A nationwide register-based follow-up study of Finnish pretrial 15- to 19-year-old offenders sent for a forensic psychiatric examination.

BACKGROUND: Aggressive and disruptive behaviors often precede the onset of schizophrenia. In this register-based follow-up study with a case-control design, we wanted to investigate if serious delinquency was associated with future diagnoses of schizophrenia or schizoaffective disorder (here, broadly defined schizophrenia) among a nationwide consecutive sample of 15- to 19-year-old Finnish delinquents sent for a forensic psychiatric examination in 1989-2010. METHODS: The sample comprised 313 delinquents with no past or current psychotic disorder. For each delinquent, four age-, gender- and place of birth -matched controls were randomly selected from the Central Population Register. Five controls (0.4%) had been treated for schizophrenia before their respective index-dates and were thus excluded from further analysis, leaving us with a control population of 1247 individuals. The subjects were followed till death, emigration or the end of 2015, whichever occurred first. Diagnoses were obtained from the Care Register for Health Care. RESULTS: Forty (12.8%) of the delinquents and 11 (0.9%) of the controls were diagnosed with schizophrenia later in life (HR 16.6, 95% CI 8.53-32.39, P<0.001). Almost half of the pretrial adolescents with later schizophrenia were diagnosed within 5years of the forensic psychiatric examination, but latency was longer among the other half of the sample, reaching up to 20.5years. CONCLUSIONS: The study supports the previous research indicating a potential link between serious delinquency and later schizophrenia. Accurate psychiatric assessments should be made in correctional services but also later in life so that any possible psychotic symptoms can be detected in individuals with a history of serious delinquency even if there were no signs of psychosis before or at the time of the crime. Future research should explore which factors influence the delinquent's risk of developing later schizophrenia.

Test-retest consistency of the event-related desynchronization/event-related synchronization of the 4-6, 6-8, 8-10 and 10-12 Hz frequency bands during a memory task.

OBJECTIVE: The aim of this study was to determine the test-retest consistency of the event-related desynchronization/event-related synchronization (ERD/ERS) method during the performance of an auditory memory task. METHODS: The EEG was recorded while 12 subjects performed an auditory memory task on two separate occasions (mean test-retest interval 9 days). Differences in the ERD/ERS responses between the first and second registrations were examined in 4 EEG frequency bands of interest: 4-6, 6-8, 8-10 and 10-12 Hz. RESULTS: We observed significant differences in the ERD/ERS responses between the first and second registration in all studied frequency bands when examined as a function of time and experimental task. The test-retest reliability of the ERD/ERS values was highest in the theta frequency range (4-6 and 6-8 Hz), poorer in the 8-10 Hz and poorest in the 10-12 Hz alpha frequency range. CONCLUSIONS: The test-retest effect was seen in the ERD/ERS responses of all studied frequency bands during an auditory memory task.

Inpatient treatment of mood disorders in the era of de-institutionalisation, depression awareness campaigns and development of new antidepressants.

OBJECTIVE: To analyse changes in inpatient treatment for mood disorders during the period of de-institutionalisation, de-centralisation of service planning, economic recession, attempts to increase depression awareness and increasing biological treatment possibilities. A special interest is paid to whether de-institutionalisation at specialist level psychiatric care results in transfer of inpatient care into non-specialised institutions. METHOD: A register study of all inpatient treatment due to psychiatric disorders from four health care districts in Northern Finland, with a population of more than 600,000. Treatment undertaken by psychiatric hospitals and wards, primary care wards and medical and surgical wards in general hospitals are distinguished. RESULTS: Inpatient treatment for mood disorders increased vastly in all kinds of health care institutions. The increase was due to growing inpatient treatment of depression. LIMITATIONS: The National Discharge Register does not include treatment episodes in private nursing homes or details about the contents of the treatment. CONCLUSION: Even during explicit active de-institutionalisation, other policies may have a greater impact on hospital use, resulting in unexpected changes in patient populations and service utilisation. In Finland, de-institutionalisation failed concerning mood disorders. The depression awareness policies during the 1990s increased inpatient use of depression across institutions.

Adolescent depression: the role of discontinuities in life course and social support.

OBJECTIVE: To study sociodemographic determinants of depression among 14-16 years old girls and boys, and the role of perceived social support in mediating the effects of the background variables. METHOD: 16464 adolescents aged 14-16 participated the School Health Promotion Study, a survey about health, health behaviour and school behaviour. Depression was measured by the Finnish modification of the 13-item Beck Depression Inventory. Moderate to severe symptoms in this scale were recorded as depression. RESULTS: Depression was associated with family structure in both sexes. Among girls, having moved recently and low parental education increased the risk for depression, among boys, unemployment in the family. Accumulating number of discontinuities in life course increased the proportion of the depressed among both girls and boys. Perceived lack of social support had the same effect. Lack of support did not explain the effect on depression of the discontinuities in life course. CONCLUSION: To detect risk groups for adolescent depressive disorders, health services should pay attention to adolescents who have experienced life changes. Perceived social support should be enquired.

Quantitative analysis of the feline dorsal column nuclei and their GABAergic and non-GABAergic neurons.

The gracile and internal and external cuneate nuclei of four adult cats were studied, using recently developed stereological techniques. The length, volume and position of the nuclei in relation to the level of obex were calculated, as well as the number of neurones, the neuronal density and volume of the three nuclei and different regions in the gracile and internal cuneate nucleus. Material processed for GABA immunocytochemistry was used in order to compare GABAergic and non-GABAergic neurones. The results demonstrate variations in the same nucleus in different animals, and in the nucleus of the left and right sides of the same animal. The same nucleus can vary up to 4 mm in its rostrocaudal position in relation to the obex. The mean sizes of the gracile, internal and external cuneate nuclei are 4.2, 8.4 and 5.6 mm3, respectively and their mean neuronal numbers are about 52,000, 76,000 and 33,000, respectively. The neuronal density was highest (12,907 cells/mm3) in the gracile, and lowest in the external cuneate nucleus (5987 cells/mm3). The external cuneate nucleus had a larger relative volume (7.9%) occupied by nerve cell bodies compared with the two medial nuclei (5.1% and 5.8%). In the gracile and internal cuneate nuclei, the GABAergic neurones constituted 28% and 25% of the whole population, respectively, while the external cuneate nucleus was devoid of such cells. All the nuclei contained GABA-positive boutons, however. The mean volume of the GABA-stained neurones in the gracile nucleus was 2319, and internal cuneate 3065 microns3, while the corresponding volume of unlabelled neurones in the gracile, internal and external cuneate nuclei was 3745, 8147 and 13318 microns3, respectively. When cyto-fibro-architectonic characteristics were used to subdivide the gracile and cuneate nuclei into rostral, middle and caudal regions, and the data of the three compartments compared, it was found that in both nuclei the middle region had the highest neuronal packing density, and the caudal region the largest mean nerve cell volume.

Early puberty and early sexual activity are associated with bulimic-type eating pathology in middle adolescence.

PURPOSE: To examine the associations between early pubertal timing and early advanced sexual development with bulimic-type eating pathology in middle adolescents. METHODS: A total of 19,321 boys and 19,196 girls aged 14-16 years (mean age 15.3 years, standard deviation 0.59) responded to the School Health Promotion Study, a class-room survey among Finnish adolescents about health, health behavior, and school experiences. Bulimic-type eating pathology was assessed with a questionnaire formulated according to the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders IV (DSM-IV) criteria. Pubertal timing was assessed by self-reported age at menarche or oigarche. Statistical methods were used chi-square and logistic regression. RESULTS: Bulimic-type eating pathology among girls was associated with early menarche, early sexual experiences, and increasing age. Among boys, onset of ejaculations at the normative age was protective for bulimic-type eating pathology, and the risk was elevated among very early and late maturers. Early sexual experience was associated with bulimic-type eating pathology. CONCLUSION: To prevent bulimia nervosa and to create opportunities for early intervention, attention should be paid to early maturing girls and off-time maturing boys, as well as those with early onset of sexual activity.

Has the attempt to reduce psychiatric inpatient treatment been successful in Finland?

The deinstitutionalisation process in Finland's psychiatric healthcare did not start until the late 1980s. Our aim is to evaluate how the use of psychiatric inpatient treatment was associated with deinstitutionalisation given the changes in the modality of treatment ideology (years 1987--1991) as well as being due to economic pressures (years 1991--1995). Special emphasis is given on the inpatient treatment of schizophrenia and other psychotic disorders. Data was retrieved using the national hospital discharge register of all treatment periods in psychiatric hospitals and treatment periods due to psychiatric disorders in other hospitals. Three years (1987, 1991, and 1995) were compared. Four healthcare districts in northern Finland were studied. Resource use was measured by number of treatment periods and inpatient days in relation to population. Psychiatric inpatient treatment was reduced in 1987--1991, when resources in community care increased. During the period of economic pressures (1991--1995), when community care resources no longer increased, inpatient treatment started to rise again. Over the whole period, psychiatric treatment in primary care institutions increased. Reduction of psychiatric beds results in increasing inpatient treatment in non-specialist institutions, especially when community care fails to serve the patients. In the future it is important to evaluate whether the quality of care remains in the standard of specialised services when treatment shifts away from the specialist level.

Involuntary medication in psychiatric inpatient treatment.

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

Coercion and restrictions in psychiatric inpatient treatment.

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

Psychiatric treatment and research unit for adolescent intensive care: the first adolescent forensic psychiatric service in Finland.

Finland does not have a history of providing forensic adolescent psychiatric units although the need for this kind of service has been established. According to legislation patients who are minors have to be treated separately from adults, however, this has not been possible in practice. Also, adolescent psychiatric wards have not always been able to admit the most severely ill patients, those with impulsive and aggressive behaviours, because of lack of staff resources, problems associated with protecting other vulnerable patients and a shortage of secure environments. A previous report demonstrated the significant increase in adolescent's involuntary treatment within adult psychiatric wards. Data from this report were acknowledged as an important starting point in the planning process for the psychiatric treatment and research unit for adolescent intensive care. This paper describes the background, development process, plan of action, tailor-made education programme and supporting evidence for the first Finnish adolescent forensic service opened in April 2003 in the Department of Psychiatry, Tampere University Hospital. The tool used for planning the unit's activities and staff education programme was the Balanced Score Card approach, the structure and development of which is also outlined within the paper.

Nurses' ethical perceptions about coercion.

PURPOSE OF THE STUDY: The purpose of this study was to describe Finnish psychiatric nurses' ethical perceptions about coercive measures in acute psychiatric setting. METHODS: The data were collected with a questionnaire developed for this study. The sample included 170 Finnish psychiatric nurses on acute wards in five psychiatric hospitals. The data were analysed using frequency and percentage distributions, mean and standard deviations. The internal consistency of the instrument was explored with Cronbach's alpha. The association between the background variables and the sum score of the items of the questionnaire was tested with Mann-Whitney U-test and Kruskal-Wallis test. The open-ended question was analysed with content analysis. RESULTS: Some psychiatric nurses perceived coercive measures as ethically problematic. In particular, the implementation of forced medication (18%), four-point restraints (16%) and patient seclusion (11%) were perceived as ethically problematic. Female nurses and nurses who worked on closed wards perceived the measures to be more problematic than male nurses and nurses who did not work on closed wards. CONCLUSION: In Finland, special attention has been paid to ethical questions related to the care of psychiatric patients and to the enhancement of patients' rights, yet the majority of the nurses participating in the survey did not perceive coercive measures as ethically problematic. More research on this issue as well as further education of the personnel and more extensive teaching of ethics in nursing schools are needed to support the ability of the psychiatric personnel to identify ethically problematic situations. In addition, it is important to consider new measures for generating genuine moral reflection among the personnel on the usage of coercive measures as well as on their effectiveness and legitimacy in the psychiatric care.

Bullying, depression, and suicidal ideation in Finnish adolescents: school survey.

OBJECTIVE: To assess the relation between being bullied or being a bully at school, depression, and severe suicidal ideation. DESIGN: A school based survey of health, health behaviour, and behaviour in school which included questions about bullying and the Beck depression inventory, which includes items asking about suicidal ideation. SETTING: Secondary schools in two regions of Finland. PARTICIPANTS: 16 410 adolescents aged 14-16. RESULTS: There was an increased prevalence of depression and severe suicidal ideation among both those who were bullied and those who were bullies. Depression was equally likely to occur among those who were bullied and those who were bullies. It was most common among those students who were both bullied by others and who were also bullies themselves. When symptoms of depression were controlled for, suicidal ideation occurred most often among adolescents who were bullies. CONCLUSION: Adolescents who are being bullied and those who are bullies are at an increased risk of depression and suicide. The need for psychiatric intervention should be considered not only for victims of bullying but also for bullies.

Management of aggressive behaviour among adolescents in forensic units: a four-country perspective.

Management of aggressive behaviour is a challenge in adolescent forensic units. Aggressive behaviour endangers the safety of the treatment milieu for patients and nursing and multidisciplinary staff. However, there is a paucity of literature about how the staff manage aggressive behaviour among patients in adolescent forensic settings, and whether the nursing practices are similar across countries. The purpose of this study was to explore nursing practices used to manage adolescent aggressive behaviour in adolescent forensic units in four European countries. An exploratory, descriptive research approach was adopted for the study. A convenience sampling was used by selecting the staff members working in adolescent forensic units (Belgium n= 15, Finland n= 18, the Netherlands n= 16, the UK n= 9). Personal thematic interviews were used to collect the data; and for data analysis, qualitative content analysis was applied. Staff members preferred using verbal and less restrictive interventions when intervening in escalated situations and perceived the use of coercive measures as the last option. Differences between countries were found in the use of restrictive methods. The principles of aggression management were fairly similar across Europe, even if differences were reported in practical solutions.