Mental health care reform in Sweden, 1995.

OBJECTIVE: To describe the content of the Community Mental Health Care reform in Sweden, in effect from 1995 and directed to severely mentally ill people (SMI). METHOD: Evaluating changes, at local and national level, in living conditions among SMI and resources of services directed to them, by using registers, questionnaires, interviews and case studies. RESULTS: A survey, covering 93% of the population, identified 43,000 SMI (prevalence of 0.63%); 4,000 long-stay patients and 400 rehabilitation programmes were transferred from psychiatric services to social services (15% of the budget of psychiatric services). Employment and rehabilitation projects, family support and user programmes and educational projects for social services staff, were launched (funded by state subsidies). CONCLUSION: SMI still have difficulties in obtaining adequate support on the basis of disability laws and there continue to be barriers between social services and psychiatric services.

Psychiatric morbidity in primary public health care: a multicentre investigation. Part II. Hidden morbidity and choice of treatment.

A total of 1,281 patients were examined during consultation with their GP in a Nordic multicentre study focusing on the prevalence of psychiatric illness, hidden psychiatric morbidity, treatment and pathways to specialized care. The methodology and prevalence were reported in an accompanying paper. The present paper presents results concerning the variables hidden psychiatric morbidity, treatment and pathways to specialized care. The GPs detected 44% of the psychiatric cases compared with the result of a diagnostic interview (PSE). The distinction between psychosis and non-psychosis did not influence the GPs' ability to detect a mental illness. According to the GPs' assessment the majority of patients suffering from a mental disorder consulted their GP about physical complaints. The GPs treated the patients themselves, and only a limited number of cases were referred to psychiatrists or psychologists.

Identified and unidentified mental illness in primary health care--social characteristics, medical measures and total care utilization during one year.

OBJECTIVE: To screen patients in general practice with regard to identified and unidentified mental illness, and to describe social and demographic profiles of the two groups and their medical measures and total care utilization. DESIGN: Cross sectional study of 333 consecutive patients with one year follow-up. SETTING: Two primary health care units in a Stockholm suburb area. PARTICIPANTS: Patients 18 years and older. MAIN OUTCOME MEASURES: Mental illness according to either ICD-9 diagnosed by GPs (identified cases) or when not identified by GPs according to a self-assessment questionnaire HSCL-25 with cut-off point 1.75 (unidentified cases). RESULTS: In comparing identified (15.3%) and unidentified patients (11.7%) with other patients (No mental illness) no differences were found in demographic antecedents. Social problems existed in 31% of identified, 49% in unidentified, and 14% in patients with no mental illness. Sick-listing and issuing of prescriptions were more frequent in patients with identified mental illness. The one year follow-up study also showed over-utilization of care in these patients. The psychiatric services were sought by about one fifth of both the patient groups with mental illness, which is to a significantly greater extent than for patients without mental illness (2%). CONCLUSION: Patients with self-assessed mental illness not identified by GPs are not deemed to be "over-medicalized" nor to overload care-services, while patients identified by GPs with a diagnosis of mental illness receive a lot of medical input and require much care. Psychosocial inputs for the latter group within primary care can presumably reduce unnecessary utilization of resources.

Test characteristics of the Hopkins Symptom Check List-25 (HSCL-25) in Sweden, using the Present State Examination (PSE-9) as a caseness criterion.

The Hopkins Symptom Check List-25 (HSCL-25) is a screening instrument designed to identify common psychiatric symptoms. It has been widely used in different settings outside Sweden and also compared to assessment of psychiatric illness made by general practitioners. The aim of the present study was to validate the HSCL-25 against a psychiatric interview using the Present State Examination (PSE-9) in a Swedish sample of patients in general practice. Validity coefficients of the HSCL-25 were calculated for two different thresholds of caseness, > or = 1.55 and > or = 1.75, respectively. When > or = 1.75 was chosen as a cutoff point, the validity coefficients obtained by the HSCL-25 in this study were comparable to those obtained in other studies.

[Mental illness in patients in primary health care. A Scandinavian multicenter study]. / Psykisk ohälsa hos patienter i primärvården. En nordisk multicenterstudie.

In a Nordic multicentre study of psychiatric illness in primary care, patients in four health districts were screened for psychiatric illness. General practitioners' ratings of psychiatric illness and patients' ratings of psychosocial problems were also included. The patients' utilisation of care and health insurance facilities was reviewed. A random subsample of patients were invited to a semi-structured diagnostic interview with a psychiatrist. Results from the Swedish part of the study showed about 1/3 of the 724 patients investigated to be probable psychiatric cases, while 1/5 were psychiatric cases in need of treatment. The psychiatric cases were characterised by a preponderance of divorced, unemployed women. At 1-year follow up, the utilisation rate of care and health insurance facilities among psychiatric cases was found to be higher than for nonpsychiatric cases.

Social conditions in a total population with long-term functional psychosis in three different areas of Stockholm County.

A number of social conditions regarding interpersonal relations, housing and employment were studied in a total population of individuals with long-term functional psychosis (n = 341) drawn from the population aged 18-64 years inhabiting three different areas of Stockholm County, altogether about 57,000 inhabitants. Individuals were included irrespective of whether they had a psychiatric treatment contact or not. They were mostly unmarried (57%) and living alone (64%). Most were unemployed (69%) and over half received a disability pension. However, 76% had their own flat and a reasonable financial standard, not deteriorating with illness duration. The diagnosis of schizophrenia led to poorer social conditions, as did early age at onset, male sex and co-morbidity of substance abuse. A larger number of individuals lived in an institution in the urban area while a greater number lived with relatives in the rural area.

Health care occupations and suicide in Sweden 1961-1985.

The sex and age standardized incidence rates of suicide and undetermined deaths in Sweden were described for physicians, dentists, registered nurses, attendants in psychiatric care and auxiliary nurses for the five years following each of the censuses, 1960, 1970, 1975 and 1980. Amongst men all the occupations apart from registered nurses show increasing suicide rates from 1960, with significantly higher suicide rates during the seventies than the total male working population. A radical fall in the number of suicides amongst physicians, dentists and registered nurses took place in the period 1981-85, whilst attendants in psychiatric care and auxiliary nurses show a continuing significant excess in suicide rate. Among female physicians, there was an extremely high suicide rate in 1960, followed by a distinct fall until the period 1981-85 although the rates were significantly elevated in all periods. Female dentists show consistently high suicide rates during the seventies and eighties. Registered nurses show a reduction from a significantly high rate in the period 1961-65 and the seventies to a level equal to the total female working population. Female attendants in psychiatric care and auxiliary nurses have low rates in almost all periods. These suicide trends are compared with an increase in the proportion of women in gainful employment as well as the radical alteration in family patterns in Sweden during the seventies. Further research should emphasize the change in social roles, both in the labour market and in the family.

Patterns of care among people with long-term functional psychosis in three different areas of Stockholm County.

This study of long-term functionally psychotic people in Stockholm County describes the psychiatric and somatic care provided as well as social welfare support and medication in a total cohort. This group included all non-organic cases of psychosis aged 18-64 years. The group was found still to be very dependent on institutional care, with an average of 75 d of psychiatric inpatient care. Males spent twice as long as females as inpatients, and people from the urban area spent a longer time than those from the other areas. Antipsychotic medication increased from the rural to the urban area. The diagnosis of schizophrenia and early age at onset were each per se associated with higher likelihood of inpatient treatment and depot medication. Contrary to expectations, medication with antipsychotic drugs was shown to increase with illness duration.

Long-term unemployment and mortality in Sweden, 1980-1986.

The mortality of a cohort of long-term unemployed men and women in Sweden (N = 28,846) was followed up during the period 1980-1986. Compared to a population of employed, the total mortality rate ratios (with 95% confidence limit) were 1.37 (1.22-1.53); for men 1.61 (1.42-1.84) and for women 1.14 (0.91-1.42). The young/middle-aged men had about four times higher relative mortality than all men. Suicide and alcohol-related deaths could not explain the excess mortality among these men. It is discussed whether the high risks for young/middle-aged men could be an effect of mental disturbances due to unemployment followed by high psycho-social stress. The effect of employment status on social and psychological identity may be greater for men than for women, for whom there may be more compensatory factors.

From community mental health services to specialized psychiatry: the effects of a change in policy on patient accessibility and care utilization.

In 1975, a community mental health (CMH) centre with most of its resources channelled to outpatient services was set up in a defined catchment area of 75,000 inhabitants near Stockholm. In 1981, the CMH centre was allocated 3 inpatient wards of its own. An outpatient unit to treat long-term psychotic patients was also built up from existing resources. Emergency cases were directed to the primary health care services or to the emergency department of a hospital. During the same period, the number of doctors in the area's primary health care services increased fourfold. The social, demographic and diagnostic composition of the patient population and its utilization of in- and outpatient care in connection with these organizational changes are described. The population of the cathment area increased by 12.5% and the patient population decreased by 40%. The decrease was particularly great among first-time visitors (-54%), patients from lower social groups (-53%) and those with crisis diagnosis (-71%). The number of patients with psychoses increased (+26%). Outpatient visits and hospital utilization increased by one third. The number of compulsory admissions increased by 20% (still being far below the mean number in Stockholm). The decrease in the patient population is attributed to the reduction in accessibility to the CMH centre at a time when primary care services in the area were undergoing a sizeable expansion. The increased care utilization is the result of an internal redistribution of resources in favour of resource-demanding, long-term psychotic patients.

Epidemiology of long-term functional psychosis in three different areas in Stockholm County.

This study is the first in a series investigating different aspects of living conditions and care utilization in a total population with long-term functional psychoses (LFP). The study cohort (n = 302) was defined as people that: were aged 18-64 years, were affected by a nonorganic psychosis continuously during at least 6 months, showed psychotic features or residual symptoms during 1984, and had their home address in the study area during 1984. The study area consists of one rural and one suburban municipality, and one urban parish (57,035 inhabitants aged 18-64 years). The LFP concept used shows a high interrater reliability (kappa = 0.93). The one-year prevalence in the rural, suburban and urban areas was 3.4, 5.6 and 6.6 per 1000 respectively, thus producing a gradient from the rural to the urban areas. The prevalence of schizophrenia (DSM-III) was 2.6, 3.8 and 5.0 per 1000 respectively. The other diagnoses covered by the LFP concept (paranoia, major affective disorder with psychotic features, and psychotic disorder not elsewhere classified) showed the same gradient, with the exception of paranoia, which showed a lower rate in the urban area. The prevalence of schizophrenia was higher among males, while for paranoia the prevalence was higher among females.

Who commits suicide after a suicide attempt? An 8 to 10 year follow up in a suburban catchment area.

One hundred and sixty-three individuals in a suburban catchment area of 72,000 inhabitants made registered suicide attempts during 1975-1976 (i.e. 159/100,000 greater than or equal to 18 years). They were followed up by means of the Swedish Register of Death Causes over a period of 8-10 years. Police reports, autopsies and psychiatric records were also studied. Six cases of verified suicide were found and four additional cases were considered as probable or possible suicides. Thus the cumulative rate over 8-10 years was 3.7-6.1%. There was a mean number of 3.5 suicide attempts before the eventual suicide. The most important common factor overall was alcohol or drug abuse with social deterioration (seven in 10 cases). The rest (three in 10 cases) were depressed women with long-standing suicidal processes. The importance of recognizing chronic abuse as probably the most important background factor is stressed. The total group encompasses individuals with longstanding and severe life problems and difficulties in relating to society. The realistic chances of being able to provide effective suicide prophylaxes for most of these patients requires well planned and longstanding treatment and rehabilitation programmes.

Introducing community mental health services. The effects on a suburban patient population.

By means of a computerised psychiatric case register, the effects on a defined population with 71,371 inhabitants were studied when the mainly hospital-based psychiatric services in the area were changed to community mental health units with substantial outpatient resources. Diagnostic, social and demographic variables and care utilisation rates were compared. A 29% increase in patients under the new system was observed. Most of the newcomers had acute crisis reactions, were younger, on average, than previous patients and registered alcohol abuse and somatic diseases. Outpatient utilisation increased (170%) and hospital admissions decreased (22%). Compulsory admissions increased (43%), as did sick-leave registrations (21%). These trends are discussed in light of the new organization.

Map analyses of psychiatric services. The application of a computerized psychiatric case register to geographical analysis.

A computerized system to make map analyses of psychiatric services (MAPS) was developed by combining data from a psychiatric case register with a demographic data base updated twice a year. The case register covered all adult psychiatric in- and out-patient services in a catchment area of 75,000 inhibitants. The analyses were carried out for homogeneous sub-areas, thus providing the clinic with knowledge about the geographical distribution of diagnostic categories and utilization of services. In a first stage, the system utilizes the flexible features of the statistical analysis system (SAS). In the final graphic stage, the SAS/GRAPH or the UNIRAS System may be used alternately. Special statistics from the epidemiological frame of reference are constructed for comparing sub-areas, such as standardized morbidity ratio, standardized relative risk with confidence interval and corresponding p-values. The system's application to planning of services and research is illustrated.

Social class and psychotherapy.

By means of a psychiatric case register the total psychiatric population in the Nacka region (75,000 inhabitants) was analysed during a 2-year period with regard to the amount of psychotherapy consumed in different social groups. Among the patients, the utilization of psychotherapy was 60% for social group I compared with 30% for social group III. However, the lowest social groups are overrepresented at the mental health unit. Thus, among the total population, the utilization of psychotherapy was 1.8% for social group I compared with 5.3% for social group III. The study discusses the "clinical fallacy", by which data from a patient population is applied to the whole population, giving wrong or restricted perspectives to the problem studied. It is claimed that the selectivity of the psychiatric organization concerning social groups is an important factor for the so-called "social class bias" in psychotherapy.