Twelve months effect of self-referral to inpatient treatment on patient activation, recovery, symptoms and functioning: A randomized controlled study.

OBJECTIVE: To investigate the effect of having a contract for self-referral to inpatient treatment (SRIT) in patients with severe mental disorders. METHODS: A randomized controlled trial with 53 adult patients; 26 participants received a SRIT contract, which they could use to refer themselves into a Community Mental Health Centre up to five days for each referral without contacting a doctor in advance. Outcomes were assessed after 12 months with the self-report questionnaires Patient Activation Measure (PAM-13), Recovery Assessment Scale (RAS), and the Behavior and Symptom Identification Scale (BASIS-32) and analyzed using linear mixed and regression models. RESULTS: There was no significant effect on PAM-13 (estimated mean difference (emd) -0.41, 95% CI (CI):-7.49-6.67), nor on the RAS (emd 0.02, CI:-0.27-0.31) or BASIS-32 (0.09, CI:-0.28-0.45). An exploratory post hoc analysis showed effect of SRIT in those with low PAM below ≤47 (p=0.049). CONCLUSION: There were no group differences after 12 months, but both groups maintained their baseline levels. PRACTICE IMPLICATIONS: SRIT contracts can be recommended as it supports the rights to self-determination, promote user participation in decision-making in own treatment without any indication of adverse effects.

Short-term effects of a peer co-led educational programme delivered before mental health treatment: A randomised controlled trial.

OBJECTIVE: To investigate the 1-month effects of an educational programme co-led by peers delivered before treatment on treatment preferences, self-management knowledge and motivation in comparison to usual care. METHODS: Adults referred to a community mental health centre were randomised to either a control group (n=48) or a peer co-led educational programme (intervention group, n=45). The programme consisted of an 8-hour group education session followed by an individual pretreatment planning session. The main topics of the educational programme were treatment options, patients' rights, self-management, the importance of patient activation and participation. RESULTS: At 1-month follow-up, a significantly larger proportion of the patients in the intervention group knew which type of treatment they preferred (76.7% vs. 32.5%, p<0.001). The intervention group had significantly higher self-management knowledge (p<0.001). There was no effect on treatment motivation (p=0.543). CONCLUSION: At 1-month following the delivery of a pretreatment educational programme, we found that participants' knowledge of treatment preferences and self-management had improved. PRACTICE IMPLICATIONS: Educational interventions co-led by peers can optimise the process of informing and educating outpatients, thereby helping patients to clarify their treatment preferences.

Effects of a psychiatric intensive care unit in an acute psychiatric department.

Psychiatric acute units use different levels of segregation to satisfy needs for containment and decrease in sensory input for behaviourally disturbed patients. Controlled studies evaluating the effects of the procedure are lacking. The aim of the present study was to compare effects in acutely admitted patients with the use of a psychiatric intensive care unit (PICU) and not in a psychiatric acute department. In a naturalistic study, one group of consecutively referred patients had access only to the PICU, the other group to the whole acute unit. Data were obtained for 56 and 62 patients using several scales. There were significant differences in reduction of behaviour associated with imminent, threatening incidents (Broset Violence Checklist), and actual number of such incidents (Staff Observation Aggression Scale-Revised) in favour of the group that was treated in a PICU. The principles of patient segregation in PICUs have favourable effects on behaviours associated with and the actual numbers of violent and threatening incidents.

Psychiatric symptoms in alpha-mannosidosis.

Alpha-mannosidosis is characterized by mild to moderate intellectual disability (ID), moderate to severe neurosensory hearing loss, frequent infections, psychomotor disturbances and skeletal dysmorphism. For the first time, a panel of nine alpha-mannosidosis patients with psychiatric symptoms is presented. The clinical picture has several similarities: a physical or psychological stressor precedes a rapid development of a state of confusion, delusions, hallucinations, anxiety and often depression leading to a severe loss of function. This usually lasts 3-12 weeks, and is followed by a period of somnolence and asthenia. It may be more prevalent in females. In four of the described patients search for organic causes of the syndrome was performed, but revealed only negative findings. Because of the limited number of cases no firm conclusion about the benefit of various psychotropic drugs can be drawn from our observation. Psychiatric symptoms could affect as many as 25% of patients with alpha-mannosidosis. First onset is typically in late puberty to early adolescence. The episodes may be recurrent, and of limited duration although medication may be necessary to alleviate symptoms. Our observations indicate that alpha-mannosidosis is associated with an increased risk of psychiatric symptoms. These should not be dismissed as part of the ID but should give rise to the initiation of adequate diagnostic work-up, treatment and support.

Psychotropic drug use among people with intellectual disability before and after deinstitutionalization.

BACKGROUND: The use of psychotropic medication among people with intellectual disability (ID) is widespread, and they are one of the most medicated groups in society. A substantial number of individuals with ID receive psychotropic medications that may be inappropriate for their diagnosis. One of the main reasons for the use of psychotropic medication is challenging behaviours. Almost all prevalence studies show higher prevalence rates of psychotropic medication in institutions compared with community living. Studies on deinstitutionalization and the use of psychotropic medication are few and inconclusive. METHOD: The present study is a prospective cohort study without control group. It examines the use of psychotropic medication among 109 subjects aged between 16 and 65 years before (1987) and after (1995) deinstitutionalization. Psychotropic drug dosages were transformed to percentage of defined daily dosage. RESULTS: We found no major changes in the use of neuroleptics after deinstitutionalization neither in frequency nor in dosages, and the trend seemed indiscriminate in relation to diagnosis. The people with schizophrenia or an anxiety disorder did not receive proper drug treatment, nor did they before deinstitutionalization. CONCLUSIONS: The main predictor variable for neuroleptic dosage both before and after deinstitutionalization was challenging behaviour. The reason for this may be the difficulties in determining the extent to which presenting behaviours are the result of a psychiatric disorder or a behaviour disorder, the lack of knowledge among the caretakers and the ensuing referral practice, the lack of knowledge among the general practitioners, and the lack of access to specialized health services.

Predictors for attacks on people after deinstitutionalization.

BACKGROUND: The deinstitutionalization movement is presently spreading in Europe, but studies evaluating the effects of deinstitutionalization on behaviour disturbances among people with intellectual disability (ID) are inconclusive. The prevalence of aggressive behaviour among people with ID is high in both institutions and in community. Aggression and attacks on people are a significant problem for people with ID in both institutions and society. In the present paper, the authors focus on individuals who started attacking people after deinstitutionalization. METHOD: The authors studied individual and environmental characteristics before and after deinstitutionalization to look for individual and environmental predictors for the development of aggression with the hope that some could be possible intervention points for preventive action. In an institution for people with ID, all who did not attack people before deinstitutionalization were included. The individuals who started attacking others after deinstitutionalization (n = 22) were the study group (group A) and those who did not (n = 42) comprised the control group (group B). The population was examined before and after deinstitutionalization. As far as possible the same methods were used at both occasions. The covariates included individual ones, such as mental health, behaviour disturbances and behaviour deficits, and environmental ones, such as caretaker education, caretaker:patient ratio, housing and leisure activities. Psychiatric disorders were identified in 1987 and 1995 with the Psychopathology Instrument for Mentally Retarded Adults (PIMRA), which was filled in by the caretakers. RESULTS: Group A showed significantly more self-injurious behaviour (SIB) than group B in 1987. The sum of behaviour disturbances shown in the past year, attacks on property, SIB and other disruptive behaviours were also significantly higher in group A than in group B. The soundness scores on the PIMRA for the people in group A were lower than for the people in group B. Group A contained significantly fewer people without behavioural problems in the past year. The authors could not find any differences on other individual characteristics such as aetiologies of ID and behaviour deficits in 1987. The caretakers' evaluations of the clients need for help, based on behaviour disturbances and mental health problems, were significantly higher in group A. The people in this study differed in age, gender and degree of ID from those in most other studies on ID and challenging behaviour. CONCLUSION: The individual predictors for starting to attack others after deinstitutionalization were SIB, a slight load of other behaviour problems and a low soundness score on the PIMRA. The only environmental predictor was the caretakers' evaluation of the subjects' need for help caused by behaviour problems and mental illness. The authors could not identify possible preventive intervention points, neither individual or environmental, and therefore, further studies are needed.

Self-injurious behaviour before and after deinstitutionalization.

The deinstitutionalization movement is presently spreading in Europe. Studies evaluating the effects of deinstitutionalization on behaviour disturbances among people with intellectual disability (ID) have been inconclusive. The present paper focuses on people without self-injurious behaviour (SIB) who developed SIB after deinstitutionalization. The present authors studied individual and environmental characteristics before and after deinstitutionalization to look for factors associated with the development of SIB which could also be possible intervention points for preventive action. All those individuals in an institution for people with ID who did not have SIB before deinstitutionalization were included in the present study. The individuals who developed SIB after deinstitutionalization (n = 15) formed the study group (group A) and those who did not (n = 53) comprised the control group (group B). The population was examined both before and after deinstitutionalization. As far as possible, the same methods were used at both occasions. The covariates were both individual (e.g. mental health, behaviour disturbances and behaviour deficits) and environmental (e.g. caretaker education, caretaker:patient ratio, housing and leisure activities). Psychiatric disorders were identified in 1987 and 1995 with the Psychopathology Instrument for Mentally Retarded Adults, which was filled in by the caretakers. In 1987, the people in group A who acquired SIB had lower developmental quotients, used wheelchairs more often and had trouble with moving around without help. They also had a greater frequency of epileptic seizures, and hearing and communication impairment. In 1995, there were only minor environmental differences between groups A and B. There were significantly more individuals involved in the rotation period and more unskilled caretakers working with the people in group A than group B. The present authors found no differences between the two groups on variables such as global mental health and behaviour disturbances, or in the use of neuroleptics before or after deinstitutionalization. Groups A and B did not show differences in behaviour disturbances or psychiatric disorders in 1987. In both 1987 and 1995, there were no differences between groups A and B on variables such as accommodation, caretaker:patient ratio, the number of caretakers involved in direct care, the caretakers' education, or the time spent in structured activities before and after deinstitutionalization. The individual characteristics indicating that a person may acquire SIB are behaviour deficits which are suggestive of central nervous system dysfunction or damage, even if the results are inconclusive. The development of SIB may also be facilitated by communication deficits or by reinforcement of a incidentally occurring SIB if the staff includes many unskilled caretakers in the rotation period.

Seasonal variation of violence in Norway.

OBJECTIVE: Seasonal variations of violence have been the subject of some controversy. Norway, situated between latitudes 58 degrees and 72 degrees N, has considerable seasonal variations of light and provides a good opportunity for studies of seasonality. METHOD: The monthly numbers of police reports of violent incidents in 1991-1997 were obtained for the entire Norwegian population of 4,450,000 inhabitants and separately for each of seven Norwegian cities at different latitudes. RESULTS: A total of 82,537 episodes of violence were recorded. There was a significant variation in violent incidents between months, with a minimum daily frequency of 28.7 in March and a maximum daily frequency of 35.1 in June. The frequency curve had one significant peak in May through June and another significant peak in October through November. The monthly frequency of violence correlated with the absolute value of monthly change in length of day from the previous month. In the seven cities the highest monthly ratio of observed to expected frequencies increased with latitude. With increasing latitude, the months with the largest increase in violence came later both in the spring and in the fall. CONCLUSIONS: There is a distinct pattern of seasonal variation in the frequency of violence that varies systematically with latitude. This pattern resembles the seasonal pattern of some forms of suicide, hospitalization for affective disorders, and mood and activity in the general population.

[Screening for psychiatric disorders among prison inmates]. / Screening for psykiatrisk lidelse blant fengselsinnsatte.

BACKGROUND: Prison inmates have high frequencies of psychiatric disorders. Most prisons have little health-personnel resources, and methods to help focus resources towards those with serious health-care needs would be useful. The Global Symptom Index (GSI) of the Symptom Check List-90 (SCL-90) has performed well in other populations. MATERIAL AND METHODS: Prisoners at Kristiansand County Prison, Norway were asked to participate in the study, and 187 of 206 (91%) consented. All filled in the SCL-90 during the first four days of incarceration, and were examined clinically by a psychiatrist. RESULTS: Clinical examination revealed 40 persons with psychiatric disorder. Of these, 37 had a GSI score > or = 1. There were three false negatives and two false positives. Based on various cut-off levels for the GSI, we found a GSI cut-off value at 1.5 to perform best with sensitivity = 0.78, specificity = 0.87, and Number Needed to Diagnose = 1.55. INTERPRETATION: SCL-90 performs well as a screening instrument for psychiatric disorders among prison inmates.

Dangerous female psychiatric patients: prevalences and characteristics.

OBJECTIVE: We wanted to study the prevalence and characteristics of dangerousness among female psychiatric patients. METHOD: A national survey was performed in Norway, covering all psychiatric in- and out-patient units. RESULTS: There were 329 persons reported to have a psychiatric disorder and to satisfy our criteria for dangerousness, giving a total prevalence of 9.9/100000 adults. There were 54 women, giving a female prevalence of 3.1/100 000. When compared to a matched sample of the men, fewer women were out-patients or had had jail sentences. We found no sex differences with regard to frequencies of psychosis, mental retardation, personality disorders, or drug or alcohol abuse. The women had an increased frequency of suicide-related and self-injurious behaviours and previous commitment for arson. CONCLUSION: The prevalence of women with psychiatric disorders who are considered to be dangerous was 3.1/100 000. The dangerous men did not show higher frequencies than the women for psychopathology, drug abuse, behaviour or criminality.

[Mental health among mentally disabled persons]. / Psykisk helse blant mennesker med psykisk utviklingshemning.

BACKGROUND: Mentally retarded persons have high prevalences of psychiatric disorders and often receive little professional help for them. MATERIAL AND METHODS: From a total of 48 mentally retarded inhabitants in a local community, 28 were selected on the basis of possible psychiatric problems. A psychiatrist diagnosed the persons and gave advice based on personal observation, contact with caregivers, and all available documentation. RESULTS: The estimated levels of functioning were adjusted for 19 persons. 32 new psychiatric diagnoses were detected. Milieu changes were recommended for 25 persons, and 26 changes in psychotropic medication were recommended. INTERPRETATION: Although the procedure is workintensive, the results justify the described approach.

Psychiatric health needs and services before and after complete deinstitutionalization of people with intellectual disability.

Before total deinstitutionalization in Norway, many believed that the ordinary health care system could give people with intellectual disability the same or even better health care than that which they received in institutions. It was said that institutions created psychiatric problems, and that these would diminish or even disappear with the closing of these establishments. The present study is a prospective cohort study without a control group. It examines the frequency of mental health problems and the psychiatric health services which 109 subjects aged between 16 and 65 years received before (1987) and after (1995) deinstitutionalization. Mental health problems were defined as behavioural disturbances, and psychiatric disorders and symptoms. Psychiatric disorders were identified with the Psychopathology Instruments for Mentally Retarded Adults (PIMRA), which were filled in by the carers. Behaviour disturbances were identified as having occurred or not during the previous year. Psychiatric problems remained frequent, and there was a significant increase in behavioural problems in spite of total deinstitutionalization and improved physical living conditions. Access to qualified help, such as psychologists and psychiatrists, had been substantially reduced. Most mental health problems among people with intellectual disability are not solved by reorganization or deinstitutionalization, and such measures are no substitution for professional assistance.

[Health and health services for the mentally retarded before and after the reform]. / Helse og helsetjenester til mennesker med psykisk utviklingshemning før og etter ansvarsreformen.

Reform of the health services in Norway for the mentally retarded led to a complete closure of all institutions for mentally retarded persons by the end of 1996. All 109 of the mentally retarded persons in the county of Sør-Trøndelag who were previously institutionalized were observed throughout this process, in 1987 and 1995. Both physical handicaps and psychiatric/behavioural problems had worsened. The carers' knowledge of their clients' physical health was inadequate in more than half (55%) of the cases. Medical treatment needed improving in 36% of the cases, while it was clearly deficient in 9%. There had been a reduction in the use of general medical services, as well as in the specialised services of psychologists, psychiatrists and neurologists. The organisation of services for this group of clients is in need of improvement.

Predictors of imminent violence in psychiatric inpatients.

Behavior and symptoms seen in 48 24-h periods preceding violent episodes and 93 control observations were studied. Six behaviors were more common before violence: confusion, irritability, boisterousness, physical threats, verbal threats and attacks on objects. A logistic regression equation based on these behaviors in a randomized half of the observations predicted the occurrence of subsequent violence in 92.1% of the other half of the sample without any false positives, giving a sensitivity of 81.3% and a specificity of 100%. It is concluded that mentally ill people display the same behaviour before violent acts as we would expect in people without such disorder. The potential for short-term prediction of violence seems good.

Validity of the schizophrenia diagnosis of the psychopathology instrument for mentally retarded adults (PIMRA): a comparison of schizophrenic patients with and without mental retardation.

The Psychopathology Instrument for Mentally Retarded Adults (PIMRA) was designed to assess psychiatric disorders among mildly and moderately mentally retarded persons. In a psychiatric population without mental retardation (n = 53), the PIMRA schizophrenia scale had an internal consistency coefficient alpha = 0.52. By removing one outlier item this increased to alpha = 0.61. By comparing the PIMRA schizophrenia diagnoses with DSM-III-R diagnoses in the psychiatric population, we found an external reliability corresponding to phi = 0.47 and an unweighted kappa = 0.43. Weighting of the mistakes resulted in a weighted kappa (w) = 0.74. A regression analysis of DSM-III-R diagnosis based on the PIMRA items was conducted. The regression equation was able to identify 75.5% of the DSM-III-R schizophrenic disorders in the psychiatric population. This equation correctly identified 75.5% of the PIMRA schizophrenias in a mentally retarded population. The intermethod reliability was phi = 0.49. We also compared the 38 psychiatric patients with DSM-III-R schizophrenic disorder with the 48 mentally retarded patients with PIMRA schizophrenic disorder. The mentally retarded patients had less delusions and more incoherence and flat affect. They also used less neuroleptic drugs.

[Psychiatric security units in Norway. Patients and activity]. / Norske psykiatriske sikkerhetsenheter. Pasienter og virksomhet.

The authors briefly discuss past and present reasons for the psychiatric security unit system in Norway. They describe the patients in these units at the beginning of 1993 (N = 123). Of these patients, 16% were females, 78% had a main diagnosis of schizophrenia, and 12% were admitted because of personality disorders. Physical restraints had been used for 25%, pharmacological restraints for 17%, and forced pharmacological treatment had been necessary for 26% of the patients during the last six months. There were high rates of behaviour problems related to criminality, abuse, violence and auto-aggression. Nearly all the patients were committed involuntarily, and additional legal restrictions were imposed for one third of them. The majority (63%) of the patients had been in security units for more than one year. The highest levels of security within the security unit system were used for those with the most serious criminality or behaviour problems prior to admission.

Assaultiveness among institutionalised adults with mental retardation.

In an institution, 57 people with mental retardation who had shown assaultive behaviour during the last year were compared with a control group of 57 people in the same institution, matched by sex, level of retardation and age. The study group were younger and had more people with a moderate level of mental retardation than the total population of the institution. Compared with the controls, the assaultive group had more resources available, had more psychopathology, consumed more psychotropic drugs, and had a higher frequency of other problem behaviour. We found no group differences in personal skills, including communication. Generally, the observed covariates of assaultive behaviour resembled that seen in other populations with assaultive behaviour.

Psychopathology in institutionalised mentally retarded adults.

The clients in an institution for the mentally retarded were screened for signs of psychopathology with the Psychopathology Instrument for Mentally Retarded Adults (PIMRA). Of the 168 clients, 146 satisfied criteria for DSM-III axis I disorders, and 153 satisfied criteria for at least one disorder on either axis I or II. Multiple diagnoses were common, and a total of 288 diagnoses were found. No particular disorder was found to be more prevalent in those with organic brain dysfunction. The level of functioning was not found to predispose to any particular diagnosis. There was a positive relationship between the presence of a psychiatric disorder and the resources available to the clients and the activities offered. The prevalence of psychiatric disorders was extremely high in the population studied, with the exception of the affective disorders, of which no case was found. One possible reason for this high prevalence is that deinstitutionalisation leaves behind those with the more severe behavioural problems.

Frequency of and determinants for psychotropic drug use in an institution for the mentally retarded.

The frequency of psychotropic and anticonvulsant drug use in 168 institutionalised mentally retarded adults was studied. Use of neuroleptics and anticonvulsants was more frequent and use of hypnotics and antidepressants less frequent than in the general population. Neuroleptics were given to 49% of the population. Clients with no psychiatric diagnosis consumed less neuroleptics than those with such a diagnosis, and there was a non-significant trend for those with a more serious diagnosis (e.g. schizophrenia) to take a higher dosage. The degree of disruptive behaviour and the availability of a physician were related to dosage of neuroleptics. The various psychiatric diagnoses given could explain only a small proportion of the variance in dosage.