Physicians' experiences with sickness absence certification in Finland.

Aims: The aim of this study was to explore Finnish physicians' perceptions of sickness absence (SA) certification. Methods: A questionnaire was sent to 50% of the physicians in Finland who provide care to working-age patients in a clinical practice setting. Of the 8867 physicians, 3089 responded. Physicians handling SA certification patients at least a few times per month were included (n = 2472). Results: At least a few times per month, 61% of all physicians perceived SA issues as problematic, 60% had experienced a lack of time in dealing with SA matters, 36% had disagreed with a patient on SA certification, and 36% had met a patient who wanted a SA certificate for reasons other than a disease or injury. Physicians were least worried about patients filing complaints (4%), exhibiting threatening behaviour (2%), or switching physicians for SA certification reasons (1%). A total of 60% of physicians had prescribed SA for a longer period than necessary because of long waiting times for further care/measures. Non-specialized physicians, general practitioners, and psychiatrists experienced problems more frequently than surgeons and occupational health physicians. Over 50% of the respondents had a fairly large or very large need to deepen their knowledge of social insurance matters. The need for national guidelines for all or some diseases was reported by 80% of the respondents. Conclusions: Many physicians perceive SA tasks as problematic and are unable to dedicate enough time to them. Shortcomings in physicians' sickness certification know-how, as well as obstacles in the healthcare and rehabilitation system, prolong the SA process. Attitudes towards the adoption of national guidelines on the duration of SA were positive.

Stroke unit care benefits patients with intracerebral hemorrhage: systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Patients with any type of stroke managed in organized inpatient (stroke unit) care are more likely to survive, return home, and regain independence. However, it is uncertain whether these benefits apply equally to patients with intracerebral hemorrhage and ischemic stroke. METHODS: We conducted a secondary analysis of a systematic review of controlled clinical trials comparing stroke unit care with general ward care, including only trials published after 1990 that could separately report outcomes for patients with intracerebral hemorrhage and ischemic stroke. We performed random-effects meta-analyses and tested for subgroup interactions by stroke type. RESULTS: We identified 13 trials (3570 patients) of modern stroke unit care that recruited patients with intracerebral hemorrhage and ischemic stroke, of which 8 trials provided data on 2657 patients. Stroke unit care reduced death or dependency (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.471-0.92; P=0.0009; I2=60%) with no difference in benefits for patients with intracerebral hemorrhage (RR, 0.79; 95% CI, 0.61-1.00) than patients with ischemic stroke (RR, 0.82; 95% CI, 0.70-0.97; Pinteraction=0.77). Stroke unit care reduced death (RR, 0.79; 95% CI, 0.64-0.97; P=0.02; I2=49%) to a greater extent for patients with intracerebral hemorrhage (RR, 0.73; 95% CI, 0.54-0.97) than patients with ischemic stroke (RR, 0.82; 95%, CI 0.61-1.09), but this difference was not statistically significant (Pinteraction=0.58). CONCLUSIONS: Patients with intracerebral hemorrhage seem to benefit at least as much as patients with ischemic stroke from organized inpatient (stroke unit) care.

Assessment of depression after stroke: a comparison of different screening instruments.

BACKGROUND AND PURPOSE: Assessing poststroke depression may be complicated by aphasia, other cognitive deficits, and several somatic stroke-related symptoms. We studied the possible differences in performance of some commonly used instruments in screening depression after stroke. METHODS: We compared the Beck Depression Inventory, Hamilton Rating Scale for Depression, Visual Analogue Mood Scale, proxy assessment, and Clinical Global Impression of the nursing and study personnel, together with Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised diagnosis, in assessing depression after stroke in a follow-up study of 100 patients. The patients were studied at 2 weeks and at 2, 6, 12, and 18 months after stroke. RESULTS: The feasibility rates of all assessment instruments studied were fairly similar, but the prevalence rates differed according to the assessment instruments, varying from the lowest rates with a Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised-based diagnosis up to 3-fold with caregiver ratings. The sensitivity and specificity against the Diagnostic and Statistical Manual of Mental Disorders criteria were acceptable with the Clinical Global Impression, Beck Depression Inventory, and Hamilton Rating Scale for Depression, mostly in the range of 0.70 to 1.00. The caregiver ratings were higher than the patient ratings (P<0.001) and correlated with the caregiver's own Beck Depression Inventory (0.60 to 0.61, P<0.001). The Visual Analogue Mood Scale was not a sensitive instrument (sensitivity, 0.20 to 0.60) and did not correlate with the Beck Depression Inventory during the first year after stroke. CONCLUSIONS: Beck Depression Inventory, Hamilton Rating Scale for Depression, and Clinical Global Impression assessment by professionals, in addition to the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised diagnosis, are useful in assessing depression, but none of these instruments clearly stood apart from the others. Proxy ratings should be used with caution, and the use of the Visual Analogue Mood Scale among patients with aphasia and other cognitive impairments cannot be recommended.

Depression among caregivers of stroke survivors.

BACKGROUND AND PURPOSE: We aimed to assess the prevalence of depressive symptoms among caregivers of stroke survivors and to determine which patient- or stroke-related factors are associated with and can be used to predict caregiver depression during an 18-month follow-up after stroke. METHODS: We examined 98 caregivers of 100 consecutive patients experiencing their first ischemic stroke in Helsinki University Central Hospital. The caregivers were interviewed at the acute phase and at 6 months and 18 months. Depression was assessed with the Beck Depression Inventory. The neurological, functional, cognitive, and emotional status of the patients was assessed 5x during the follow-up with a comprehensive test battery. RESULTS: A total of 30% to 33% of all caregivers were depressed during the follow-up; the rates were higher than those of the patients. At the acute phase, caregiver depression was associated with stroke severity and older age of the patient, and at 18 months the older age of the patient was associated with depression of the spouses. In later follow-up, caregiver depression was best predicted by the caregiver's depression at acute phase. CONCLUSIONS: Identifying those caregivers at highest risk for poor emotional outcome in follow-up requires not only assessment of patient-related factors but also interview of the caregiver during the early poststroke period.

Poststroke depression: an 18-month follow-up.

BACKGROUND AND PURPOSE: This prospective study was designed to examine the course, associates, and predictors of depressive symptoms during the first 18 months after stroke. METHODS: A total of 100 patients were followed up for 18 months after stroke. Depressive symptoms were assessed at 2 weeks and 2, 6, 12, and 18 months after stroke with the Beck Depression Inventory and the Hamilton Rating Scale for Depression, and diagnoses were performed using criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised. Stroke severity was assessed with the Scandinavian Stroke Scale and cognitive functions with a comprehensive neuropsychological battery. Patients participated in a randomized clinical trial of antidepressive medication. RESULTS: In all, 54% of patients felt at least mildly depressive at some time during the follow-up; 46% of those who were depressive during the first 2 months were also depressive at 12 and/or 18 months. Only 12% of patients were depressive for the first time at 12 or 18 months. The male sex was associated with a more negative change in depressive symptoms during the follow-up. Older age was associated with depressive symptoms during the first 2 months, stroke severity from 6 to 12 months, and the male sex at 18 months. Depressive symptoms were unrelated to the lesion location. CONCLUSIONS: Depressive symptoms are frequent and they often have a chronic course. Depression is associated with stroke severity and functional impairment, and with the male sex at 18 months. Attention should be focused on the long-term prognosis of mood disturbances and adaptation.

Administration of nonionic iodinated contrast medium does not influence the outcome of patients with ischemic brain infarction.

Some reports indicate that exposure to iodinated contrast medium (CM) could worsen the outcome of patients with brain infarction. In this prospective study, we compared the outcome of 77 patients receiving and 128 not receiving nonionic iodinated CM. Stroke severity was assessed by the Scandinavian Prognostic Stroke Score, and outcome by the Rankin Scale. All radiological studies using intravenous or intra-arterial CM were registered. Two nonionic iodinated CM (iopamidol and iohexol) were used. Exposure to CM did not influence case fatality, ability to live at home, ability to walk, disability and stroke severity. Initial stroke severity and arterial hypertension were independent determinants of poor neurological recovery or death. Large infarct, age, male gender, and baseline stroke severity were independent determinants of major disability or death. CM enhancement on CT did not show any harmful effect on stroke severity or outcome. As a conclusion, intravascular administration of nonionic iodinated CM did not influence stroke severity or outcome of our patients.

Complaints of poststroke insomnia and its treatment with mianserin.

We assessed the prevalence and associations of symptoms of insomnia in patients with acute ischemic stroke, and evaluated whether mianserin as a sedative antidepressant is beneficial in the treatment of poststroke insomnia. One hundred consecutively hospitalized patients were randomized to receive 60 mg/day of mianserin (n = 51) or placebo for 1 year in a double-blind trial with a 6-month follow-up after the therapy. Symptoms of insomnia were assessed with the three insomnia-related items of the Hamilton Depression Scale; patients were defined as insomniacs if any of these items was positive. Complaints of insomnia occurred in 68% of patients on admission, and in 49% at 18 months, and they were as frequent in all subgroups of patients. From 2 months, symptoms of insomnia were associated independently with depression. Living alone before stroke (at 0 and 2 months) and age (at 12 months) were other independent predictors of insomnia. The rate of recovery as evaluated by the insomnia score was more rapid in patients on mianserin than in those on placebo. At 2 months, the scores were significantly different favoring mianserin treatment (1.3 vs. 0.8, p = 0.02). We conclude that insomnia is a common complaint after ischemic stroke. Mianserin had a beneficial influence on the recovery from symptoms of insomnia, even though the intensity of poststroke depression was low.