Do psychological job demands, decision control and social support predictreturn to work three months after a return-to-work (RTW) programme? The rapid-RTW cohort study.

BACKGROUND: Long-term sickness absence is a considerable health and economic problem in the industrialised world. Factors that might predict return to work (RTW) are therefore of interest. OBJECTIVE: To examine the impact of psychosocial work characteristics on RTW three months after the end of a RTW programme. METHODS: A cohort study of 251 sick-listed employees from 40 different treatment and rehabilitation services in Norway recruited from February to December 2012. The Job Content Questionnaire was used to gather information on the psychosocial work conditions. Full or partial RTW was measured three months after the end of the RTW programme, using data from the national sickness absence register. Logistic regression analyses were performed to investigate the association between the psychosocial work characteristics and RTW. RESULTS: Having low psychological job demands (OR = 0.4, 95% CI: 0.2-0.9), high co-worker- (OR = 3.4, 95% CI: 1.5-5.8), and supervisor support (OR = 3.4, 95% CI: 1.6-7.3), and being in a low-strain job (low job demands and high control) (OR = 4.6, 95% CI: 1.1-18.6) were predictive of being in work three months after the end of the RTW programme, after adjusting for several potential prognostic factors. CONCLUSION: Interventions aimed at returning people to work might benefit from putting more emphasise on psychosocial work characteristics in the future.

Lorazepam provocation test in purported schizophrenia with lack of treatment response.

Some patients with severe mental disorders are refractory to psychotherapeutic or psychopharmacological interventions. We present a patient who at the age of 19 developed several schizophrenia - suspect symptoms. Soon inexplicable general seizures where observed. He was treated with antipsychotics, but had two bouts of malignant neuroleptic syndrome. Electroconvulsive therapy (ECT) gave some symptom relief and he continued on maintenance ECT for years with weekly intervals. Interruption of this treatment pattern rapidly increased symptom load. After seven years a lorazepam provocation test was performed as he had a new relapse after 3 weeks without ECT. In the ensuing hours his aggressiveness and nonsense speaking rapidly diminished. Kahlbaums observation of seizures as part of a catatonia was not understood in this case. The publication of the new DSM-V diagnosis of catatonia may hopefully reduce the probability of treating a patient for schizophrenia for years without access to a more targeted medication and ECT plan.

Substance abusers in an acute psychiatric facility: a diagnostic and logistic challenge.

Acute resident psychiatric facilities in Norway usually get their patients after referral from a medical doctor. Acute psychiatric wards are the only places accepting persons in need of emergency hospitalisation when emergency units in somatic hospitals do not accept the patient. Resident patients at one random chosen day were scrutinized in an acute psychiatric facility with 36 beds serving a catchment area of 165 000. Twenty-five patients were resident in the facility at that particular day. Eight of 25 resident patients (32.0%) in the acute wards were referred for a substance-induced psychosis (SIP). Another patient may also have had a SIP, but the differential diagnostic work was not finished. A main primary diagnosis of substance use was given in the medical reports in only 12.9% of patients during the last year. Given that the chosen day was representative of the year, a majority of patients with substance abuse problems were given other diagnoses. There seems to be a reluctance to declare the primary reason for an acute stay in a third of resident stays. Lack of specialized emergency detoxification facilities may have contributed to the results.

Doctor-certified sickness absence in first and second trimesters of pregnancy among native and immigrant women in Norway.

AIMS: The authors sought to estimate differences in doctor-certified sickness absence during pregnancy among immigrant and native women. METHODS: Population-based cohort study of pregnant women attending three Child Health Clinics in Groruddalen, Oslo, and their offspring. Questionnaire data were collected at gestational weeks 10-20 and 28. The participation rate was 74%. A multivariate Poisson regression was used to analyse differences in sickness absence in pregnancy between immigrant and native women. RESULTS: A total of 573 women who were employed prior to their pregnancies were included, 51% were immigrants. After adjusting for age, years of education, marital status, number of children, occupation, part-time/full-time work, health status, severe pregnancy-induced emesis and language proficiency, the immigrant/native differences in number of weeks with sickness absence decreased from 2.0 to 1.2 weeks. Part-time/full-time work, health status, severe pregnancy-induced emesis and language proficiency were significant predictors of sickness absence. CONCLUSION: Immigrant women had higher sickness absence than native women during pregnancy. The difference in average number of weeks between native and immigrant women was partly explained by poorer health status prior to pregnancy, severe pregnancy-induced emesis and poorer proficiency in the Norwegian language among the immigrant women.

Leadership by fragmented destruction after a merger: an example from a facility of acute psychiatry.

Hospitals are labor intensive facilities based on highly skilled employees. A merger of hospitals is an effort to increase and rationalize this production. Decisions behind a merger are made at the top leadership level. How this might be done is demonstrated by examples from a 36 bed acute psychiatric facility. The aim of the study was to calculate the hidden costs of fragmented destruction of parts of a total hospital supply to patients after a merger. Fragmented destruction is the deliberate stopping of activities deemed not part of the core activities of the hospital without due consideration of the impact on core activities. The proposed changes to operational expenses at a single acute psychiatric hospital were materials for the study. The changes included activities as a reduction in local laboratory service, cleaning services, closure of physiotherapy unit, closing of cultural activities and reduced productivity. The selected activities are calculated as giving an imputed gain of € 630,000 as indicated by the leadership. The not calculated costs of reducing or removing the selected activities are estimated at € 1,955,640. The cost of staff disappointment after a merger is difficult to assess, but is probably higher than assumed in the present calculations. Imputed cost containment is not attained. The calculations indicate that implemented changes may increase cost, contrary to the belief of the leadership at both the hospital level and further up in the hospital trust. Arguments in favor of a merger have to be scrutinized thoroughly for optimistic neglect of uncalculated costs of mergers. Future hospital mergers and selected fragmentation of productive tasks at ward or hospital levels should include calculations of unavoidable costs as shown in the present paper.

Intractable schizo-affective disorder successfully treated with electroconvulsive treatment over six years.

Some patients with severe mental disorders are refractory to psychotherapeutic or psychopharmacological interventions. We describe a patient with severe symptoms from the age of 16 to 44. Her illness is best described as a schizo-affective disorder. Several series of electroconvulsive therapy (ECT) followed by maintenance once a week for more than six years has kept her out of hospital beds for three years. The patient demonstrates the feasibility of long term ECT and the absence of disturbing cognitive reductions.

Memory loss after electroconvulsive treatment--may the sudden alleviation of depression-inducing memories explain patient despair?

UNLABELLED: Electroconvulsive treatment (ECT) has developed over 70 years to a modern, effective way of lifting depressive moods. Memory loss after electroconvulsive treatment is the only remaining relevant criticism of the treatment modality when considering the overall rate of remission from this treatment compared to all other treatment modalities. A depressive state impedes memory. After treatment memory improves on several qualities of cognition. However, comparing a person's memory ability from the months before depression started to the level after a course of ECT is never done, of obvious reasons. There are great clinical difficulties explaining who would develop memory problems, regardless of stimulation techniques, age or sex of the patient. HYPOTHESES: The memory loss seen in some patients undergoing electroconvulsive treatment (ECT) is not explained by the treatment alone. After ECT unpleasant memories are disclosed rapidly and the patient may unconsciously try to defend herself by extending memory repression to other areas of memory. This may be unrelated to treatment modality, number of sessions or severity of depression. Psychological factors may partly explain why some patients unfold memory problems when the depression is rapidly lifted, rather than the treatment modality itself.

Electroconvulsive treatment of a patient with Parkinson's disease and moderate depression.

Depression is a usual comorbidity in patients with Parkinson's disease. It has been known for more than 50 years that electroconvulsive treatment (ECT) has a positive effect on the muscular symptoms of Parkinson's disease. Many countries do not allow giving ECT for this indication. We have recently treated a resident patient in an acute psychiatric facility referred to the hospital with moderate depressive symptoms and strong suicidal ideation. Before and after a series of ECT he filled out the Beck Depression Inventory and the Antonovsky Sense of Coherence test. The scores before ECT were 20 and 2.69, respectively, and after 12 treatments 14 and 3.38. Both test results indicate improvement regarding level of depression and coping in life. The physiotherapists treating him observed that his rigidity was reduced and his gait improved. Muscular tonus was reduced and increased his tendency of falling as he had less tonus in muscles close to joints. Self help efficiency in daily tasks improved. He got cognitive impairment during and in the weeks after ECT. Electroconvulsive treatment should be offered to more patients with Parkinson disease and depression in order to lessen the burden of both depression and Parkinson symptoms.

Migrant participation in Norwegian health care. A qualitative study using key informants.

BACKGROUND: Little is known about how migrants adapt to first-world public health systems. In Norway, patients are assigned a registered general practitioner (RGP) to provide basic care and serve as gatekeeper for other medical services. OBJECTIVES: To explore determinants of migrant compliance with the RGP scheme and obstacles that migrants may experience. METHODS: Individuals in leadership positions within migrant organizations for the 13 largest migrant populations in Norway in 2008 participated in this qualitative study. Semi-structured interviews, with migrants serving as key informants, were used to elucidate possible challenges migrant patients face in navigating the local primary health-care system. Conversations were structured using an interview guide covering the range of challenges that migrant patients meet in the health-care system. RESULTS: According to informants, integration into the RGP scheme and adequacy of patient-physician communication varies according to duration of stay in Norway, the patient's country of origin, the reason for migration, health literacy, intention to establish permanent residence in Norway, language proficiency, and comprehension of information received about the health system. Informants noted as obstacles: doctor-patient interaction patterns, conflicting ideas about the role of the doctor, and language and cultural differences. In addressing noted obstacles, one strategy would be to combine direct intervention by migrant associations with indirect intervention via the public-health system. CONCLUSION: Our results will augment the interpretation of forthcoming quantitative data on migrant integration into the public-health system and shed light on particular obstacles.

Death by suicide long after electroconvulsive therapy. Is the sense of coherence test of Antonovsky a predictor of mortality from depression?

Prediction of increased risk of suicide is difficult. We had the opportunity to follow up 20 patients receiving electroconvulsive therapy (ECT) because of severe depression. They filled in the Antonovsky sense of coherence test (SOC) and Beck depression inventory (BDI) before and after a series of ECT treatments. Seventeen surviving patients had a mean observation time of 20.6 months, whereas the three deceased patients had 11.3 months. There was a lower mean age at onset of illness and a longer mean duration of disease in the deceased. Other clinical parameters did not differ. The surviving patients had a significant decrease on the BDI from 35 to 18 (P<0.001) and an increase on the SOC test after ECT from 2.45 to 3.19 (P<0.001), indicating both less depression and better functioning in life. The deceased had a larger change on the BDI from 32 to 13, not attaining significance because of the low number of deceased. The SOC test, however, did not increase to a purported normal level; that is, from 2.43 to 2.87. Although the SOC scale has been shown to predict mortality in substance abusers, the SOC test has not been part of earlier reviews of predictive power. Tentatively, a low pathological score on the SOC test may indicate low sense of coherence in life that might increase the propensity for suicide. These preliminary results need replication in larger studies.

Sense of coherence in patients treated for depression with ECT.

OBJECTIVE: The purpose of the study was to investigate whether the Antonovsky Sense of Coherence test administered before and after electroconvulsive treatment (ECT) can contribute more information pertinent to outcome than a test of depression. METHOD: Twenty patients with a severe unipolar or bipolar depression underwent a series of unipolar ECT under standard conditions. As part of the routine of the department, the patients filled in, before and after ECT, the following questionnaires: Beck Depression Inventory (Beck), 20-item version and Antonovsky Sense of Coherence test (SOC), 13-item version. Mean age was 40.3, somewhat less for women. RESULTS: A reduction was obtained from 35 to 17 in total score on Beck, i.e., to mild depression. The SOC value increased to the normal range from a mean of 2.5 to 3.2, indicating a better manageability, comprehensibility and meaningfulness in life. Four patients had an invalidity pension. Ten of the 16 remaining patients attained work after ECT, and scored better than those not starting to work on both tests, SOC > Beck. A low SOC value may indicate increased mortality risk. CONCLUSIONS: Patients who are favorably treated with ECT against any depression, but who do not show a considerable improvement in SOC, would need special follow-up on factors not directly related to mental illness to reduce relapse and mortality risk.

Electroconvulsive treatment--more than electricity?: An Odyssey of facilities.

OBJECTIVE: To investigate whether the practice of electroconvulsive treatment (ECT) today is done in a comparable way in different hospitals on several continents. MATERIALS AND METHODS: During visits to the ECT facilities of 14 hospitals on 3 continents, comparisons were made, and responsible health professionals were interviewed using a semistructured guide. It is emphasized that the present article is not the result of a well-structured research, but of reflections after observing a lack of homogeneity among facilities. RESULTS: A total of more than 18,000 modified ECT sessions were given per year in the 14 hospitals. The opinion of the public and regulatory bodies on ECT strongly influences the possibility of giving ECT to patients. Indications for ECT are wider than the cases of depression in most facilities visited. A psychiatrist gives ECT in all but 1 facility. Anesthesia is given by an anesthesiologist in all but 1 facility. A mouthpiece was not used in 2 (or 3) facilities, although the rationale was the same as in facilities using mouthpieces. No facility gave unmodified ECT. Holding on to the patient during seizures was judged unnecessary in 12 of 14 facilities. CONCLUSIONS: In severe mental illness, the practice of using ECT seems to have its merit also in cases with debilitating illnesses other than unipolar and bipolar depression. Giving ECT may be done by qualified or specially certified nurses, but the giving of anesthesia should be the realm of the anesthesiologist. Mouthpieces are judged by some facilities to be a superfluous device. The holding of patients during seizure can be omitted. Some of the facilities visited give ECT to a huge number of patients each year. They differ in the practice of ECT and could be the focus of comparative research. Despite the differences observed, and procedures that could be altered, giving ECT in a modified way effectively relieves suffering in the patients.

The level of non-Western immigrants' use of acute psychiatric care compared with ethnic Norwegians over an 8-year period.

Immigrants are assumed by many to have more mental health problems than the population in the countries they have emigrated to, and clinicians have the impression that an increasing number of non-Western immigrants are referred to acute psychiatric care. Patients referred over an 8-year period to an acute care facility, responsible for a catchment area of close to 100,000 inhabitants in Oslo, Norway, were scrutinized to study the latter assumption. In total 792 men and 701 women (47.0%) were referred. There were 168 men and 59 women among the non-Western immigrants, i.e. 26.0% of the non-Western immigrants were women, whereas 50.2% or 611 out of 1217 ethnic Norwegians were women. Non-Western immigrants were referred twice as often in 2007, n=40, as in 2000, n=19. Non-Western immigrants as a percentage of the other referred patients increased from 15.2% to 16.0% in 2006, which was lower than the representation in the general population. Mean age was lower for non-Western immigrants, 34.6 (standard deviation, s=14.7) than for ethnic Norwegians 39.5 (s=11.6). Mean length of stay was lower for ethnic Norwegians. If the prevalence of mental disorders is the same or higher in immigrants than in the original population, this study indicates that they are under-represented among referred patients from the catchment area population. This seems to be the case especially for women.

Duration of bed occupancy as calculated at a random chosen day in an acute care ward. Implications for the use of scarce resources in psychiatric care.

BACKGROUND: Psychiatric acute wards are obliged to admit patients without delay according to the Act on Compulsive Psychiatric Care. Residential long term treatment facilities and rehabilitation facilities may use a waiting list. Patients, who may not be discharged from the acute ward or should not wait there, then occupy acute ward beds. MATERIALS AND METHODS: Bed occupancy in one acute ward at a random day in 2002 was registered (n = 23). Successively, the length of stay of all patients was registered, together with information on waiting time after a decision was made on further treatment needs. Eleven patients waited for further resident treatment. The running cost of stay was calculated for the acute ward and in the different resident follow-up facilities. Twenty-three patients consumed a total of 776 resident days. 425 (54.8%) of these were waiting days. Patients waited up to 86 days. RESULTS: Total cost of treatment was 0.69 million Euro (0.90 mill. dollars), waiting costs were 54.8% of this, 0.38 million Euro (0.50 million dollars). The difference between acute care costs and the costs in the relevant secondary resident facility was defined as the imputed loss. Net loss by waiting was 0.20 million Euro (0.26 million dollars) or 28.8% of total cost. DISCUSSION: This point estimate study indicates that treating patients too sick to be released to anything less than some other intramural facility locks a sizable amount of the resources of a psychiatric acute ward. The method used minimized the chance of financially biased treatment decisions. Costs of frustration to staff and family members, and delayed effect of treatment was set to zero. Direct extrapolation to costs per year is not warranted, but it is suggested that our findings would be comparable to other acute wards as well. The study shows how participant observation and cost effectiveness analysis may be combined.

Serum albumin and blood pressure: a population-based, cross-sectional study.

BACKGROUND AND PURPOSE: Information about the association between serum albumin and blood pressure is limited. The purpose of the present paper was to investigate this relationship in different age groups in males and females. METHODS: In the cross-sectional Norwegian Oslo Health Study, the concentration of serum albumin and blood pressure was determined in 5071 men and women 30-75 years of age. The albumin-blood pressure relationship was studied using multiple regression. RESULTS: In general, men had higher albumin values than women, and young subjects had higher albumin values than old. Within all age groups and in both sexes, systolic and diastolic blood pressure increased with increasing albumin concentration within the physiological range. An increase in the albumin concentration over the physiological range from approximately 40 to 50 g/l was associated with an increase in the systolic blood pressure between 5 and 11 mmHg in males, depending on age, and between 6 and 17 mmHg in females. Corresponding increases in diastolic blood pressure were between 3 and 7 mmHg in males, and 4 to 9 mmHg in females. Per one SD increment in the albumin concentration the blood pressure increase was 1-3 mmHg. CONCLUSION: Within the different age groups, irrespective of sex and age, a positive association was found between serum albumin and blood pressure. Since albumin, in contrast to high blood pressure, is considered to be cardioprotective, the two variables probably affect cardiovascular risk by unrelated mechanisms.

[Lipid balance and cardiovascular risk in patients in a psychiatric long-term facility]. / Lipidbalanse og risiko for hjerte- og karsykdom hos langtidspsykiatriske pasienter.

UNLABELLED: Increase in weight and changes in lipid and glucose metabolism often occur in severe mental illness. It is established that this may hinge on the mental illness as such, and on lifestyle, resident living in institutions and on medication. We performed an explorative study of these factors in a general psychiatric long-term facility. MATERIAL: 30 resident patients gave fasting blood samples that were analysed for lipid and glucose variables. Body mass index, blood pressure and smoking habits were noted, as was medication history of neuroleptics. Patients were asked about family risk of coronary heart disease and diabetes. RESULTS: Body mass index was > 25 in 80% and > 30 in 40% of patients. Four patients had diabetes. Total cholesterol was > 6 mmol/l in 10 patients. The ratio of total cholesterol to HDL cholesterol was > 5 in 60%. An atherogenic index containing apolipoprotein measurements was above cut-off in 11 patients. The patients had experience with the use of a mean of 4.1 (SD = 2.1) different neuroleptics. 9 out of 12 patients who had used clozapin and/or olanzapin had a body mass index > 30. 25 patients smoked a mean of 17 cigarettes a day. INTERPRETATION: Most of our patients carry a high risk of coronary heart disease and diabetes. Even if this risk may partly be due to the mental illness itself, risk is also attributable to a combination of an unhealthy life style, medication and smoking. It is of utmost importance that health professionals, leisure time therapists and catering personnel do their best in order to reduce organisationally induced risk, as these patients cannot be expected to respond adequately to advice.