The impact of immigration detention on the mental health of torture survivors is poorly documented--a systematic review.

INTRODUCTION: Torture has enduring mental and physical health consequences for survivors. Detention of asylum seekers is an integrated part of the immigration systems in many countries. Among the asylum seekers are vulnerable groups such as survivors of torture and severely traumatized refugees. The aim of the present study is to review the scientific evidence on the mental health consequences of immigration detention for adult survivors of torture. METHODS: The review was conducted according to a modified version of the PRISMA guidelines. A systematic search was made in: PubMed (Medline), PsychINFO, PILOTS and IBSS, and reference lists were screened. RESULTS: The search yielded 241 results and two records came from additional sources. A total of 15 studies were included. Merely two case studies focused on survivors of torture. Both reported severe effects of detention on the detainees' mental health. High levels of psychological problems were found in studies identifying torture survivors among the asylum seekers. CONCLUSION: The impact of detention on the mental health of torture survivors is poorly documented, and the available data are insufficient to allow analysis of any specific effects. The studies do report severe mental health issues among detained torture survivors. In general, serious mental health problems are found among the detainees and formerly detained asylum seekers. Systematically identifying torture survivors and other vulnerable groups, and assessing and monitoring mental health issues is crucial. The health risks that detention may pose to the wellbeing of each individual should be carefully considered.

GPs and involuntary admission: a qualitative study.

BACKGROUND: In many countries, medical authorities are responsible for involuntary admissions of mentally ill patients. Nonetheless, very little is known about GPs' experiences with involuntary admission. AIM: The aim of the present study was to explore GP's experiences from participating in involuntary admissions. SETTING: General practice, Aarhus, Denmark. METHOD: One focus group interview and six individual interviews were conducted with 13 Danish GPs, who had recently sectioned one of their own patients. RESULTS: GPs experienced stress and found the admission procedure time consuming. They felt that sectioning patients was unpleasant, and felt nervous, but experienced relief and professional satisfaction if things went well. The GPs experienced the doctor-patient relationship to be at risk, but also reported that it could be improved. GPs felt that they were not taken seriously by the psychiatric system. CONCLUSION: The unpleasant experiences and induced feelings resulting from involuntary admissions reflect an undesirable and stressful working environment.

Health tests and health consultations reduced cardiovascular risk without psychological strain, increased healthcare utilization or increased costs. An overview of the results from a 5-year randomized trial in primary care. The Ebeltoft Health Promotion Project (EHPP).

BACKGROUND: Few randomized controlled trials (RCT) have evaluated health tests and health consultations in primary care with a long follow-up period. The Ebeltoft Health Promotion Project (EHPP) evaluated health tests and health consultations over a period of 5 years in the frame of a health technology assessment. OBJECTIVE: To review the results of EHPP. DESIGN: RCT with a control group answering questionnaires and two intervention groups having questionnaires, a comprehensive health test with written advice followed by either a normal consultation on demand or a planned 45 minutes patient-centred consultation. SETTING: Primary care. PARTICIPANTS: The target population was all 30-49 year old persons in the municipality of Ebeltoft, Denmark. Invitations were received by 2000 randomly selected persons. INTERVENTION: A comprehensive biomedical health test including a cardiovascular risk score (CVRS) followed by written advice and health consultations. MAIN OUTCOME MEASURES: Biomedical measures, psychological measures, healthcare contacts, life years gained, direct and total health costs. RESULTS: At baseline 75% participated. During the 5 years 85% participated at least once. Elevated CVRS was found in 19% in the control group compared to 10% in the intervention groups (p<0.01) after 5 years. There were no measurable long term psychological reactions. Numbers of contacts to the healthcare system were not increased. Significantly better life expectancy was found without extra direct and total costs. CONCLUSIONS: An offer of health tests and patient-centred health consultations to the middle-aged population can be cost-effective and may be considered in the fight against the increasing burden of lifestyle diseases.

Preventive health screenings and health consultations in primary care increase life expectancy without increasing costs.

AIMS: The intention was to investigate whether preventive health checks and health discussions are cost effective. METHODS: In a randomized trial the authors compared two intervention groups (A and B) and one control group. In 1991 2,000 30- to 49-year-old persons were invited and those who accepted were randomized. Both intervention groups were offered a broad (multiphasic) screening including cardiovascular risk and a personal letter including screening results and advice on healthy living. Individuals in group A could contact their family physician for a normal consultation whereas group B were given fixed appointments for health consultations. The follow-up period was six years. Analysis was carried out on the "intention to treat" principle. Outcome parameters were life years gained, and direct and total health costs (including productivity costs), discounted by 3% annually. Costs were based on register data. Univariate sensitivity analysis was carried out. RESULTS: Both intervention groups have significantly better life expectancy than the control group (no intervention). Group B and (A) significantly gain 0.14 (0.08) life years more than the control group. There were no differences in average direct (3,255 euro (3,703 euro) versus 4,186 euro) and total costs (10,409 euro (9,399 euro) versus 10,667 euro). The effect in group B is, however, better than in group A with no significant differences in costs. The results are insensitive to a range of assumptions regarding costs, effects, and discount rates. CONCLUSIONS: Preventive health screening and consultation in primary care in 30- to 49-year-olds produce significantly better life expectancy without extra direct and total costs over a six-year follow-up period.

Secondary healthcare contacts after multiphasic preventive health screening: a randomized trial.

AIM: To analyze the consequence of preventive health screenings and discussions on the utilization of secondary healthcare. METHODS: All 30- to 49-year-old residents registered with a general practitioner in the district of Ebeltoft, Denmark, were included (n = 3,464) in a randomized controlled trial with eight years' follow-up. A random sample of 2,030 subjects was selected for invitation (Invited). The remaining 1,434 persons were never contacted and served as external control group (Non-Invited). Persons accepting participation were randomly divided into one internal control group (Questionnaire) and two intervention groups. One intervention group was offered three health screenings (Health Screening) during the five years. The other intervention group were in addition offered a yearly health discussion with their general practitioner (Health Screening and Discussion). RESULTS: The rate ratio for hospital admissions was 0.97 (95% confidence interval 0.80 to 1.18) in the Invited group compared with the Non-Invited. The annual admission rates showed a significant trend (p = 0.0003) with a decrease four and five years after intervention launch for the Invited group compared with the Non-Invited. A similar trend was found when comparing the internal control group with intervention groups (p = 0.0016). CONCLUSIONS: A 30- to 49-year-old general population's utilization of secondary healthcare did not increase in response to a general health promotion offer. During the observation period a significant decline in annual hospital admission rates was seen.

Differences in perceived coercion at admission to psychiatric hospitals in the Nordic countries.

BACKGROUND: International variation in compulsory admissions to psychiatric care has mainly been studied in terms of civil commitment rates. The objectives of this study were to compare and analyse the levels of perceived coercion at admission to psychiatric in-patient care among the Nordic countries and between centres within these countries, in relation to legal prerequisites and clinical practice. METHOD: From one to four centres each in Denmark, Iceland, Norway, Finland and Sweden, a total of 426 legally committed and 494 formally voluntarily admitted patients were interviewed within 5 days from admission. RESULTS: The proportion of committed patients reporting high levels of perceived coercion varied among countries (from 49% in Norway to 100% in Iceland), and in Sweden, only, among centres (from 29 to 90%). No clear variations in this respect were found among voluntary patients. A wide concept of coercion in the Civil Commitment Act and no legal possibility of detention of voluntary patients were associated to low levels of perceived coercion at admission among committed patients. CONCLUSION: For committed patients, differences in national legal prerequisites among countries were reflected in differences in perceived coercion. The results from Sweden also indicate that local care traditions may account for variation among centres within countries.

Perspectives on lifestyle intervention: the views of general practitioners who have taken part in a health promotion study.

AIM: A study was carried out to discover the views of Danish general practitioners on the possibility of intervening in their patients' lifestyles in general and on the obstacles to doing so, based on their experience of participating in a health promotion study. METHOD: A focus group interview was conducted with five general practitioners who had participated in "The Ebeltoft Health Promotion Study" to assess their views on their preventive role. RESULTS: The general practitioners have internalized the view advanced by society and the medical profession that they have an important role to play in preventing lifestyle-related illness. However, they are sceptical about the effectiveness of intervention and have ethical concerns about giving lifestyle advice. They are also somewhat irritated by the fact that patients are chiefly interested in having their health checked, rather than in following up by changing their behaviour. The general practitioners differ in their views as to when, and how actively, they should initiate discussions with individual patients to encourage them to change their lifestyles. CONCLUSIONS: If the medical profession and those responsible for overall health policy wish to make general practitioners change their behaviour towards their patients, it is important that they understand the aims, values, and working conditions of general practitioners that underlie their present attitudes and behaviour.

Electrocardiogram interpretation in general practice.

BACKGROUND: The 12-lead electrocardiogram (ECG) is a common diagnostic test available to the GP in the evaluation of patients with cardiac complaints. In daily clinical practice it is important for GPs to know the sensitivity and specificity of their ECG interpretation skills. OBJECTIVES: The purpose of the present study was to evaluate the ECG interpretation skills of GPs and the value of automatic ECG recorder interpretations in general practice. METHODS: A total of 902 ECGs were recorded in a random sample of the population aged 31-51 years in the district of Ebeltoft, Denmark, from December 1991 to June 1992. They were interpreted automatically by an interpretive ECG recorder and by the GPs in the clinic in Ebeltoft, with a cardiologists interpretation as a gold standard. Sensitivity, specificity and predictive values of diagnoses were calculated. RESULTS: Overall, the sensitivity of abnormal diagnoses made by the GPs (69.8%) was significantly lower (P <0.001) than that of diagnoses made by the interpretive ECG recorder (84.4%). The overall specificity of abnormal diagnoses made by the GP (85.7%) was significantly higher (P <0.001) than that achieved by the interpretive ECG recorder (75.6%). CONCLUSIONS: GPs in this study were good at correcting false-positive diagnoses made by the interpretive ECG recorder. In order to avoid unfortunate reclassifications of true-positive to false-negative diagnoses, GPs are recommended to pay special attention to the diagnoses of ST-segment deviation, T-wave inversion or the presence of Q-waves made by interpretive ECG recorders, when ECGs are used in individual risk assessment.

Discordance between self-evaluated health and doctor-evaluated health in relation to general health promotion.

OBJECTIVE: To describe the occurrence of "health realists", "health pessimists" and "health optimists" in a non-patient population by identifying cases of concordance and discordance between doctor-evaluated health and self-evaluated health and to describe the distribution of selected life-style-related physiological risk factors among these health-groups. DESIGN: Comparative study. SETTING: Primary health care. SUBJECTS: 456 middle-aged persons registered with a general practitioner (GP) were after a general health screening invited to a health discussion. Prior to the health screening the participants had assigned their health status to one of five categories ranging from "very poor" to "excellent". After the health discussion the GP rated the participants' general health status on a visual analogue scale. On basis of this information patients were classified as "health realists", "health optimists" and "health pessimists". RESULTS: 54% of the participants could be classified as "good-health realists", 14% as "poor-health realists", 22% as "health optimists", and 10% as "health pessimists". "Poor-health realists" had the greatest accumulation of risk factors, followed by "health optimists", "health pessimists" and "good-health realists". Among the "health pessimists" there was a significantly higher risk score of future cardiovascular disease and poor physical endurance compared with the "good-health realists". CONCLUSION: Discordance between doctor-evaluated health and self-evaluated health was found in 32% of the cases studied. "Health pessimists" had more risk factors than "good-health realists" even though the GPs had rated their general health status as good in both cases.

No long-term psychological reaction to information about increased risk of coronary heart disease in general practice.

BACKGROUND: Randomised, controlled trials focusing on long-term psychological reactions to information about increased risk of coronary heart disease are scarce. DESIGN: A population-based randomised, controlled, 5-year follow-up trial was conducted in general practice. METHODS: In 1991, invitations were sent to 2,000 middle-aged people registered in the general practices in the district of Ebeltoft, Denmark. A total of 1,507 (75.4%) agreed to participate and were randomised into a control group and two intervention groups: one included health screening, a written feedback and an optional follow-up visit with the general practitioner; the other included health screening, written feedback and a planned 45-min follow-up visit with the general practitioner. The participants were informed at screening about their risk of developing coronary heart disease. Psychological distress was measured by the GHQ-12 before screening and at the 1 and the 5-year follow-up. RESULTS: Before the screening (0 year), 1 and 5 years after there were no significant differences in the GHQ-12 score between the control group and the two intervention groups. Nor were there any differences related to information about increased risk of coronary heart disease between scores obtained at the 1 and the 5-year follow-up. CONCLUSION: Middle-aged persons had no long-term psychological reaction after information about increased risk of developing coronary heart disease following a health screening in general practice evaluated by the GHQ-12, 1 year and 5 years after the examinations.

The course of low back pain in a general population. Results from a 5-year prospective study.

OBJECTIVES: To investigate the course of low back pain (LBP) in a general population over 5 years. DESIGN: Prospective population-based survey by postal questionnaires in 1991, 1992, and 1996. SETTING: The municipal of Ebeltoft, Denmark. SUBJECTS: Two thousand people aged 30 to 50 years, representative of the Danish population. Main outcome measure Number of days with low back pain during the past year. RESULTS: One thousand three hundred seventy were recruited of whom 813 (59%) were followed to 5 years. The responders could be divided into 3 groups with regard to LBP: no pain, short-term pain, and long-lasting/recurring pain. More than one third of people who experienced LBP in the previous year did so for >30 days. Forty percent of people with LBP >30 days at baseline remained in that group 1 and 5 years later, and 9% with LBP >30 days in year 0 were pain free in year 5. People with LBP in year 0 were 4 times more likely to have LBP in year 1, and 2 times more likely to be affected in year 5. CONCLUSIONS: Low back pain should not be considered transient and therefore neglected, since the condition rarely seems to be self-limiting but merely presents with periodic attacks and temporary remissions. On the other hand, chronicity as defined solely by the duration of symptoms should not be considered chronic.

Low prevalence of ischemic electrocardiographic findings in a Danish population.

OBJECTIVE: Mortality and incidence of cardiovascular disease have declined during the past 35-40 years. The dual aim of this study is to investigate whether the prevalence of electrocardiographic findings is low compared with older studies and to describe the prevalence of electrocardiographic findings in the Danish population, which has not been reported since 1981. DESIGN: Cross-sectional study based on electrocardiograms obtained from a random sample of the population in the district of Ebeltoft, Denmark, December 1991-June 1992. RESULTS: The age and sex stratified prevalence of abnormal electrocardiograms ranged from 6.8% (95% CI: 4.01-10.7%) in women to 15.0% (95% CI: 10.6-20.4%) in men aged 41-51 years. Men had significantly more electrocardiographic changes than women (p = 0.004). Frequent findings were signs of earlier myocardial infarction (3.1%; 95% CI: 2.1-4.5%), axis deviation (3.1%; 95% CI: 2.1-4.5%) and incomplete right bundle branch block (1.2%; 95% CI: 0.6-2.2%). CONCLUSION: Prevalence of ischemic electrocardiographic findings is low when compared with studies from the past 50 years.

Adverse social factors predict early ageing in middle-aged men and women: the Ebeltoft Health Study, Denmark.

AIMS: This study examined whether adverse social factors are associated with an increased rate of biological ageing in middle-aged subjects. METHODS: The authors investigated five markers of biological ageing in 690 subjects followed for five years in Ebeltoft, Denmark. Mean age at baseline was 40 years (range 30-50 years). These markers included repeated measures of pulse pressure, lung function, hearing, physical work capacity and a cardiovascular risk score. A zeta-score was calculated based on a factor analysis of the five markers used. The relative biological age was finally calculated in relation to chronological age in subgroups of different social class (occupation, educational level) and marital status, at baseline and after follow-up. RESULTS: Men and women from a higher social class appeared to be biologically younger than corresponding subjects from a lower social class (p < 0.001). This difference was still evident after 5 years of follow-up (p < 0.01) for men and women of different occupations and for women of different educational levels (p < 0.01). Married/cohabiting men were biologically younger than single men and this difference increased during the follow-up period in that the difference between groups at five-year follow-up was significant (p < 0.05). CONCLUSIONS: Middle-aged men and women from a higher social class showed signs of being biologically younger than their corresponding chronological age, while the opposite was found for men and women of lower social class. This discrepancy was still evident after five years of follow-up, and even tended to increase for single men. Differential ageing may thus be an important biological aspect of differences in health according to social class.

[Can systematic general health screening and patient-physician health discussions improve the cardiovascular profile of the population? A randomized controlled trial in general practice with a 5-year follow-up]. / Kan systematiske generelle helbredsundersøgelser og helbredssamtaler forbedre den kardiovaskulaere risikoprofil i befolkningen? En randomiseret og kontrolleret undersøgelse i almen praksis med fem års opfølgning.

INTRODUCTION: We investigated the impact of general health screenings and discussions with general practitioners on the cardiovascular risk profile of the population. MATERIAL AND METHODS: A population-based, randomised, controlled, 5-year follow-up trial conducted in a primary care setting. In total 2000 randomly selected men and women, aged 30-50 years, from family practices in the district of Ebeltoft, Denmark. Of these persons, 1507 (75.4%) agreed to participate, and were randomised into: (1) a control group who did not receive health screenings; (2) an intervention group that received two health screenings; or (3) an intervention group that received both the two screenings and a 45-minute follow-up consultation annually with their general practitioner. All were followed up after 5 years by questionnaires and health screenings. The outcome measures were: cardiovascular risk score (CRS), body mass index (BMI), blood pressure, serum cholesterol, carbon monoxide in expiratory air, and use of tobacco. RESULTS: After 5 years, the CRS, BMI, and serum cholesterol levels were lower in the intervention groups, as compared with the control group. The improved outcome was greater in the baseline risk groups. The number of persons with elevated CRS in the intervention groups was about half the number of persons with elevated CRS in the control group. The difference was not a result of medication use. There was no difference between the group that received consultations after the screenings and the group that had health screenings alone. DISCUSSION: Systematic health screenings reduce the cardiovascular risk score in a middle-aged population. After 5 years of follow-up, the number of persons at elevated cardiovascular risk was about half the expected. The impact of intervention is higher in at-risk individuals. Planned consultations about health did not appear to improve the cardiovascular profile of the study population.

General health screenings to improve cardiovascular risk profiles: a randomized controlled trial in general practice with 5-year follow-up.

OBJECTIVES: To investigate the impact of general health screenings and discussions with general practitioners on the cardiovascular risk profile of a random population of patients. STUDY DESIGN: A population-based, randomized, controlled, 5-year follow-up trial conducted in a primary care setting. POPULATION: The study group consisted of 2000 patients, randomly selected middle-aged men and women aged 30 to 50 years from family practices in the district of Ebeltoft, Denmark. Of these patients, 1507 (75.4%) agreed to participate. Patients were randomized into (1) a control group who did not receive health screenings, (2) an intervention group that received 2 health screenings, (3) an intervention group that received both the 2 screenings and a 45-minute follow-up consultation annually with their general practitioner. OUTCOMES MEASURED: Cardiovascular risk score (CRS), body mass index (BMI), blood pressure, serum cholesterol, carbon monoxide in expiratory air, and tobacco use. RESULTS: After 5 years, the CRS, BMI, and serum cholesterol levels were lower in the intervention groups compared with the control group. The improved outcome was greater in the baseline risk groups. The number of patients with elevated CRS in the intervention groups was approximately half the number of patients with elevated CRS in the control group. The difference was not a result of medication use. There was no difference between the group that received consultations after the screenings and the group that had health screenings alone. CONCLUSIONS: Health screenings reduced the CRS in the intervention groups. After 5 years of follow-up, the number of persons at elevated cardiovascular risk was about half that expected, based on the prevalence/proportion in a population not receiving the health checks (the control group). The impact of intervention was higher among at-risk individuals. Consultations about health did not appear to improve the cardiovascular profile of the study population.

[The association between physical workload and low back pain clouded by the "healthy worker" effect]. / Sammenhaengen mellem fysisk arbejdsbelastning og laenderygsmerter sløres af "healthy worker"-effekten.

INTRODUCTION: Both physical and psychosocial workplace factors are considered risk factors for low back pain (LBP). However, today, no consensus has been reached regarding the exact role of these factors in the genesis of LBP. MATERIAL AND METHODS: Questionnaire data were collected at baseline for 1,397 (and after five years for 1,163) men and women aged 31-50 years at baseline. LBP (any LBP within the past year; LBP < or = 30 days in total during the past year; LBP > 30 days in total during tha past year) was analysed in relation to physical workload (sedentary, light physical, and heavy physical work) using logistic regression and controlling for age, gender, and social group. The proportions af workers changing between the workload groups over the five-year period were analysed in relation to LBP status. RESULTS: A baseline no statistically significant differences in LBP outcomes were found for workers exposed to sedentary, light physical, or heavy physical work. This was true for both genders and all age and social groups. At follow-up these was a statistically significant dose-response association between any LBP and long-standing LBP during the past year and increasing physical workload at baseline, also after controlling for age, gender and social group. Subjects with a heavy physical workload at baseline changed significantly more often to sedentary work, if they had experienced LBP for more than 30 days out of the past year. DISCUSSION: Having a sedentary job might have a protective or neutral effect in relation to LBP, whereas having a heavy physical job constitutes a significant risk factor. Because og migration between exposure groups (the "healthy worker" effect), longitudinal studies are necessary for investigating the associations between physical workload and LBP.