Cognitive behavioural therapy for insomnia (CBT-I) in schizophrenia and schizoaffective disorder: protocol for a randomised controlled trial.

INTRODUCTION: Insomnia is a common symptom among patients with schizophrenia and schizoaffective disorder, negatively impacting symptom severity, functioning and well-being; however, it is rarely the direct focus of treatment. The main recommended treatment for insomnia is cognitive behavioural therapy (CBT-I). There is some evidence that CBT-I can also be used to treat insomnia in patients with schizophrenia, but only a few randomised controlled trials (RCTs) have been published. The aim of this ongoing RCT is to determine whether we can alleviate symptoms of insomnia and improve the quality of life in patients with schizophrenia and schizoaffective disorder through CBT-I delivered via the internet or in a group mode. METHODS AND ANALYSES: The aim of this study is to recruit 84-120 outpatients from the Psychosis Clinics of Helsinki University Hospital and the City of Helsinki Health Services. The main inclusion criteria are a diagnosis of schizophrenia or schizoaffective disorder and self-reported sleep problems. The study will be performed on a cyclic basis, with a target of 12-24 patients per cycle. Participants are randomly assigned into three groups: (1) a group receiving only treatment as usual (TAU), (2) internet-based individual therapy for insomnia (iCBT-I)+TAU or (3) group therapy for insomnia (GCBT-I) conducted via a virtual platform+TAU. The primary outcome measures are quantitative changes in the Insomnia Severity Index score and/or changes in health-related quality of life using the 15D quality of life measure. Secondary outcomes include self-reported variables for sleep, health, stress and the severity of psychotic and depressive symptoms; objective outcomes include actigraphy and bed sensor data to evaluate circadian rhythms and motor activity. Outcome measures are assessed at baseline and after the treatment period at weeks 12, 24 and 36. ETHICS AND DISSEMINATION: The Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, approved the study protocol. The results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04144231.

All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996-2019: a register study.

BACKGROUND: All-cause and suicide mortalities of gender-referred adolescents compared with matched controls have not been studied, and particularly the role of psychiatric morbidity in mortality is unknown. OBJECTIVE: To examine all-cause and suicide mortalities in gender-referred adolescents and the impact of psychiatric morbidity on mortality. METHODS: Finnish nationwide cohort of all <23 year-old gender-referred adolescents in 1996-2019 (n=2083) and 16 643 matched controls. Cox regression models with HRs and 95% CIs were used to analyse all-cause and suicide mortalities. FINDINGS: Of the 55 deaths in the study population, 20 (36%) were suicides. In bivariate analyses, all-cause mortality did not statistically significantly differ between gender-referred adolescents and controls (0.5% vs 0.3%); however, the proportion of suicides was higher in the gender-referred group (0.3% vs 0.1%). The all-cause mortality rate among gender-referred adolescents (controls) was 0.81 per 1000 person-years (0.40 per 1000 person-years), and the suicide mortality rate was 0.51 per 1000 person-years (0.12 per 1000 person-years). However, when specialist-level psychiatric treatment was controlled for, neither all-cause nor suicide mortality differed between the two groups: HR for all-cause mortality among gender-referred adolescents was 1.0 (95% CI 0.5 to 2.0) and for suicide mortality was 1.8 (95% CI 0.6 to 4.8). CONCLUSIONS: Clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for. CLINICAL IMPLICATIONS: It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide.

Have the psychiatric needs of people seeking gender reassignment changed as their numbers increase? A register study in Finland.

BACKGROUND: The number of people seeking gender reassignment (GR) has increased everywhere and these increases particularly concern adolescents and emerging adults with female sex. It is not known whether the psychiatric needs of this population have changed alongside the demographic changes. METHODS: A register-based follow-up study of individuals who contacted the nationally centralized gender identity services (GIS) in Finland in 1996-2019 (gender dysphoria [GD] group, n = 3665), and 8:1 age and sex-matched population controls (n = 29,292). The year of contacting the GIS was categorized to 5-year intervals (index periods). Psychiatric needs were assessed by specialist-level psychiatric treatment contacts in the Finnish Care Register for Hospital Care in 1994-2019. RESULTS: The GD group had received many times more specialist-level psychiatric treatment both before and after contacting specialized GIS than had their matched controls. A marked increase over time in psychiatric needs was observed. Among the GD group, relative risk for psychiatric needs after contacting GIS increased from 3.3 among those with the first appointment in GIS during 1996-2000 to 4.6 when the first appointment in GIS was in 2016-2019. When index period and psychiatric treatment before contacting GIS were accounted for, GR patients who had and who had not proceeded to medical GR had an equal risk compared to controls of needing subsequent psychiatric treatment. CONCLUSION: Contacting specialized GIS is on the increase and occurs at ever younger ages and with more psychiatric needs. Manifold psychiatric needs persist regardless of medical GR.

Snoring was related to self-reported daytime sleepiness and tiredness in young adults performing compulsory conscript service.

STUDY OBJECTIVES: In young adults performing compulsory military service, fatigue and somnolence are common and presumably associated with objective or self-reported sleep deprivation. We aimed to find out whether objective sleep parameters from ambulatory polysomnography could explain their self-reported tiredness and sleepiness and whether habits were associated with sleep parameters or tiredness. METHODS: Seventy (67 male, age 18-24 years) participants had their sleep assessed with polysomnography. Their self-reported symptoms and demographic data were obtained from online survey including Epworth Sleepiness Scale, Beck's Depression Inventory, items from Basic Nordic Sleep Questionnaire, Internet Addiction Scale, and lifestyle questions. RESULTS: Snoring (audio recording, percentage of total sleep time) was associated with self-reported sleepiness (P = .010) and tiredness (P = .030) and snoring seemed to, partially, explain sleepiness (P = .029). Twenty-six percent of the conscripts had self-reported sleep deprivation (mismatch between reported need for sleep and reported sleep). Self-reported sleep deprivation was significantly associated with somnolence (P = .016) and fatigue (P = .026). Smartphone usage, both average time (P = .022) and frequency of usage (P = .0093) before bedtime, was associated with shorter total sleep time. On average, objective sleep time was rather short (7 hours, 6 minutes), sleep efficiency high (94.9%), proportion of N3 sleep high (27.7%), and sleep latency brief (9 minutes)-suggesting that many of the conscripts might have chronic partial sleep deprivation. CONCLUSIONS: Snoring might predispose to tiredness in presumably healthy young adults. Conscripts may have partial sleep deprivation. CITATION: Orjatsalo M, Toppila J, Heimola M, et al. Snoring was related to self-reported daytime sleepiness and tiredness in young adults performing compulsory conscript service. J Clin Sleep Med. 2023;19(2):243-251.

Healthcare workers' heterogeneous mental-health responses to prolonging COVID-19 pandemic: a full year of monthly follow up in Finland.

BACKGROUND: The COVID-19 pandemic strained healthcare workers but the individual challenges varied in relation to actual work and changes in work. We investigated changes in healthcare workers' mental health under prolonging COVID-19 pandemic conditions, and heterogeneity in the mental-health trajectories. METHODS: A monthly survey over a full year was conducted for employees of the HUS Helsinki University Hospital (n = 4804) between 4th June 2020 to 28th May 2021. Pandemic-related potentially traumatic events (PTEs), work characteristics (e.g., contact to COVID-19 patients), local COVID-19 incidence, and demographic covariates were used to predict Mental Health Index-5 (MHI-5) and Insomnia Severity Index (ISI) in generalized multilevel and latent-class mixed model regressions. RESULTS: Local COVID-19 log-incidence (odds ratio, OR = 1.21, with 95% CI = 1.10-1.60), directly caring for COVID-19 patients (OR = 1.33, CI = 1.10-1.60) and PTEs (OR = 4.57, CI = 3.85-5.43) were all independently associated with psychological distress, when (additionally) adjusting for age, sex, profession, and calendar time. Effects of COVID-19 incidence on mental health were dissociable from calendar time (i.e., evolved in time) whereas those on sleep were not. Latent mental-health trajectories were characterized by a large class of "stable mental health" (62% of employees) and minority classes for "early shock, improving" (14%) and "early resilience, deteriorating" mental health (24%). The minority classes, especially "early shock, improving", were more likely to live alone and be exposed to PTEs than the others. CONCLUSIONS: Healthcare workers faced changing and heterogeneous mental-health challenges as the COVID-19 pandemic prolonged. Adversity and mental ill-being may have accumulated in some employees, and factors like living arrangements may have played a role. Knowledge on employees' demographic and socioeconomic background, as well as further research on the factors affecting employees' resilience, may help in maintaining healthy and efficient workforce in the face of a prolonging pandemic.

COVID-19 Pandemic and Helsinki University Hospital Personnel Psychological Well-Being: Six-Month Follow-Up Results.

The COVID-19 pandemic has caused an unequally distributed extra workload to hospital personnel and first reports have indicated that especially front-line health care personnel are psychologically challenged. A majority of the Finnish COVID-19 patients are cared for in the Helsinki University Hospital district. The psychological distress of the Helsinki University Hospital personnel has been followed via an electronic survey monthly since June 2020. We report six-month follow-up results of a prospective 18-month cohort study. Individual variation explained much more of the total variance in psychological distress (68.5%, 95% CI 65.2-71.9%) and negative changes in sleep (75.6%, 95% CI 72.2-79.2%) than the study survey wave (1.6%, CI 0.5-5.5%; and 0.3%, CI 0.1-1.2%). Regional COVID-19 incidence rates correlated with the personnel's psychological distress. In adjusted multilevel generalized linear multiple regression models, potentially traumatic COVID-19 pandemic-related events (OR 6.54, 95% CI 5.00-8.56) and front-line COVID-19 work (OR 1.81, 95% CI 1.37-2.39) was associated with personnel psychological distress but age and gender was not. While vaccinations have been initiated, creating hope, continuous follow-up and psychosocial support is still needed for all hospital personnel.

Chronotype as self-regulation: morning preference is associated with better working memory strategy independent of sleep.

Study Objectives: We set out to examine how chronotype (diurnal preference) is connected to ability to function in natural conditions where individuals cannot choose their sleep schedule. We conducted a cross-sectional study in military conscript service to test the hypothesis that sleep deprivation mediates the adverse effects of chronotype on cognitive functioning. We also examined the effects of time of day. Methods: One hundred forty participants (ages 18-24 years) completed an online survey, including the Morningness-Eveningness Questionnaire and a Cambridge Neuropsychological Test Automated Battery. Most (n = 106) underwent an actigraphy recording. After bivariate analyses, we created a mediation model (self-reported sleepiness and sleep deprivation mediating effect of chronotype on cognition) and a moderation model (synchrony between most alert time and testing time). Results: Reaction times in inhibition task correlated negatively with sleep efficiency and positively with sleep latency in actigraphy. There was no relation to ability to inhibit responses. More significantly, spatial working memory performance (especially strategicness of performance) correlated positively with morning preference and negatively with sleep deprivation before service. Synchrony with most alert time of the day did not moderate these connections. No other cognitive task correlated with morningness or sleep variables. Conclusions: In line with previous research, inhibitory control is maintained after insufficient sleep but with a tradeoff of slower performance. The connection between morning preference and working memory strategy is a novel finding. We suggest that diurnal preference could be seen as an adaptive strategy, as morningness has consistently been associated with better academic and health outcomes.

Personnel Well-Being in the Helsinki University Hospital during the COVID-19 Pandemic-A Prospective Cohort Study.

In March 2020, strict measures took place in Finland to limit the COVID-19 pandemic. Majority of Finnish COVID-19 patients have been located in southern Finland and consequently cared for at the Hospital District of Helsinki and Uusimaa (HUS) Helsinki University Hospital. During the pandemic, HUS personnel's psychological symptoms are followed via an electronic survey, which also delivers information on psychosocial support services. In June 2020, the baseline survey was sent to 25,494 HUS employees, 4804 (19%) of whom answered; altogether, 62.4% of the respondents were nursing staff and 8.9% were medical doctors. While the follow-up continues for a year and a half, this report shares the sociodemographic characteristics of the respondents and the first results of psychological symptoms from our baseline survey. Out of those who were directly involved in the pandemic patient care, 43.4% reported potentially traumatic COVID-19 pandemic-related events (PTEs) vs. 21.8% among the others (p < 0.001). While over a half of the personnel were asymptomatic, a group of respondents reported PTEs and concurrent depression, insomnia, and anxiety symptoms. This highlights the need to ensure appropriate psychosocial support services to all traumatized personnel; especially, nursing staff may require attention.

Clinical Characteristics of Disability in Patients with Indoor Air-Related Environmental Intolerance.

BACKGROUND: Chronic nonspecific symptoms attributed to indoor nonindustrial work environments are common and may cause disability, but the medical nature of this disability is unclear. The aim was to medically characterize the disability manifested by chronic, recurrent symptoms and restrictions to work participation attributed to low-level indoor pollutants at workplace and whether the condition shares features with idiopathic environmental intolerance. METHODS: We investigated 12 patients with indoor air-related work disability. The examinations included somatic, psychological, and psychiatric evaluations as well as investigations of the autonomic nervous system, cortisol measurements, lung function, and allergy tests. We evaluated well-being, health, disability, insomnia, pain, anxiety, depression, and burnout via questionnaires. RESULTS: The mean symptom history was 10.5 years; for disabling symptoms, 2.7 years. Eleven patients reported reactions triggered mainly by indoor molds, one by fragrances only. Ten reported sensitivity to odorous chemicals, and three, electric devices. Nearly all had co-occurrent somatic and psychiatric diagnoses and signs of pain, insomnia, burnout, and/or elevated sympathetic responses. Avoiding certain environments had led to restrictions in several life areas. On self-assessment scales, disability showed higher severity and anxiety showed lower severity than in physician assessments. CONCLUSION: No medical cause was found to explain the disability. Findings support that the condition is a form of idiopathic environmental intolerance and belongs to functional somatic syndromes. Instead of endless avoidance, rehabilitation approaches of functional somatic syndromes are applicable.

Predictors of employment in young adults with psychiatric work disability.

AIM: Mental disorders are the leading cause of work disability among young adults in the industrialized world. Factors predicting employment after long-term psychiatric work disability are largely unknown. METHODS: We linked personal and clinical information from the benefit applications and medical certificates of 1163 young adults (18-34 years) with a new-onset fixed-term psychiatric disability pension in 2008 with employment records between 2005 and 2013. The outcomes were starting employment during and being employed at the end of follow-up. RESULTS: Of the participants, 48% had been employed during and 22% were employed at the end of follow-up. Sustained employment history, university education (master's degree) and no recorded psychological symptoms in childhood were associated with both subsequent employment outcomes. Women and participants under 25 years were more likely to start employment. Depression and other mental disorders (vs psychotic diagnose) and having no comorbid mental disorders or substance abuse were associated with employment at the end of follow-up. CONCLUSIONS: Sustained employment history, university education and no recorded psychological symptoms during childhood predict a return to employment among young adults after a fixed-term psychiatric work disability pension. Pro-active interventions in psychological problems during childhood could enhance employment after a period of work disability.

Subjective and objective measures of function and return to work: an observational study with a clinical psychiatric cohort.

PURPOSE: To evaluate the association between two measurement tools (Social and Occupational Functioning Assessment Scale, SOFAS and Sheehan Disability Scale, SDS), returning to work (RTW) and their inter-correlation. METHODS: 132 psychiatric patients referred to assessment of work ability participated. The association between SOFAS and SDS Work to RTW were assessed by logistic regression. Inter-correlations between SOFAS and SDS were assessed with the Spearman's rho correlation coefficient. RESULTS: SOFAS and SDS Work scores were associated with a 1-year RTW and SOFAS and SDS were inter-correlated. CONCLUSIONS: When assigning the ability to work, both subjective and objective measures of function predict RTW.

[New self-assessment tools for evaluating work ability].

Assessment and support of the work ability and function is an elementary responsibility of health care. The focus of assessment lies in the remaining functional capacity and its sufficiency with respect to occupational demands. Objective and subjective perspectives, personal resources and limitations, and the subject's relationship to the environment are taken into account according to biopsychosocial models of work ability. We recommend three useful self-report measurement tools for work ability and function. Return-to-Work-Readiness Questionnaire (RTW-RQ), Return-to-Work Self-Efficacy (RTW-SE) and Sheehan Disability Scale (SDS). These tools structure an interactive evaluation providing possibilities for follow-up. They provide means to discuss one's personal resources and limitations and to promote return-to-work.

Psychotherapeutic and work-oriented interventions: employment outcomes among young adults with work disability due to a mental disorder.

BACKGROUND: We examined the extent to which psychotherapeutic and work-oriented interventions were included in a medical treatment and rehabilitation plan and whether they predicted future employment among young adults with work disability due to a mental disorder. METHODS: Data were obtained from the treatment and rehabilitation plans of 1163 young adults aged 18‒34 years, who in 2008 were granted fixed-term work disability compensation due to a mental disorder and were followed for 5 years. RESULTS: Forty-six percent had no proposal for psychotherapy or a work-oriented intervention in their treatment and rehabilitation plan, 22 % had a plan for only a psychotherapeutic intervention, 23 % had a plan for only a work-oriented intervention, and 10 % had both types of interventions planned. Having a planned psychotherapeutic intervention (HR = 1.35, 95 % CI 1.07-1.69) and of the work-oriented interventions, planned rehabilitative courses and training (HR = 1.34, 95 % CI 1.03-1.70) predicted quicker entry into competitive employment. Having a plan for both a psychotherapeutic and work-oriented intervention was associated with being employed at the end of the follow-up (OR = 1.77, 95 % CI 1.07-2.95). CONCLUSIONS: Young adults with a long-term psychiatric work disability episode rarely have a recorded plan for rehabilitation in their treatment and rehabilitation plan although psychotherapeutic interventions and a combination of a psychotherapeutic and work-oriented intervention might help them gain employment.

Cultural events provided by employer and occupational wellbeing of employees: A cross-sectional study among hospital nurses.

BACKGROUND: Occupational well-being in health care is essential for the quality of care and productivity. Some of the major challenges facing hospital nurses are the personnel turnover, emotional loading and health care reforms. After primary occupational safety and risk management, complementary positive health promotion approaches with cultural interventions can be experimented. OBJECTIVE: To examine the association between well-being indicators of hospital nurses and their participation in cultural events provided by the employer (theater, concerts, exhibitions, museums, sight-seeing, and musicals) during past 6 months. METHODS: Subjective well-being was measured by work engagement, workplace support for new ideas, work satisfaction and experienced stress. RESULTS: A dose-dependent association was found between participation in cultural events and positive psychology parameters of occupational well-being (support for new ideas and work engagement), but the experience of stress was unrelated to participation in cultural events. Collective participation has a positive covariant effect on work engagement and seems to mediate the innovative work climate measured by workplace support for new ideas. CONCLUSIONS: Collective cultural events for employees may promote positive aspects of occupational wellbeing.

Association Between Unstable Work and Occupational Wellbeing Among Artists in Finland: Results of a Psychosocial Survey.

OBJECTIVE: Although artistic work is in transition, the occupational wellbeing of artists has been less studied than wellbeing among other workers. This study aimed to explore the relationship between work characteristics and occupational (psychosocial) wellbeing of artists. METHODS: A national questionnaire was sent to all artists (theatre artists, writers, and visual artists) reached by four major labor unions in Finland. Type of employment (permanent full-time work vs other), working field (own field of art vs other), regularity of working hours (regular vs irregular), and control of workload were assessed. The wellbeing outcomes were work engagement, recovery from work, and experience of stress and low mood. RESULTS: Full-time permanent employment, regular working hours, and working in one's own field of art were positively associated with work engagement. Furthermore, regular working hours were positively associated with recovery and negatively associated with subjective report of low mood. Ability to control workload was positively associated with recovery and negatively associated with stress and low mood. Higher age was associated with lower stress and better recovery. CONCLUSIONS: Artists with regular working hours, secure employment, ability to control workload, working in one's own field of art, and higher age reported better wellbeing in this study. The late stages of career appear to guarantee more stability and wellbeing than the more insecure beginning of a career.

Cultural leisure activities, recovery and work engagement among hospital employees.

This study explored the relationship between cultural leisure activities, recovery experiences and two outcomes among hospital workers. The differences in recovery experiences (detachment, relaxation, mastery and control) and outcomes (work engagement and subjective recovery state) among hospital personnel (N=769) were analysed by the type (receptive or creative) and frequency of cultural activities. The cross-sectional data were collected by a digital questionnaire. Employees who reported both receptive and creative cultural leisure activities on a weekly basis had the highest relaxation, mastery and control experiences during off-job time. In addition, those with weekly creative activities had beneficial mastery experiences. There were no differences in recovery outcomes after adjustment for age, except in work engagement. Cultural leisure activities, and creative activities in particular, play an important role in certain aspects of recovery.

[Rehabilitation outcomes and return to work after psychiatric examination of work ability]. / Kuntoutustulokset ja työhön paluu psykiatrisen työkykyarvion jälkeen.

The aim of the study was to find out the rehabilitation outcomes and predictors of return to work after psychiatric examination of work ability. Methods. The examination and one-year follow-up were performed at Helsinki University Central Hospital Psychiatric outpatient unit for the assessment of function and capacity. Results. The occupational activity, self-reported functional capacity and quality of life were enhanced. Half of the vocational rehabilitation plans were successful. Conclusions. An absence of less than 6 months and active return to work strategies at occupational health care in co-operation with psychiatrists lead to better outcomes.

Postural control in restless legs syndrome with medication intervention using pramipexole.

Central dopamine regulation is involved in postural control and in the pathophysiology of restless legs syndrome (RLS) and Parkinson's disease (PD). Postural control abnormalities have been detected in PD, but there are no earlier studies with regard to RLS and postural control. Computerized force platform posturography was applied to measure the shift and the velocity (CPFV) of center point of forces (CPF) with eyes open (EO) and eyes closed (EC) in controls (n = 12) and prior and after a single day intervention with pramipexole in RLS subjects (n = 12). CPFV (EO) was significantly lower in the RLS group (p < 0.05) than in controls. After pramipexole intake, the difference disappeared and the subjective symptom severity diminished. Pramipexole did not significantly influence CPFV (EC) or CPF shift direction. Subjects with RLS used extensively visual mechanisms to control vestibule-spinal reflexes to improve or compensate the postural stability. Further research is needed to clarify altered feedback in the central nervous system and involvement of dopamine and vision in the postural control in RLS.

[Vocational rehabilitation in mental disorders]. / Ammatillinen kuntoutus mielenterveyshäiriöissä.

Supporting the working careers of patients having mental disorders is in the best interest of the individual, the community and the society. In mental disorders, recovery to be able to work is more challenging than in other disease groups. Vocational rehabilitation yields the best results when implemented early enough and in close association with work. Work trial and preparation for work are among the most common means of rehabilitation supporting mental patients' return to work. Collaboration with the workplace is needed when the work and working hours are adapted to the needs of the rehabilitee. Supported employment helps even the severely ill to be able to return to work.

[Psychiatric evaluation of functional and work capacity--why, when and how?]. / Psykiatrinen työ- ja toimintakykyarvio--miksi, milloin ja miten?

Evaluation and support of functional capacity are an essential part of treatment and rehabilitation of mental disorders. The evaluation requires objective observations from the examination situation and functional environment and is best effected multi-professionally and in network collaboration. In addition to functional limitations it is important to elucidate the remaining functional capacity, resources, strengths and coping mechanisms of the examined person and the possibilities of the workplace to support continuation in the work. Functional activity, social environment and suitably planned working will support mental health, prevent dropouts and lowering of the quality of life.