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Introduction: Research shows that people in prison often have poor mental health (1). Prisoners often lack access to sufficient and integrated mental health services (1). Social support can be defined as the perceived availability or actual provision of social resources in the context of relationships. It is an important determinant for mental health and has been found to be relevant in a range of settings (2-4). Imprisonment is a stressful experience. In line with the stress-buffering hypothesis, social support in prison could increase the ability to cope, which in turn would promote mental well-being.Objectives and methods: The study draws on elements from constructivist grounded theory to explore prisoners’ perceptions of social support, its significance for mental health, and the factors influencing the availability and acceptability of seeking social support from different sources in a prison setting. Drawing on collaboration with a prisoner support organization, we conducted in-depth interviews with eight prisoners from a prison in Northern Norway. They were asked about their mental health knowledge and about the factors that influenced their mental health during imprisonment.Key findings: The participants viewed the support of fellow prisoners as important for their mental health, while support from friends, family and prison officers were not granted the same significance. Limited and expensive phone hours and security measures were among the barriers for support from people on the outside. Some of the prison officers were perceived to be supportive while others were labelled uncaring, and the participants claimed that they would have to make calculated choices of whom they turned to for support. The prison's electronic records were a prominent barrier for confiding in prison officers, as the prisoners feared information could recorded and used against them. Although fellow prisoners were the most accessible and acceptable source of support, the participants claimed that fewer activities and more time in lock-up along with unwanted criminal talk in the prison wing and trust issues were barriers to social support from peers.Conclusions: The perceived significance of social support from fellow prisoners was amplified by the barriers to support from people on the outside, and from officers. Shared activities with peers could be important both for coping with prison life, and for reducing criminal influence that seemed to be associated with unstructured spare-time.Implications: Facilitating social support may help prevent or alleviate mental health challenges among prisoners. References1. Fazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R. Mental health of prisoners: prevalence, adverse outcomes, and interventions. Lancet Psychiatry. 2016; 3:871–881. 2. House JS, Kahn RL. Measures and concepts of social support. In Cohen S, Syme SL (eds.) Social support and health, San Diego, CA: Academic Press, 1985: 83-108.3. Gabarron E, Larbi D, Årsand E, Wynn R. Engaging social media users with health education and physical activity promotion. Stud Health Technol Inform. 2021;281:789-793. 4. Vambheim SM, Wangberg SC, Johnsen JA, Wynn R. Language use in an internet support group for smoking cessation: development of sense of community. Inform Health Soc Care. 2013;38:67-78.

Introduction: The case report has played a role in medicine since antiquity (1,2). The genre has traditionally been characterized by a format emphasizing biomedical aspects (1-3). As the health services have become more attentive to the importance of patients' life circumstances and patients' active involvement in treatment and research, psychosocial aspects and the patients' own perspectives are being included in more case reports (2,4). Aims, Objectives, Theory or Methods: We discuss recent developments in the case report genre, including the focus on increasing user involvement.Highlights or Results or Key Findings: Through the history of medicine, the core of the case report has remained the description of the illness of a patient and how the patient is treated (1-3). However, the case report genre has shown a strong ability to adjust to changes in medicine as well as in society. In modern times, it has become essential for clinicians to take into consideration the importance of psychological and social factors when communicating with patients and diagnosing and treating their illnesses (4,5). Accordingly, the medical case report should also encompass these perspectives, and this is becoming increasingly commonplace. More recently, user involvement both in clinical practice as well as in research has become mainstream (6). Patients rightly expect to have a central role in their own treatment and also to play an important role in medical research that is of importance to them. Thus, medical case reports should include the patients' perspectives on their own illness and treatment, and some patients may also take an interest in participating more broadly in the research process.Conclusions: The medical case report is adjusting to recent developments in medicine and society. Considering the importance of psychological and social factors for the patient’s illness and treatment and inviting the patients’ perspectives to the research have become increasingly important when working on case reports.Implications for applicability/transferability, sustainability, and limitations: As the practice of medicine is changing, so is the medical case report. Patients’ perspectives should be an integral part of case reporting, and there is also a need to take into consideration how psychological and social aspects impact the patients.References1. Nissen T, Wynn R. The history of the case report: a selective review. JRSM Open. 2014;5(4):2054270414523410.2. Nissen T, Wynn R. The recent history of the clinical case report: a narrative review. JRSM Short Reports. 2012;3(12):1-5.3. Nissen T, Bergvik S, Wynn R. The case of case reports: A decade of publications by staff at a major university hospital. European Journal for Person Centered Healthcare. 2015;3(2):215-2214. Nissen T, Wynn R. Clenched fist syndrome: a case report. J Med Case Rep. 2018;12(1):1-7.5. Wynn R. The linguistics of doctor-patient communication: An analysis of the methodology of doctor-patient communication research. Oslo: Novus Press, 1995.6. Sangill C, Buus N, Hybholt L, Berring LL. Service user's actual involvement in mental health research practices: A scoping review. Int J Ment Health Nurs. 2019;28(4):798-815.

IntroductionWhile nine out of ten prisoners in Norway meet the criteria for at least one psychiatric illness or personality disorder (1), it has been a challenge that mental health services for inmates have been insufficient and fragmented. Many prisoners are reluctant to seek professional help, possibly because of a lack of awareness or a fear of stigma. Mental health literacy (MHL) represents a person’s knowledge and beliefs about mental disorders. A person with a sufficient level of MHL can better recognise, manage, and prevent mental health problems (2,3). Recent definitions of MHL have incorporated knowledge of how to gain positive mental health. Theory/MethodsThis study will examine MHL among prisoners in Norway. While there is some knowledge of help-seeking attitudes and behaviour among prisoners, the broader concept of MHL is unexplored in a prison context. Participants will be recruited from prisons in Northern Norway. Data will be collected using qualitative interviews. In a first sample, the questions will focus on the prisoners' knowledge and beliefs about positive mental health, and their experiences of factors in the prison context that promote well-being. In a second sample, the questions will focus on prisoners' knowledge, beliefs, and attitudes towards mental illness and its causes. In addition, prisoners will be asked about where they could gain information about mental health, how they would prefer to manage mental distress, and about their opinions on professional treatment for mental illness. An organisation for the welfare of prisoners participates in the project.Results and Discussion (Expected outcomes)Knowledge of MHL among prisoners will contribute to a greater understanding of how prisoners conceptualize mental health, and the grounds for the decisions prisoners make regarding mental health issues. This knowledge will be useful for tailoring information and programs on the subject of mental health for people in prison and might also help improve clinical communication and the therapeutic alliance (4,5). Also, the knowledge gained from this project will be useful for designing interventions aimed at enhancing the effectiveness of self-management strategies, help-seeking behavior, and adherence to treatment among prisoners. Conclusions/lessons learned, limitations and suggestions for future researchImproving the mental health of prisoners is a major challenge and the services provided so far in Norway have been insufficient and fragmented. This study represents a central step in tailoring mental health interventions to prisoners in Norway by drawing on the concept of mental health literacy. References1. Cramer V. Forekomst av psykiske lidelser hos domfelte i norske fengsel. Prosjektrapport 2014-1. OUS, Norway, 2014.2. Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. “Mental health literacy”: a survey of the publics’ ability to recognize mental disorders and their beliefs about the effectiveness of treatment. Med J Australia. 1997;166:182–186. 3. Mitchell J, Latchford G. Prisoner perspectives on mental health problems and help-seeking. J Forensic Psychiatry Psychol. 2010;21:773–788. 4. Wynn R. Provider-patient interaction. Norwegian Academic Press. Oslo, Norway, 1998.5. Littauer H, Sexton H, Wynn R. Qualities clients wish for in their therapists. Scand J Caring Sci. 2005;19:28-31.

Introduction In many health care systems, patients experience a fragmented service where different clinical specialities are not well integrated. A lack of clinical overview can be missing as each clinician focuses on his or her part. This lack of overview can have consequences as patients can be given sub-optimal care and it may also affect doctor-patient communication (1). Theory/Methods We focus on how the scientific genre of the medical case history can help clinicians gain a more integrated overview of patients' history and treatment and how the process of composing case histories may be conducive to better integrated clinical work. The clinical case report has a long tradition in medicine (2,3). Following a period when this genre was less popular, it has recently had a renaissance in part due to the availability of online publishers and the open-access movement (3,4). Results and Discussion In a clinical case report, a patient's medical history is briefly presented. A case report will often include some contextual information about the patient, but the focus is usually on a clinical phenomenon or an illness (1-4). Sometimes, the case is presented because it has scientific value, other times it is the educational value that it highlighted (4). Many patients with illnesses that are rare or otherwise challenging to diagnose or treat are treated by different types of clinical specialists that cooperate to a varying extent. While optimal clinical cooperation may sometimes be difficult to achieve due to how clinical work is organised in many hospitals, collaborations across specialities and departments where clinicians in retrospect work out case histories are probably often easier to achieve (4). The most interesting case reports may be those where the authors are able to integrate perspectives from different parts of patient's treatment, for instance medical and surgical or medical and psychiatric (5,6). Especially novice clinicians can learn much both about the integration of clinical work and scientific method by working out case reports together with clinicians from different areas of medicine (4). Conclusions/lessons learned, limitations and suggestions for future research Working out case reports may help clinicians get a broader understanding of the medical history and clinical challenges of individual patients, and may also be conducive to better cooperation between clinicians from different specialities. More research is needed to examine to what degree working on case histories can result in better clinical integration. References 1. Wynn R. Provider-patient interaction. Oslo: Norwegian Academic Press, 1998. 2. Nissen T, Wynn R. The history of the case report: a selective review. JRSM Open 2014;5(4):2054270414523410. 3. Nissen T, Wynn R. The recent history of the clinical case report: a narrative review. JRSM Short Reports 2012;3(12):1-5. 4. Nissen T, Wynn R. The clinical case report: a review of its merits and limitations. BMC Research Notes 2014;7:264. 5. Nissen T, Wynn R. Clenched fist syndrome: a case report. Journal of Medical Case Reports 2018;12:168 6. Nissen T, Rorvik P, Haugslett L, Wynn R. Physical restraint and near death of a psychiatric patient. Journal of Forensic Sciences 2013;58:259-262.

Introduction : Social media use for health purposes is gaining ground, and individuals and organizations are increasingly using social media to inform about and discuss health-related issues and even to offer treatment [1,2]. The health-related use of the Internet and the social media can empower patients in dealing with their own health and illness [3]. However, there has been concern relating to how social media may influence the health professional-patient relationship [4], and guidelines have been developed on health professionals’ social media use [5]. Methods : In a pilot study, we performed in-depth interviews with five healthcare providers (one doctor, two psychologists, and two nurses) working at a Norwegian psychiatric university clinic. They were asked about their work-related experiences with social media and especially whether they had experienced that their patients had discussed their treatment on social media. The interviews were analyzed drawing on the method of content analysis. Results : All had private social media accounts, but none had extensive work-related experience with social media. None had posted on social media as part of their work. Three had read social media comments posted by their patients relating to treatment. Patients’ posting of criticism was perceived of as potentially problematic for the health professional-patient relationship. Discussion, limitations, and lessons learnt : It may represent a challenge for health providers when patients discuss and evaluate their treatment on social media. While patients may post about their interaction with health professionals and treatment, confidentiality makes this off limits to health professionals [4,5]. Moreover, such posts can in some cases reflect ongoing problems in the health professional-patient relationship that should be addressed by the patient and the health professional. If health professionals feel that they are publicly unfairly evaluated by patients, this might provoke negative feelings towards patients and thereby negatively influence the health professional-patient relationship [3-6]. The study suggests that there is a need for discussion amongst health professionals regarding how to handle online criticism in a professional manner. This was a small exploratory study and more research is needed to confirm its findings. References : 1. Gabarron E, Serrano JA, Wynn R, Armayones M. Avatars using computer/smartphone mediated communication and social networking in prevention of sexually transmitted diseases among North-Norwegian youngsters. BMC Med Inform Decis Mak 2012;12:120. 2. Gabarron E, Serrano JA, Wynn R, Lau AY. Tweet content related to sexually transmitted diseases: no joking matter. J Med Internet Res 2014;16(10):e228. 3. Santana S, Lausen B, Bujnowska-Fedak M, Chronaki CE, Prokosch HU, Wynn R. Informed citizen and empowered citizen in health: results from an European survey. BMC Fam Pract 2011;12:20. 4. Moubarak G, Guiot A, Benhamou Y. Facebook activity of residents and fellows and its impact on the doctor-patient relationship. J Med Ethics 2011;37:101-4. 5. Mansfield SJ, Morrison SG, Stephens HO, et al. Social media and the medical profession. Med J Aust 2011;194:642-4. 6. Wynn R. Provider-patient interaction: A corpus-based study of doctor-patient and student-patient interaction, Oslo, Norway, Norwegian Academic Press, 1998.

Introduction: The Internet and the social media offer great potential for empowering patients, who can obtain updated information, peer support, and Internet-based treatment [1-3]. However, initial research and feedback from some patients have suggested that it is unclear to what degree the social media, including Twitter, overall are beneficial to patients [4, 5]. We therefore examined to what degree tweet content could be perceived of as negative or non-supportive of various disorders. Methods: We used the Twitter search engine to sample 150 random tweets containing either #schizophrenia, #bipolar, or #breastcancer. We classified the tweets as supportive, non-supportive or as a misuse of the disease term. As we examined the tweets, we became particularly interested in their affective content, thinking that this was of importance to how patients would react to the tweets. We therefore sampled 1000 random tweets relating to the same three disorders, and in addition, 1000 random tweets including #depression, #HIV, #AIDS, #COPD, #diabetes, and #Alzheimer, respectively (in total 9000 tweets). We subsequently used the computer program LIWC [6] to analyze the tweets. We focused specifically on the affective categories of ‘negative emotion’, ‘positive emotion’, ‘anxiety,’ and ‘sadness’. Results: Nearly all of the breast cancer tweets were supportive, while a majority of the tweets on schizophrenia and bipolar disorder were non-supportive or in the misuse of term category. Interestingly, the tweets including the terms #depression and #bipolar ranked highest in the categories of ‘negative emotion’, ‘anxiety’, and ‘sadness’, with #schizophrenia in third (‘anxiety’) and fourth place (‘sadness’ and ‘negative emotion’). #AIDS came in third for ‘negative emotion’ and diabetes third for ‘sadness’. For the ‘positive emotion’ category, #breast cancer ranked highest, followed by #depression, #HIV, and #bipolar, suggesting that there are also many tweets with positive affective content related to depression and bipolar disorder. Discussion, limitations, and lessons learned: While this is an initial, relatively small study, it suggests that social media such as Twitter may not consistently be a source of support or comfort to all patient groups, and patients and clinicians should be aware of this. References: 1. Santana S, Lausen B, Bujnowska-Fedak M, et al. Informed citizen and empowered citizen in health: results from an European survey. BMC Fam Pract 2011 Apr 16;12:20. 2. Kummervold PE, Wynn R. Health information accessed on the Internet: the development in 5 European countries. Int J Telemed Appl 2012;2012:297416. 3. Vambheim SM, Wangberg SC, Johnsen JAK, Wynn R. Language use in an internet support group for smoking cessation: development of sense of community. Inform Health Soc Care 2013;38:67-78. 4. DeAndrea DC, Anthony JC. Online peer support for mental health problems in the United States: 2004-2010. Psychol Med 2013;43:2277-88. 5. Oyeyemi SO, Gabarron E, Wynn R. Ebola, Twitter, and misinformation: a dangerous combination? BMJ 2014;349:g6178. 6. Pennebaker JW, Chung CK, Ireland M, Gonzales A, Booth RJ. The development and psychometric properties of LIWC2007. Austin, TX, LIWC. Net, 2007. Available at http://www.liwc.net/LIWC2007LanguageManual.pdf.

Introduction: The deinstitutionalization of psychiatry has in its essence been a downsizing of central psychiatric institutions in favor of outpatient- and community-based services. ‘Continuity of care’ has been a key concept from the onset in these ever more complex systems, both used as a measure of outcome and processes as well as a strategic priority (1). Recent research advocates systems that facilitate continuous clinical relationships between patients and clinicians rather than collaboration between specialized teams, but findings are limited (2-4). At the same time, the international literature has seen an increasing interest of the General Practitioners` (GP) role in the care of mental health patients, and underlines the need for integration of primary care and psychiatric services (5, 6). Recent studies suggest that for patients with severe conditions, cross boundary continuity are poor, and many are not seen in specialized care (7, 8). Purpose and methods: We review and discuss findings from studies on continuity of care in North Norway, focusing on the collaboration in the total of mental health services. We now want to focus on the continuity of care for individual patients with severe conditions between primary care and specialized mental health services: 1. Municipality (GPs), 2. Community mental health centers (CMHC), and 3. Central Mental hospitals (CMH). The two neighboring CMHCs of Vesteralen and of Lofoten, County of Nordland, North-Norway represent an interesting opportunity for mental health services research, because they are organized quite differently in spite of almost identical catchment-area characteristics. The one may be termed a central institution based model, the other a local institution based model. Both operate in concert with the county’s` CMH. These two models compared, particularly whether if local psychiatric beds rather than at a central hospital affects the utilization of GPs and municipality care. It is a retrospective cohort study of the total psychiatric care for all patients in two areas in North Norway, based on a prevalence sample from the routine case-registries of general practice and specialist services over the five years 2008-2012. Results and discussion: The most interesting result is that model of services exert at profound effect on the collaborative care between primary and specialist care. From a total of 971 inpatients included in the study, a majority in the local institution based model also utilized GPs- as well as specialist outpatient consultations. This was not the case in the centralized model, where a substantial proportion of inpatients did not receive specialist outpatient care at all. Further, those patients did neither use GP-care to the same extent as those who utilized both in- and outpatient services. Condition (diagnosis) and length of inpatient stay modified these findings, but system model still exerted an independent and profound effect on whether patients received collaborative care or not. Demographic and clinical variables like gender, age, or diagnosis did not alter these effects. The distinction between ‘continuity systems’ and ‘specialization systems’ described in recent literature may at least partly explain this (2). It may be that our two models facilitate continuous clinical contact between a therapist and patient to a different degree, and that this exerts an effect at both the primary and specialist level of services. In our local institution based system, one therapist may keep continuous contact with the patients over the transition from inpatient to outpatient care, whereas the central institution based model is more specialized and that patients may establish new relationships depending on in need of inpatient or outpatient services. Conclusion: The results suggests that smaller local inpatient units rather than central mental institutions might represent one way of achieving better continuity of care between primary and specialist services for patients with severe conditions. Further, utilization of both in-and outpatient services predicts also more use of general practitioners care. This relationship should be examined further in future research involving the North Norwegian psychiatric health services. References: 1- Myklebust LH, Olstad R, Bjorbekkmo S, Eisemann M, Wynn R, Sorgaard K. Impact on continuity of care of decentralized versus partly centralized mental health care in Northern Norway. International journal of integrated care. 2011;11:e142. 2- Omer S, Priebe S, Giacco D. Continuity across inpatient and outpatient mental health care or specialisation of teams? A systematic review. European psychiatry : the journal of the Association of European Psychiatrists. 2015;30:258-270. 3- Myklebust LH, Sorgaard K, Rotvold K, Wynn R. Factors of importance to involuntary admission. Nordic journal of psychiatry. 2012;66:178-182. 4- Myklebust LH, Sorgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC health services research. 2014;14:64. 5- Fleury MJ IA, Aube D, Farand L, Lambert Y General practitioners`management of mental disorders: A rewarding practice with considerable obstacles. BMC Family Practice. 2012;13. 6- Mykletun A KA, Tangen T, Overland S. General practitioners`opinions on how to improve treatment of mental disoders in primary helath care. Interviews with one hunders Norwegian general practitioners. BMC Health Service Research. 2010;10. 7- Reilly S PC, Hann M, Reeves D, Nazareth I, Lester H. The Role of Primary Care in Service Provision for People with Severe Mental Illness in the United Kingdom. PLoS ONE. 2012;7. 8- Myklebust LH SK, Wynn R. Local inpatient units may increase patients’ utilization of outpatient services. A case-register study. Submitted.

Introduction: Psychiatric patients may be subjected to coercion in many different forms, including involuntary admission to psychiatric hospital, involuntary outpatient treatment, and involuntary treatment with medications [1]. The use of coercion in the psychiatric services involves a range of ethical, clinical, and legal issues [2,3]. The Norwegian authorities have stated that it is a goal to reduce the use of coercion in the psychiatric services, as it is believed that this will improve the services and increase the quality of care [4]. Purpose and methods: We review and discuss findings from studies on coercion in North Norway, focusing on the relationship between the services available to patients in primary care and at local psychiatric clinics and the use of coercion. Results and discussion: A lack of services at the municipal level might increase the use of coercion. For instance, approximately half of the involuntary admissions had been referred from doctors working at municipal out-of-hours clinics [5]. These doctors often felt pressured to commit patients to psychiatric hospital, as few other options were available at nights and week-ends [5-7]. The increased availability of other services at nights and week-ends could therefore possibly result in reduced levels of coercion. Having sufficient resources available at the secondary level might also reduce the amount of coercion patients are subjected to. For instance, an area that had beds available for emergencies at local psychiatric clinics had significantly fewer (95% CI for EXP(B)=1.133-2.206, p=0.005) involuntary admissions than a comparable area without such beds [8]. While much of the coercion of psychiatric patients takes place at the tertiary/hospital level, this study suggests that the availability of services at the primary and secondary levels might influence the level of coercion at the tertiary/hospital level. Conclusion: The present study suggests that increasing the availabilty of voluntary psychiatric services at the primary and secondary levels might represent one way of achieving the goal of reducing coercion in the psychiatric services. This relationship should be examined further in future research involving the North Norwegian psychiatric health services. References: 1. Wynn R, Myklebust LH, Bratlid T. Psychologists and coercion: decisions regarding involuntary psychiatric admission and treatment in a group of Norwegian psychologists. Nordic Journal of Psychiatry 2007;61:433-437. 2. Wynn R. Coercion in psychiatric care: clinical, legal, and ethical controversies. International Journal of Psychiatry in Clinical Practice 2006;10:247-251. 3. Wynn R. The use of physical restraint in Norwegian adult psychiatric hospitals. Psychiatry Journal 2015; 2015: 347246. 4. Stuen HK, Rugkasa J, Landheim A, Wynn R. Increased influence and collaboration: a qualitative study of patients’ experiences of community treatment orders within an assertive community treatment setting. BMC Health Services Reserach 2015;14:409. 5. Rotvold K, Wynn R. Involuntary psychiatric admission: Characteristics of the referring doctors and the doctors' experiences of being pressured. Nordic Journal of Psychiatry 2015;69:373-379. 6. Rotvold K, Wynn R. Involuntary psychiatric admission: how the patients are detected and the general practitioners’ expectations for hospitalization. An interview study. International Journal of Mental Health Systems 2016; 10: 20. 7. Myklebust LH, Sorgaard K, Rotvold K, Wynn R. Factors of importance to involuntary admission. Nordic Journal of Psychiatry 2012;66:178-182. 8. Myklebust LH, Sorgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC Health Services Research 2014;14:64.