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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.

Immunological abnormalities have been demonstrated in several psychiatric disorders. Predominantly, studies have focused on younger adults, and research on elderly psychiatric in-patients is scant. In this naturalistic study, we investigated changes in cytokine levels during the treatment of diagnostically unselected elderly psychiatric in-patients, and whether these changes could be related to clinical outcomes. Clinical variables, demographic data, lifestyle data, and blood samples, including 27 plasma cytokines representing a broad spectrum of inflammatory mediators, were collected from 81 patients, 60 years and older, at admission and discharge. A subgroup of 49 patients also completed a self-reported clinical, psychiatric status form, indicating their level of recovery during hospitalisation. Statistical analyses demonstrated that a broad range of cytokines fell during treatment, and the fall was associated with clinical improvement, irrespective of psychiatric and somatic diagnoses. Exploiting cytokines as biomarkers of clinical traits might to be of limited use in a general population of elderly psychiatric in-patients as the field stands now. © 2019 The Authors. Published by Elsevier Ltd. Open Access CC-BY-NC-ND

The role of e-health is increasing worldwide. We surveyed the use of e-health in a large-scale population-based study, involving a representative sample of the Norwegian population aged above 40 years. Two-thirds of the health professionals had used search engines, apps, social media or video services for health purposes – while this was the case for approximately half of the non-health professionals.

Background As the population of older adults continues to grow, changes in alcohol consumption are important to monitor because an increase may have public health consequences. Rates of alcohol use vary with geographical location. The aim of this study was to examine trends in alcohol consumption among older adults in a geographically defined area in Norway, especially changing sex differences in drinking patterns over a 22-year period. Methods Repeated cross-sectional survey (in 1994–95, 2007–08, and 2015–16) of a general population of older adults. Eligible for this study were 20,939 participants (aged 60–99 years). The data were analysed using generalized estimating equations, stratified by age and sex. Alcohol consumption and drinking patterns were assessed, using an adaptation of the AUDIT-C. Results Between 1994 and 2016, there has been a significant increase in the proportion of current drinkers among older adults. Furthermore, the probability of frequent drinking (alcohol consumption at least twice weekly) increased significantly between 1994 and 2016, particularly among older women; OR 8.02 (CI 5.97–10.79) and OR 5.87 (CI 4.00–8.63) in the age groups 60–69 and 70+ respectively for women, and OR 4.13 (CI 3.42–4.99) and OR 3.10 (CI 2.41–3.99), in the age groups 60–69 and 70+ respectively for men. The majority of older adults drank small amounts of alcohol on typical drinking days, but there was an increasing probability of drinking three drinks or more on each occasion over the study period, except among women aged 70+ years. Conclusions Among older adults in Norway, alcohol consumption in terms of frequency and quantity on typical drinking days has increased considerably from 1996 to 2016. This change is in the opposite direction of what has been reported among younger adults. The gap between women and men in frequent drinking has been markedly narrowed, which indicate that women’s drinking patterns are approaching those of men. This may involve a need to change alcohol policy in Norway to more targeted interventions aimed at older people.

Introduction The SCARE Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case reports and are used and endorsed by authors, journal editors and reviewers, in order to increase robustness and transparency in reporting surgical cases. They must be kept up to date in order to drive forwards reporting quality. As such, we have updated these guidelines via a DELPHI consensus exercise. Methods The updated guidelines were produced via a DELPHI consensus exercise. Members were invited from the previous DELPHI group, as well as editorial board member and peer reviewers of the International Journal of Surgery Case Reports. The expert group completed an online survey to indicate their agreement with proposed changes to the checklist items. Results 54 surgical experts agreed to participate and 53 (98%) completed the survey. The responses and suggested modifications were incorporated to the 2018 guideline. There was a high degree of agreement amongst the SCARE Group, with all SCARE Items receiving over 70% scores 7-9. Conclusion A DELPHI consensus exercise was completed, and an updated and improved SCARE Checklist is now presented.

Background Patients who suffer from different diseases may use different electronic health (eHealth) resources. Thus, those who plan eHealth interventions should take into account which eHealth resources are used most frequently by patients that suffer from different diseases. Objective The aim of this study was to understand the associations between different groups of chronic diseases and the use of different eHealth resources. Methods Data from the seventh survey of the Tromsø Study (Tromsø 7) were analyzed to determine how different diseases influence the use of different eHealth resources. Specifically, the eHealth resources considered were use of apps, search engines, video services, and social media. The analysis contained data from 21,083 participants in the age group older than 40 years. A total of 15,585 (15,585/21,083; 73.92%) participants reported to have suffered some disease, 10,604 (10,604/21,083; 50.29%) participants reported to have used some kind of eHealth resource in the last year, and 7854 (7854/21,083; 37.25%) participants reported to have used some kind of eHealth resource in the last year and suffered (or had suffered) from some kind of specified disease. Logistic regression was used to determine which diseases significantly predicted the use of each eHealth resource. Results The use of apps was increased among those individuals that (had) suffered from psychological problems (odds ratio [OR] 1.39, 95% CI 1.23-1.56) and cardiovascular diseases (OR 1.12, 95% CI 1.01-1.24) and those part-time workers that (had) suffered from any of the diseases classified as others (OR 2.08, 95% CI 1.35-3.32). The use of search engines for accessing health information increased among individuals who suffered from psychological problems (OR 1.39, 95% CI 1.25-1.55), cancer (OR 1.26, 95% CI 1.11-1.44), or any of the diseases classified as other diseases (OR 1.27, 95% CI 1.13-1.42). Regarding video services, their use for accessing health information was more likely when the participant was a man (OR 1.31, 95% CI 1.13-1.53), (had) suffered from psychological problems (OR 1.70, 95% CI 1.43-2.01), or (had) suffered from other diseases (OR 1.43, 95% CI 1.20-1.71). The factors associated with an increase in the use of social media for accessing health information were as follows: (had) suffered from psychological problems (OR 1.65, 95% CI 1.42-1.91), working part time (OR 1.35, 95% CI 0.62-2.63), receiving disability benefits (OR 1.42, 95% CI 1.14-1.76), having received an upper secondary school education (OR 1.20, 95% CI 1.03-1.38), being a man with a high household income (OR 1.67, 95% CI 1.07-2.60), suffering from cardiovascular diseases and having a high household income (OR 3.39, 95% CI 1.62-8.16), and suffering from respiratory diseases while being retired (OR 1.95, 95% CI 1.28-2.97). Conclusions Our findings show that different diseases are currently associated with the use of different eHealth resources. This knowledge is useful for those who plan eHealth interventions as they can take into account which type of eHealth resource may be used for gaining the attention of the different user groups.

Background Diabetes patient associations and diabetes-specific patient groups around the world are present on social media. Although active participation and engagement in these diabetes social media groups has been mostly linked to positive effects, very little is known about the content that is shared on these channels or the post features that engage their users the most. Objective The objective of this study was to analyze (1) the content and features of posts shared over a 3-year period on 3 diabetes social media channels (Facebook, Twitter, and Instagram) of a diabetes association, and (2) users’ engagement with these posts (likes, comments, and shares). Methods All social media posts published from the Norwegian Diabetes Association between January 1, 2017, and December 31, 2019, were extracted. Two independent reviewers classified the posts into 7 categories based on their content. The interrater reliability was calculated using Cohen kappa. Regression analyses were carried out to analyze the effects of content topic, social media channel, and post features on users’ engagement (likes, comments, and shares). Results A total of 1449 messages were posted. Posts of interviews and personal stories received 111% more likes, 106% more comments, and 112% more shares than miscellaneous posts (all P Conclusions Diabetes social media users seem to be least engaged in posts with content topics that a priori could be linked to greater empowerment: research and innovation on diabetes, and health education. Diabetes social media groups, public health authorities, and other stakeholders interested in sharing research and innovation content and promoting health education on social media should consider including videos and emoji in their posts, and publish on popular and visual-based social media channels, such as Facebook and Instagram, to increase user engagement. International Registered Report Identifier (IRRID) RR2-10.1186/s12913-018-3178-7

Background There is a paucity of studies on inflammatory markers in elderly psychiatric patients. Hence, our study was undertaken to investigate cytokines as biomarkers in diagnostically unselected elderly patients admitted to a psychiatric hospital. Methods Demographic data, clinical data and blood samples, including 27 cytokines, were collected from 98 patients above 60 years, consecutively admitted to a psychiatric hospital in Tromsø, Norway (69°N). Results The most common diagnosis was Recurrent depressive disorder (26.5%), the second most common was dementia in Alzheimer’s disease (20.4%). The most frequent somatic disease was cardiovascular disease (28%). No statistical association (p

Background The internet is being widely used for seeking health information. However, there is no consensus on the association between health information seeking on the internet and the use of health care services. Objective We examined the association between health information seeking via the internet and physician visits. In addition, we investigated the association between online health information seeking and the decisions to visit and not to visit a physician. Methods We used the cross-sectional electronic health (eHealth) data of 18,197 participants from the seventh survey of the Tromsø Study (Tromsø 7). The participants were aged ≥40 years and living in Tromsø, Norway. We used logistic regression models to examine the association between online health information seeking and physician visits, the decision to visit a physician, and the decision not to visit a physician, with adjustment for the demographic status, socioeconomic status, and health status of the participants. Results The use of Web search engines was associated with a physician visit. However, the association was moderated by age, and the OR decreased as age increased. The ORs for the use of Web search engines were 1.99 (95% CI 1.94-2.02) and 1.07 (95% CI 1.03-1.12) at ages 40 and 80 years, respectively. The decision to visit a physician was associated with the use of Web search engines (OR 2.95, 95% CI 2.03-4.46), video search engines (OR 1.43, 95% CI 1.21-1.70), and health apps (OR 1.26, 95% CI 1.13-1.42). The association between social media use and the decision to visit a physician was moderated by gender. Women who used social media had 1.42 (95% CI 1.31-1.55) times higher odds of deciding to visit a physician, whereas the decision to visit a physician was not different between men who used social media and those who did not use social media. Conversely, the decision not to visit a physician was associated with the use of Web search engines (OR 2.78, 95% CI 1.92-4.18), video search engines (OR 1.27, 95% CI 1.07-1.51), social media (OR 1.28, 95% CI 1.10-1.49), and health apps (OR 1.20, 95% CI 1.07-1.35). Conclusions Health information found on the internet was positively associated with both the decision to visit a physician and the decision not to visit a physician. However, the association of health information seeking with the decision to visit a physician was slightly stronger than the association with the decision not to visit a physician. This could imply that the use of eHealth services is associated with a resultant increase in physician visits. In summary, our findings suggest that the internet serves as a supplement to health care services rather than as a replacement.

Source at https://doi.org/10.1155/2018/9602821. Introduction: The rising incidence of mental illness and its impact on individuals, families, and societies is becoming a major public health concern, especially in resource-constrained countries. Consequently, there is an increasing demand for mental health services in many middle- and low-income countries (LMIC). Challenges such as inequality in access, lack of staff and hospital beds, and underfunding, often present in the LMIC, might in part be addressed by telemental health services. However, little is known about telemental health in the LMIC. Methods: A systematic review was performed, drawing on several electronic databases, including PubMed, PsycINFO, Web of Science, Springer Link, and Google Scholar. Original English language studies on the practice of telemental health in LMIC, involving patients and published between 1 January 2000 and 16 February 2017, were included. Results: Nineteen studies met the inclusion criteria. Most of the articles were recent, which may reflect an increasing focus on telemental health in the LMIC. Eight of these studies were from Asia. Eight of the studies were interventional/randomized controlled trials, and 11 examined general mental health issues. Videoconferencing was the most frequently (6) studied telemental modality. Other modalities studied were online decision support systems (3), text messaging and bibliotherapy (1), e-chatting combined with videoconferencing (1), online therapy (2), e-counseling (1), store-and-forward technology (1), telephone follow-up (1), online discussion groups (1), audiovisual therapy and bibliotherapy (1), and computerized occupational therapy (1). Although many of the studies showed that telemental services had positive outcomes, some studies reported no postintervention improvements. Conclusion: The review shows a rising trend in telemental activity in the LMIC. There is a greater need for telemental health in the LMIC, but more research is needed on empirical and theoretical aspects of telemental activity in the LMIC and on direct comparisons between telemental activity in the LMIC and the non-LMIC.

Introduction The PROCESS guidelines were published in 2016 to provide a structure for reporting surgical case series. The PROCESS guidelines have since been widely endorsed by a number of journals. The requirement to report compliance with each item outlined in the PROCESS statement has improved the reporting transparency of case series across a number of surgical specialties. Here, we undertook a new Delphi consensus exercise to update the PROCESS guidelines. Methods All members of the previous Delphi group were invited to participate. In addition, researchers, editors, and reviewers who have previously published or reviewed case series with the International Journal of Surgery were invited to collaborate. An online questionnaire was sent to participants asking them to rate their agreement with amendments to each of the 29 items. Results 140 experts were invited to participate, 56 people agreed to participate, and 45 (80%) recipients completed the survey. There was a high level of agreement amongst the expert group, and unanimous consensus was reached in the first round. All except three proposed items were accepted, and the original guidelines were modified accordingly. Conclusion A modified and improved PROCESS checklist is presented, after a Delphi consensus exercise was completed.

The following article ,Gabarron, E., Årsand, E. & Wynn, R. (2018). Social media use in interventions for diabetes: Rapid evidence-based review. Journal of Medical Internet Research, 20:e10303(8). https://doi.org/10.2196/10303, was first published in Journal of Medical Internet Research. Source at https://doi.org/10.2196/10303. BACKGROUND: Health authorities recommend educating diabetic patients and their families and initiating measures aimed at improving self-management, promoting a positive behavior change, and reducing the risk of complications. Social media could provide valid channel to intervene in and deliver diabetes education. However, it is not well known whether the use of these channels in such interventions can help improve the patients' outcomes. OBJECTIVE: The objective of our study was to review and describe the current existing evidence on the use of social media in interventions targeting people affected with diabetes. METHODS: A search was conducted across 4 databases (PubMed, Scopus, EMBASE, and Cochrane Library). The quality of the evidence of the included primary studies was graded according to the Grading of Recommendations Assessment, Development and Evaluation criteria, and the risk of bias of systematic reviews was assessed by drawing on the Assessment of Multiple Systematic Reviews guidelines. The outcomes reported by these studies were extracted and analyzed. RESULTS: We included 20 moderate- and high-quality studies in the review: 17 primary studies and 3 systematic reviews. Of the 16 publications evaluating the effect on glycated hemoglobin (HbA1c) of the interventions using social media, 13 reported significant reductions in HbA1c values. The 5 studies that measured satisfaction with the interventions using social media found positive effects. We found mixed evidence regarding the effect of interventions using social media on health-related quality of life (2 publications found positive effects and 3 found no differences) and on diabetes knowledge or empowerment (2 studies reported improvements and 2 reported no significant changes). CONCLUSIONS: There is very little good-quality evidence on the use of social media in interventions aimed at helping people with diabetes. However, the use of these channels is mostly linked to benefits on patients' outcomes. Public health institutions, clinicians, and other stakeholders who aim at improving the knowledge of diabetic patients could consider the use of social media in their interventions.

Source at: http://doi.org/10.1136/bmjopen-2017-018708 Introduction: Women with bulimia nervosa and binge eating disorder often suffer for many years before they seek professional help. Evidence-based treatments like cognitive–behavioural therapy (CBT) might be poorly accessible, and about 50% of those who receive CBT respond to it. Such outcome may reflect the heterogeneous nature of eating disorders, and addressing this heterogeneity calls for expanding the portfolio of treatment options. In particular, it is important to explore such options’ acceptability, tolerability and affordability expressed through experiences with the treatment. This protocol outlines the rationale and design of a qualitative study. It captures experiences from patients and therapists who were involved in a randomised controlled trial (RCT) exploring the efficacy of a new group-based treatment programme combining physical exercise and dietary therapy. Methods and analysis: 15 patients with bulimia nervosa or binge eating disorder, 10 therapists (physical trainers and dietitians) and 6–10 patients who dropped out of the RCT will be semistructurally interviewed. All interviews will be analysed using a systematic text condensation approach. Ethics and dissemination: Results will be presented in peer-reviewed international journals, and at relevant international conferences. Key findings will be available to study participants as well as to patient organisations and health authorities. The overall study meets the intent and requirements of the Health Research Act and the Declaration of Helsinki. It is approved by the regional committee for medical research ethics (2013/1871).

Background It is an important objective of the psychiatric services to keep the use of involuntary procedures to a minimum, as the use of coercion involves clinical, ethical, and legal issues. It has been claimed that Norway has a relatively high rate of involuntary admissions. We reviewed the peer-reviewed literature on the use of involuntary admission in Norway, with the purpose of identifying the current state of knowledge and areas in need of further research. Methods A systematic review following the PRISMA statement was conducted. We searched the electronic databases PsycInfo, PubMed, Web of Science, CINAHL, and Embase for studies relating to involuntary admission to Norwegian adult psychiatric hospitals published in the period 1 January 2001 to 8 August 2016. The database searches were supplemented with manual searches of relevant journals, reference lists, and websites. Results Seventy-four articles were included and grouped into six categories based on their main topics: Patients’ experiences, satisfaction and perceived coercion (21 articles), the Referral and admission process (11 articles), Rates of admission (8 articles), Characteristics of the patients (17 articles), Staff attitudes (9 articles), and Outcomes (8 articles). Four of the included articles described intervention studies. Fifty-seven of the articles had a quantitative design, 16 had a qualitative design, and one a mixed-method design. There was a broad range of topics that were studied and considerable variation in study designs. The findings were largely in line with the international literature, but the particularities of Norwegian legislation and the Norwegian health services were reflected in the literature. The four intervention studies explored interventions for reducing rates of involuntary admission, such as modifying referring routines, improving patient information procedures, and increasing patients’ say in the admission process, and represent an important avenue for future research on involuntary admission in Norway. Conclusions The review suggests that Norway has a relatively high rate of involuntary admissions. The identified studies represent a broad mix of topics and designs. Four intervention studies were identified. More studies with strong designs are needed to bring research on involuntary admission in Norway to a next level. Electronic supplementary material The online version of this article (10.1186/s13033-018-0189-z) contains supplementary material, which is available to authorized users.

In Norway, GPs may decide to refer patients to involuntary psychiatric treatment. Internationally, there has been a discussion regarding criteria for involuntary admission. In Norway and in other countries where the treatment criterion is still used, some have suggested its removal.To examine which legal criteria GPs used to refer patients to involuntary admission, whether they had thought about using a different criterion, and on which information they based their decision.A total of 74 doctors who had referred patients to involuntary admission at one major Norwegian psychiatric hospital participated in semi-structured interviews.In total, 38% (28) had applied the danger criterion only and 23% (17) had applied the treatment criterion only; 32% (24) had applied both criteria, while 7% (5) did not answer this question; 74% (55) said that they could not have chosen a different criterion; 45% (33) had based their decision on events/behaviour prior to and during the consultation, 43% (32) on events prior to the consultation only, and 8% (6) on information obtained during the consultation only; 4% (3) did not answer this question. None had used tools to aid in the assessment of danger.The danger criterion was frequently used by the referring GPs. It is unclear how a removal of the treatment criterion from Norwegian legislation might impact clinical practice.While the danger criterion was applied by a majority, the treatment criterion was also chosen by many and was of importance to the doctors' reasoning regarding referrals to involuntary admission. Most thought they could not have chosen a different criterion.

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.

Background Sufferers from bulimia nervosa (BN) and binge eating disorder (BED) underestimate the severity risk of their illness and, therefore, postpone seeking professional help for years. Moreover, less than one in five actually seek professional help and only 50% respond to current treatments, such as cognitive behavioral therapy (CBT). The impetus for the present trial is to explore a novel combination treatment approach adapted from physical exercise- and dietary therapy (PED-t). The therapeutic underpinnings of these separate treatment components are well-known, but their combination to treat BN and BED have never been previously tested. The purpose of this paper is to provide the rationale for this new treatment approach and to outline the specific methods and procedures. Methods The PED-t trial uses a prospective randomized controlled design. It allocates women between 18 and 40 years (BMI range 17.5–35.0) to groups consisting of 5–8 members who receive either CBT or PED-t for 16 weeks. Excess participants are allocated to a waiting list control group condition. All participants are assessed at baseline, post-treatment, 6, 12 and 24 months’ post-follow-up, respectively, and monitored for changes in biological, psychological and therapy process variables. The primary outcome relates to the ED symptom severity, while secondary outcomes relates to treatment effects on physical health, treatment satisfaction, therapeutic alliance, and cost-effectiveness. We aim to disseminate the results in high-impact journals, preferable open access, and at international conferences. Discussion We expect that the new treatment will perform equal to CBT in terms of behavioral and psychological symptoms, but better in terms of reducing somatic symptoms and complications. We also expect that the new treatment will improve physical fitness and thereby, quality of life. Hence, the new treatment will add to the portfolio of evidence-based therapies and thereby provide a good treatment alternative for females with BN and BED. Trial registration Prospectively registered in REC the 16th of December 2013 with the identifier number 2013/1871 , and in Clinical Trials the 17th of February 2014 with the identifier number NCT02079935 .

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.

Background: Clozapine is the archetypical atypical antipsychotic, its primary indication being treatment resistant schizophrenia. Severe side effects caused by clozapine, including leukopenia, agranulocytosis, and myocarditis, are well known. A rarely described side effect is concurrent perimyocarditis and parenchymal lung disease. Case presentation: A previously physically healthy 23-year-old male Caucasian that suffered from schizophrenia presented with flu-like symptoms 1 week after starting clozapine treatment. Treatment with clozapine was discontinued. He developed respiratory distress. Investigations showed significant parenchymal infiltration in both of the lungs, pericardial fluid, and heart failure. He initially received treatment for suspected malignant neuroleptic syndrome and later for suspected infection, but these tentative diagnoses were not confirmed. The patient’s condition gradually improved. In retrospect, clozapine-induced parenchymal lung disease and perimyocarditis were deemed the most probable causes. Conclusions: Concurrent perimyocarditis and parenchymal lung disease are rare side effects of clozapine. Clozapine-induced disease in general is considered an exclusion diagnosis. Lacking a verifiable diagnosis when suspecting a side effect of clozapine, clinicians might treat the most likely and serious condition presenting and consider discontinuing clozapine until the diagnostic uncertainty is reasonably resolved.

Introduction: e-Health is becoming increasingly important to individuals and health services in Europe and around the world (1-3). As various forms of treatment and other interventions are becoming available over the Internet, the bulk of e-health remains related to information about health and illness (1-5). While the positive aspects of health information on the Internet have been highlighted, less has been published about related challenges. Methods: We performed a narrative review of the literature on challenges connected to health information on the Internet. A literature search containing various search terms relating to challenges with health information retrieval from the Internet was performed on PubMed and Web of Science and supplemented with hand searches. Results: A range of challenges were found to be associated with online health information, including a lack of searching skills, not being able to identify misinformation or commercialized or biased information, information overload, not properly understanding correct information, and not being able to make use of the information in terms of taking some action. Discussion and conclusion: Health information on the Internet can enable people to make better choices, for instance regarding life-style and treatment. However, several challenges need to be addressed in order to improve the use of the Internet as a channel for health information. Stakeholders who use the Internet for the dissemination of health-related information should be aware of these factors when planning and implementing their strategies. Lessons learnt, limitations and suggestions for future research: A main lesson learnt was that while health information on the Internet is positive overall, there are some challenges related to obtaining, understanding and making use of this type of information. This was a narrative review and the method has several important limitations, including that the literature search was not systematic. There is a need to focus also on the challenges related to the use of e-Health and more research is needed in order to know more about how to overcome these challenges. References: 1- Andreassen HK, Bujnowska-Fedak MM, Chronaki CE, Dumitru RC, Pudule I, Santana S, Voss H, Wynn R. European citizens' use of E-health services: A study of seven countries. BMC Public Health. 2007;7:53. 2- Andreassen HK, Wangberg SC, Wynn R, Sorensen T, Hjortdahl P. Health-related use of the Internet in the Norwegian population. Tidsskr Nor Legeforen. 2006;126:2950-52. 3- Kummervold PE, Wynn R. Health information accessed on the Internet: the development in 5 European countries. Int J Telemed Appl. 2012;2012: 297416. 4- Santana S, Lausen B, Bujnowska-Fedak M, Chronaki CE, Prokosch H-U, Wynn R. Informed citizen and empowered citizen in health: results from an European survey. BMC Fam Pract. 2011;12:20. 5- Gabarron E, Wynn R. Use of social media for sexual health promotion: a scoping review. Glob Health Action. 2016;9:32193.

In years past, primary hyperparathyroidism (pHPT) would often present itself as a problem related to bone disease or to kidney stones. Today, most patients with pHPT are so-called asymptomatic and discovered incidentally because of elevated levels of serum calcium and parathyroid hormone (PTH). Patients suffering from asymptomatic hyperparathyroidism may display a range of neuropsychiatric symptoms, including depression, anxiety, behavioral disturbances and psychosis, and reduced neurocognitive function. Table 1 shows typical signs and symptoms of pHPT, a condition that is more common in the elderly and in women. A prevalence of 21/ 1000 has been found in women aged 55-75 years (Table 1). The diagnosis of pHPT may easily be missed if not suspected by the clinician and if the appropriate biochemical tests are not performed. A high level of albumin-corrected calcium is often the sign that leads to further investigation. Other relevant biochemical tests are ionized calcium, urinary calcium excretion, phosphate, PTH, vitamin D, and creatinine. Patients with pHPT will usually, but not always, have an increased serum calcium level as well as an increased level of PTH. The level of vitamin D may be normal, but patients with pHPT more often have a vitamin D deficiency than matched controls. Figure 1 presents a flow chart that outlines a biochemical examination procedure for patients with treatment-resistant depression, in order to detect whether a patient suffers from HPT. We present a patient with pHPT and treatment-resistant depression, where the level of calcium was in the normal range. His symptoms disappeared after surgery. Our discussion of the case is placed in the context of recent literature on the topic of pHPT and neuropsychiatric symptoms.

Background In Norway, it is usually GPs that refer patients to involuntary admission. A high proportion of such referrals come from out-of-hours clinics. Little is known about who first initiate the contact between the patients and the referring doctors and which expectations the referring doctors have with respect to the involuntary admissions. The aim of the study was to examine who first detected the patients who were subsequently involuntarily admitted, and to examine the referring doctors’ expectations for the admissions. Methods Semi-structured interviews with 74 doctors that had referred patients for involuntary admission at a psychiatric hospital. Results Patients who were involuntarily admitted were detected by other branches of the health service (52 %, n = 39), family (25 %, n = 19), and the police (17 %, n = 13). The doctors mentioned these expectations for the admission (more than one expectation could be given): start treatment with neuroleptics: 58 % (n = 43), take care of the patient: 45 % (n = 34), extensive changes to the treatment regime: 37 % (n = 28), solve an acute situation: 35 % (n = 26), and clarify the diagnosis: 22 % (n = 17). Female doctors significantly more often expected that the patients would be examined and treated, while the male doctors significantly more often expected that the patients would be cared for. Conclusions Involuntary admissions are typically complex processes involving different people and services and patients with various needs. More knowledge about the events preceding hospitalization is needed in order to develop alternatives to involuntary admissions. Electronic supplementary material The online version of this article (doi:10.1186/s13033-016-0048-8) contains supplementary material, which is available to authorized users.

Physical restraint is used as a last resort emergency measure to calm and safeguard agitated and/or aggressive psychiatric patients. This can sometimes cause injuries, and rare fatalities have occurred. One mechanism of injury and death while in physical restraint is that of severe asphyxiation. We present the case of a hospitalized man in his mid-30s, suffering from schizophrenia. The patient was obese. He became aggressive and had to be manually restrained with a "takedown." After having been put in the prone position on the floor with a significant weight load on his body, he lost respiration and consciousness. Subsequently, he was given CPR. He regained consciousness and respiration, while the cyanosis receded in 1-2 min. Psychiatrists and pathologists should be aware that physically restraining a patient in the prone position with a significant weight load on the torso can, in rare cases, lead to asphyxiation.

IntroductionMental illness are among the most prevalent causes of death [1]. Larger population based studies are needed in order to control the high mortality rates for psychiatric patients [2].ObjectiveTo examine the relationship between psychiatric disease and somatic illness.MethodData from health-related databases and registries are cross-matched by social security number for all psychiatric patients in North-Norway for 2008–2016/2017. n = 4000–6000.(Table 1)Mortality is considered multifactorial, and risk factors may appear as both direct and indirect causes. A high number of demographic, somatic, psychiatric and service related variables allow the study to control for interactions and confounding associations by multivariate analyses.Results/planned papersA case-register study of the comorbidity of mental and somatic disorders in North Norway: Research protocol.Increased mortality in psychiatric patients: A case-registry study.Comorbidity of cancer and psychiatric illness: Findings from North Norway.Cardiovascular disease is prevalent among people suffering from depression and anxiety.The importance of the use of antipsychotic medication for physical health.Coercion and general health among psychiatric patients. The importance in continuity of care.Substance-use among psychiatric patients. Implications for general health and care pathways.Psychiatric patients use of general practitioner medical treatment.Table 1An overview of the information that will be retreived from the registries.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Objectives. Return To Work (RTW) is an important indicator of recovery from coronary artery disease (CAD), associated with social and economical benefits, and improved quality of life. Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery are effective procedures relieving symptoms and reducing the risk for new events, but psychosocial problems are frequent among these patients. The aim was to determine psychosocial and treatment-related factors associated with RTW among PCI and CABG patients in Northern Norway. Design. Cross-sectional design based on questionnaire data from CABG and PCI patients 3–15 months following discharge, and from hospital records. Methods. Of the 348 responding patients, 168 were younger than 67 years and working prior to hospitalization. Factors associated with RTW were examined in a logistic regression analysis. Results. A total of 108 (64%) had RTW within 3–15 months. Four factors made unique significant contributions to the model, including higher education, time since hospital discharge and Internal Locus of Control (LoC) of the Multidimensional Health Locus of Control Scale (MHLC) as positively associated factors, and Powerful Others LoC as a negatively associated factor. Analyses controlled for data on demographics, emergency status, type of treatment, number of days at the hospital, physical exercise, attending a rehabilitation program, mental distress, Type D personality, and for the CABG patients additional data on coronary health. Conclusions. Patients’ control beliefs and educational level are significant psychosocial factors associated with RTW following PCI and CABG treatment. Implications for hospital treatment and rehabilitation programs are discussed.

Motivation is a widely used concept in substance use treatment, and is commonly seen as a premise for change during treatment. Different measures of motivation have been suggested. A relatively new instrument is the Drug Use Disorders Identification Test–Extended (DUDIT–E), developed in Sweden. This instrument has recently been introduced in Norway. The present study examined the Motivational Index of the Norwegian version of the Drug Use Disorders Identification Test-Extended (DUDIT–E). We tested whether the three-factor model (“Positive aspects of substance abuse”; “Negative aspects of substance abuse”; and “Treatment readiness”) suggested by previous studies could be replicated in a sample of Norwegian inpatients. Responses to the DUDIT–E were obtained from 105 patients admitted to inpatient substance abuse treatment in Northern Norway. Exploratory common factor analyses were used to compare the factor structure from the current sample with the Swedish sample of mainly detoxification patients and prison inmates. The current sample did not include prison inmates, and it consisted of more women than the Swedish sample. The samples did not differ according to age or substance dependency. The analyses suggested that six primary factors was the most efficient way of combining the item scores, and not 11 as in the Swedish sample. A second-order factor analysis found best support for a two-factor solution, and hence, did not replicate the previously suggested three-factor model either. Several regression analyses comparing the efficiency of the different ways of combining the DUDIT scores in primary or secondary factor scores indicated that the model involving six sum scores had best merit and should be explored further.

Aims. Participation in everyday activities positively influences well-being, but few have studied how participation in activities influences well-being among patients with substance use disorders. The authors examined the number of past, recent, and desired future activities of patients being admitted to five units for inpatient substance abuse treatment at a Norwegian university hospital. Major findings. The total number of activities had dropped significantly compared with before the respondents started abusing substances, and the respondents desired an increase in activities in the future. A lower level of well-being as measured by the WHO-5 was predicted by a more pronounced drop in number of activities from past to recent and by more severe use of alcohol and other substances. Principal conclusion. Substance abuse is associated with a change in number of activities. Losing activities may contribute to a decrease in well-being. Helping substance abuse patients regain positive activities could...

Many countries allow for the use of restraint and seclusion in emergencies with psychiatric inpatients. Authors have suggested that the attitudes of staff are of importance to the use of restraint and seclusion.To examine the attitudes to coercion at two Norwegian psychiatric units. In contrast to the idea that attitudes to coercion vary much within and between institutions, we hypothesized that staff's attitudes would be quite similar.We distributed a questionnaire to staff at two psychiatric units in two Norwegian counties. Eight wards were included. The questionnaire contained fictitious case histories with one patient that was violent and one patient that was self-harming, and staff were asked to describe how they would intervene in each emergency. Emergency strategies were sorted according to degree of restrictiveness, from the highly restrictive (restraint, seclusion) to the unrestrictive (talking, offering medication). Data were analysed with regression analyses.There was only a limited degree of variance in how staff at the different units and various groups of staff responded. Staff were more likely to favour a highly restrictive intervention when the patients were physically violent. Male staff and unskilled staff were significantly more prone to choosing a highly restrictive intervention.Our hypothesis was confirmed, as there was a limited degree of variance in staff's responses with respect to degree of restrictiveness. The study supported the idea that a range of different interventions are used in emergency situations.

Coronary artery bypass graft (CABG) surgery is stressful, and the patient’s coping affects recovery and outcome. The aim of the study was to identify patients’ thoughts and concerns, and explore the relevance of approach/avoidant coping and Regulatory Focus Theory (RFT). Nine patients were interviewed, using an interpretative phenomenological approach. The patients made use of various avoidant (e.g. neglecting symptoms, delaying help-seeking, avoiding thoughts) and approach strategies (e.g. persistent search for the diagnosis, mental preparation for surgery). RFT versus approach/avoidant coping is discussed. RFT may contribute to our understanding of motivational cognitions in patients’ coping with illness and treatment.

Dual diagnosis of substance abuse and severe psychiatric illness is frequent, and the building of therapeutic relationships with this group of patients seems to be both important and difficult. An integrated treatment model has been claimed to be the preferred treatment for dual diagnosis patients. This study explores how providers in an integrated treatment model, and a substance abuse treatment model with less emphasis on psychiatric co-morbidity, handle relationship building. Two focus groups included providers working in a Therapeutic Community (TC) and a Dual Diagnosis (DD) ward. Participants were given a short case history and asked to describe how they would approach the case. The analysis was based on a phenomenological method. All providers perceived a good relationship to be central to the treatment. Providers in the DD ward were more ready to build close relationships with the patients, and described their relationship with the patients as more crucial to treatment. The providers in the TC ascr...

We examined changes in serum levels of a selection of neurotrophic factors, TSH, HGH and cortisol in conjunction with ECT treatment. Fifteen patients suffering from affective disorders were included, all were treated with antidepressants and psychotherapy and 10 also with ECT. The patients were examined clinically and with blood samples during treatment. Serum levels of cortisol, thyroid stimulating hormone (TSH), nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT3), neuropetide Y (NPY) and human growth hormone (HGH) were studied. No significant changes were found in levels of NGF, BDNF, NT3, HGH and TSH. A change in NPY levels was statistically significant, but of uncertain clinical value as it affected only two patients. Levels of cortisol rose significantly during treatment. We did find significant correlations between the base values of NGF and HAM-D scores at inclusion and between the end-values of NT3 and NPY and the HAM-D scores prior to discharge. We were unable to reproduce findings from animal studies suggesting that a range of neurotrophic factors rise during ECT treatment. This may be because of physiological differences between animals and humans or, possibly, a result of the small number of patients included in this pilot study.

Aims: To examine the occurrence of comorbid non‐substance abuse axis‐1 disorders among patients being treated for substance abuse.Design, setting and participants: Prospective study of patients admitted to a Norwegian clinic for substance abuse treatment. All patients in treatment during a 3‐month period were invited to participate.Measurements: Patients were clinically interviewed and MINI and GAF were scored. Data were analysed with Chi‐square tests and multiple regression analyses.Findings: Twenty‐four patients (77.4%) participated, of whom 91.7% had at least one comorbid non‐substance abuse axis‐1 disorder. Of the patients, 70.8% had suffered a psychotic episode and prior episodes of psychosis occurred significantly more often among those who had a main abuse of amphetamines. Many patients also abused benzodiazepines and/or cannabis as secondary substances.Conclusions: A high level of prior psychotic episodes could be related to a high use of amphetamine and cannabis, and possibly to a shortage of low...

Accepted manuscript version. The final publication is available at Springer via http://dx.doi.org/10.1007/s10826-015-0221-8. The present meta-analytic review explored long-term treatment effects in children and adolescents, age ranging from 2 to 17 years, treated because of conduct problems. The presumed mediators were examined. Various treatments, in all 56 studies including 2589 participants, were included. 32 studies involved an untreated control condition, whereas 24 studies did not. The overall weighted effect size (ES) in conduct problems after termination of treatment was a reduction of ES = 0.08 for a mean follow-up period of 8.9 months. Long-term changes on the presumed mediator showed a small deterioration of ES = -0.06. The moderator analysis confirmed that treatment effects in conduct problems and mediators were related. Changes in conduct problems from post-treatment to follow-up were larger in studies with cognitive behavior therapy (CBT) or a combination of behavior therapy (BT) and CBT compared to BT and family therapy. Individual treatments resulted in larger changes in aggressive behaviour as compared to group treatments or a combination of these. Treatment effects for both conduct problems and the presumed mediators seem to last, but changes were small. Few studies included teenagers and knowledge of lasting treatment effects is limited for older children including CBT treatments. More knowledge of the mediators involved in treatment is needed, in particular for cognitive and family therapeutic interventions.

Background.The use of coercion within the psychiatric services is problematic and raises a range of ethical, legal, and clinical questions. “Physical restraint” is an emergency procedure used in psychiatric hospitals to control patients that pose an imminent physical danger. We wished to review the literature published in scientific peer-reviewed journals describing studies on the use of physical restraint in Norway, in order to identify the current state of knowledge and directions for future research.Design. The databases PubMed, PsycINFO, CINAHL, Web of Science, and Embase were searched for studies relating to physical restraint (including holding) in Norwegian psychiatric hospitals, supplemented with hand searches.Results. 28 studies were included. Most of the studies were on rates of restraint, but there were also some studies on perceptions of patients and staff, case studies, and ethnographic studies. There was only one intervention study. There are differences in use between wards and institutions, which in part may be explained by differences in patient populations. Staff appear to be less negative to the use of restraint than patients.Conclusions. The studies that were identified were primarily concerned with rates of use and with patients’ and staff’s perspectives. More interventional studies are needed to move the field forward.

While the use of coercion, such as involuntary medication and physical restraints, is widespread in psychiatric treatment, little is known about the outcomes of the use of these interventions. Nineteen patients who had been involuntarily medicated, physically restrained, or secluded from other patients, were matched to 19 controls. Outcome variables were overall satisfaction with treatment, self-rated improvement, recommendation of treatment to others, satisfaction with information about treatment, and degree of influence over own treatment. Data were analysed with paired t tests. There were no statistically significant differences between the patients who had been subjected to the coercive interventions and their controls. Overall satisfaction with treatment was poor for both groups, while self-rated improvement was rated as neither poor nor good. It is possible that other factors, such as the nature of the disorder and the duration of treatment, are of greater importance than the use of coercive interve...

The purpose of this study was to examine how coronary bypass surgery patients experienced their care.In many hospitals, including the study hospital, perioperative care is still organized in such a manner that theatre nurses have little contact with patients prior to and after surgery. Little is known about how patients experience this type of perioperative care.Nine patients were interviewed approximately a year after their operations. The interviews were qualitative and were analysed by drawing on the phenomenological method.The patients were generally satisfied with the quality of the staff-patient interactions and the information that was given prior to surgery, but some patients expressed a need for a closer postoperative followup by staff directly involved in the surgery. Most patients believed that information and support given by fellow patients was even more important to them than the support and information that was given by staff.The findings suggest that the quality of care and patients' satisfaction can be further enhanced by implementing principles from the perioperative dialogue model. For instance, by allowing for a postoperative meeting between the patient and a theatre nurse, continuity of care can be further enhanced.

In Norway, doctors may make the decision to refer patients to involuntary psychiatric treatment. This is a difficult decision, as it involves a range of medical, legal and ethical challenges. The decision to commit is presumed based on an independent assessment of the patient and whether a set of medico-legal criteria is met.To examine characteristics of GPs that admitted patients involuntarily to a psychiatric hospital, and to examine how the GPs assessed this process.74 doctors who had referred patients to involuntary admission at one major Norwegian psychiatric hospital participated in semi-structured interviews. The questions posed were in part factual and in part about the participating doctors' assessments and considerations with respect to the involuntary admission of psychiatric patients.Approximately half of the participating doctors worked at the public out-of-hours clinics, while a fifth were the patients' family doctors. Those working at the out-of-hours clinics had less work experience and fewer had prior knowledge of the patients they committed. About half the doctors felt it was difficult to apply the medico-legal criteria. More than half had felt pressured/advised to refer the patient to hospital and about half had felt pressured/advised to do so involuntarily.While doctors considering the commitment of psychiatric patients are presumed to make independent assessments of patients based on medico-legal criteria, this study suggests that many doctors feel pressured to commit.The assessment made by doctors who refer patients involuntarily to psychiatric hospital may be influenced by other parts of the health service, the patient's family and the police. Many doctors feel that it is difficult to apply the medico-legal criteria when referring patients involuntarily.

Medicate, restrain or seclude? Strategies for dealing with violent and threatening behaviour in a Norwegian university psychiatric hospital The aim of this study was to examine staff strategies for applying emergency procedures with patients who were violent or threatening. The study addressed those situations where verbal intervention, voluntary medication, and other interventions had been tried unsuccessfully and where staff found it necessary to apply emergency procedures in the shape of forced emergency medication (pharmacological restraint), physical restraint, and seclusion. The study was conducted in a 100-bed Norwegian university psychiatric hospital. By retrospectively examining hospital records we found there were 797 episodes of physical restraint, 384 episodes of pharmacological restraint, and 88 episodes of seclusion during a five and a half year period. The preferred emergency procedures varied significantly with patients' sex, age, and diagnoses. Physical restraint was preferred more often with male, younger, and nonpsychotic patients. Pharmacological restraint was preferred more often with female patients and older patients with a nonorganic psychotic disorder. Seclusion was preferred more often with older male patients with an organic psychotic disorder.

Source at https://doi.org/10.1177/2050312117724311 Objectives: Studies on the dynamics between service organization and acute admissions to psychiatric specialized care have given ambiguous results. We studied the effect of several variables, including service organization, coercion, and patient characteristics on the rate of acute admissions to psychiatric specialist services. In a natural experiment-like study in Norway, we compared a “deinstitutionalized” and a “locally institutionalized” model of mental health services. One had only community outpatient care and used beds at a large Central Mental Hospital; the other also had small bed-units at the local District Psychiatric Centre. Methods: From the case registries, we identified a total of 5338 admissions, which represented all the admissions to the psychiatric specialist services from 2003 to 2006. The data were analyzed with chi-square tests and Z-tests. In order to control for possible confounders and interaction effects, a multivariate analysis was also performed, with a logistic regression model. Results: The use of coercion emerged as the strongest predictor of acute admissions to specialist care (odds ratio = 7.377, 95% confidence interval = 4.131–13.174) followed by service organization (odds ratio = 3.247, 95% confidence interval = 2.582– 4.083). Diagnoses of patients predicted acute admissions to a lesser extent. We found that having psychiatric beds available at small local institutions rather than beds at a Central Mental Hospital appeared to decrease the rate of acute admissions. Conclusion: While it is likely that the seriousness of the patients’ condition is the most important factor in doctors’ decisions to refer psychiatric patients acutely, other variables are likely to be important. This study suggests that the organization of mental health services is of importance to the rate of acute admissions to specialized psychiatric care. Systems with beds at local District Psychiatric Centers may reduce the rate of acute admissions to specialized care, compared to systems with local community outpatient services and beds at Central Mental Hospitals.

Introduction : During the last 20 years, there has been a shift in Norway, with an increase in services provided at local district psychiatric units and in municipalities and a reduction in centralized hospital services [1]. Simultaneously, attention has been directed to the negative effects of use of coercion within the services [2]. While it has been pointed out that rates of coercion in Norway are relatively high, few have examined the implications of this organizational change for the use of coercion [3]. Methods : Drawing on data obtained from the Norwegian Patient Register, we analyzed all episodes of specialized psychiatric care given in the area of Vesteralen and Lofoten, North Norway, for the periods 2003-2006 and 2008-2012 (data from 2007 were unavailable). Patients subjected to involuntary admission and involuntary outpatient treatments were identified. Results : The number of patients being treated in the study area increased from 886 in 2003 to 1347 in 2012. The number of involuntarily admitted patients and patients in involuntary outpatient treatment fell from 110 in 2003 to 30 in 2012. Discussion, limitations and lessons learnt : Our data suggest that while the number of patients in treatment increased with more than 50% during the study period, the number of patients being coerced was reduced with more than 70%. Several factors (on which we lack data here) may be of importance to rates of involuntary admission and treatment, including patients’ diagnoses [4, 5] and staffs’ attitudes [5, 6]. However, the increased provision of decentralized psychiatric services is likely to be one important factor in the reduction of coercion [3]. Local and low-threshold psychiatric services increase access and give patients the opportunity to get help at an earlier stage, which may reduce the need for coercion [3, 5]. Further studies are needed to examine the importance of psychiatric services organization on rates of coercion. 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. Int J Integr Care. 2011;11:e142. 2. Wynn R. Coercion in psychiatric care: clinical, legal, and ethical controversies. Int J Psychiatry Clin Pract. 2006;10(4):247-51. 3. Myklebust LH, Sorgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC Health Serv Res. 2014;14:64. 4. Myklebust LH, Sorgaard K, Rotvold K, Wynn R. Factors of importance to involuntary admission. Nord J Psychiatry. 2012 Jun;66(3):178-82. 5. Rotvold K, Wynn R. Involuntary psychiatric admission: The referring general practitioners' assessment of patients' dangerousness and need for psychiatric hospital treatment. Nord J Psychiatry. 2015;69(8):637-42. d 6. Wynn R, Kvalvik AM, Hynnekleiv T. Attitudes to coercion at two Norwegian psychiatric units. Nord J Psychiatry. 2011;65:133-7.

BackgroundSome prior studies of brainstem audiometry have found illness-specific aberrations, suggesting that this procedure can be of use to clinicians in diagnosing certain psychiatric illnesses.AimsThe study aimed to examine the diagnostic properties of a brain stem audiometry procedure (SD-BERA®) for patients suffering from schizophrenia and bipolar disorder.MethodsA blinded study including 12 patients with schizophrenia, 12 patients with bipolar disorder, and 12 healthy controls was performed in 2014/2015. The patients were recruited from psychiatric specialist services and a primary care office in the County of Troms, Norway. The patients and controls were examined with brainstem audiometry. The clinical diagnoses were not known to the researchers who analysed the brain stem audiometry data at the Swedish company SensoDetect. Sensitivity and specificity for each group (compared to healthy controls) was calculated.ResultsThe brain stem audiometry procedure had a high degree of sensitivity (1.00), but a lower degree of specificity (0.45) when patients suffering from bipolar disorder were compared to healthy controls. For the diagnosis of schizophrenia, the brain stem audiometry procedure had a high degree of specificity (0.91), but a lower degree of sensitivity (0.33) when patients were compared to healthy controls.ConclusionsThis method may help clinicians by lending support to a clinically suspected diagnosis of schizophrenia. The relatively low specificity for bipolar disorder could suggest that the method needs further development before it can be useful clinically when the diagnosis of bipolar disorder is suspected. Further scientific testing is needed to verify these findings.Disclosure of interestThe authors have not supplied their declaration of competing interest.

To examine how general practitioners (GPs) respond to patients who are non-compliant with medical advice and who doctors believe act irresponsibly towards their health.Quantitative analysis of responses to questionnaire with case histories.93 questionnaires completed by a random stratified sample of Norwegian GPs.Scores relating to GPs' feelings and choice of main and sub-strategies for further treatment of patients.The respondents typically felt discouraged or unaffected by non-compliant patients, younger doctors more often felt helpless while older ones were more content, and female doctors more often than male doctors felt irritated or angry. The main strategy preferred was to give the patient a new appointment. The young, the inexperienced, and females tended more often to ask a colleague for advice or refer to a specialist. Patient-centred sub-strategies were generally preferred, especially by younger doctors.GPs' feelings towards and strategies for dealing with non-compliant patients vary, and the doctor's age, sex and clinical experience are central variables.

This pilot study addressed the problem of patients' assaults on staff at a Norwegian psychiatric university hospital. The questionnaire-based study had a retrospective design, and involved a random sample of staff (n = 85). It revealed that 100% of the nursing staff and 60.9% of the therapists (doctors, psychologists, and social workers) had been physically assaulted by patients at least once during their careers at the hospital. Most of the assaults did not result in sick leave, and could as such be classified as not serious. There were no significant differences in the number of assaults on male and female staff or between staff in the emergency, intermediary, rehabilitation and psycho-geriatric wards. The staff responded that they believed male patients were more violent and threatening than female patients, although a majority had been assaulted more frequently by female than by male patients. Assault was the reason most frequently given for physically restraining patients, and most of the staff did not believe that physically restraining patients reduced their chances of recovery. The study suggests that patients' assaults on staff in Norwegian psychiatric hospitals is an important problem, which needs further attention.

To investigate the relationship of the amount of words spoken by general practitioners and patients to the main topics of the consultations and the sex of the patients.Sample of 60 face-to-face doctor-patient consultations, with five different doctors and 60 different patients, randomly chosen from a database of British general practitioner-patient consultations. All the doctors were male; 33 patients were female, 27 male.Number of words spoken by doctors and patients, related to sex of patients and the consultations' main topics.There was no significant difference in the overall amount of words spoken by doctors and patients. However, doctors uttered significantly more words than their patients in those consultations in which the main topic was somatic, while patients spoke significantly more words than their doctors in those consultations in which the main topic was psychosocial.The main topics of the consultations were more important than the sex of the patients with regard to the proportion of words uttered by doctors and by patients.

This article is part of Ole Grønli's doctoral thesis which is available in Munin at http://hdl.handle.net/10037/6930 Background: Mounting evidence suggests a link between low zinc levels and depression. There is, however, little knowledge about zinc levels in older persons with other psychiatric diagnoses. Therefore, we explore the zinc status of elderly patients suffering from a wide range of psychiatric disorders. Methods: Clinical data and blood samples for zinc analyzes were collected from 100 psychogeriatric patients over 64 of age. Psychiatric and cognitive symptoms were assessed using the Montgomery and Aasberg Depression Rating Scale, the Cornell Scale for Depression in Dementia, the Mini-Mental State Examination, the Clockdrawing Test, clinical interviews and a review of medical records. In addition, a diagnostic interview was conducted using the Mini International Neuropsychiatric Interview instrument. The prevalence of zinc deficiency in patients with depression was compared with the prevalence in patients without depression, and the prevalence in a control group of 882 older persons sampled from a population study. Results: There was a significant difference in zinc deficiency prevalence between the control group (14.4%) and the patient group (41.0%) (x2 = 44.81, df = 1, p,0.001). In a logistic model with relevant predictors, zinc deficiency was positively associated with gender and with serum albumin level. The prevalence of zinc deficiency in the patient group was significantly higher in patients without depression (i.e. with other diagnoses) than in patients with depression as a main diagnosis or comorbid depression (x2 = 4.36, df = 1, p = 0.037). Conclusions: Zinc deficiency is quite common among psychogeriatric patients and appears to be even more prominent in patients suffering from other psychiatric disorders than depression. Limitations: This study does not provide a clear answer as to whether the observed differences represent a causal relationship between zinc deficiency and psychiatric symptoms. The blood sample collection time points varied in both the control group and the patient group. No data regarding zinc supplementation were collected.

Objectives. There has recently been an increased focus on the use of coercion in psychiatric care and on the need to consider the patients’ autonomy. Staff that are faced with aggressive, violent, or self-harming inpatients, must consider patient and staff safety, as well as the need to provide humane and efficient treatment. Although physical and pharmacological restraint and seclusion are used regularly in psychiatric institutions in many countries, little has been published about staff’s motivation for using the interventions, and the effects they have. In the present work, the objectives were to identify the number of incidents and the characteristics of the patients involved, the staff’s reasons for the use and choice of a particular type of intervention, the effects of the interventions, and possible alternatives to the use of restraint and seclusion. (Int J Circumpolar Health 2004; 63(4):445-447) Keywords: psychiatry, coercion, violence, physical restraint, pharmacological restraint, seclusion, staff’s attitudes, patients’ experiences, Norway

Gunn Pettersen,1 Jan H Rosenvinge,1 Kari-Brith Thune-Larsen,2 Rolf Wynn1,31Faculty of Health Sciences, University of Tromsø, Tromsø, Norway; 2Oslo University Hospital, Oslo, Norway; 3Division of Addictions and Specialized Services, University Hospital of North Norway, Tromsø, NorwayAbstract: There are an increasing number of educational programs to improve clinical competence and skills to treat mental disorders. For complex disorders there is also a focus on improving the quality of interprofessional work. This paper reports on interprofessional outputs of an educational program on eating disorders. A total of 207 professionals who completed the program were requested to describe up to 12 possible scenarios depicted as realistic prospects for their future work within this field. Analyzing the scenarios resulted in three categories of describing the participants' preferences: (1) interprofessional interventions and treatment; (2) the further development of competence; and (3) organization of the health care system. The findings showed that the participants were considering working across new lines in their current workplaces or crossing borders to new frontiers in the execution of competence. Our findings may be summarized into the concept of "clinical confidence." This concept has so far been understood as some kind of personal trait, disposition, or attitude. The present findings add nuances to this concept in terms of state-dependent encouragement, engagement, and a potential to act and to cross professional borders in order to better treat complex mental disorders.Keywords: interprofessional educational programs, interprofessional work, clinical confidence, eating disorders program, health care professional

Prior research on psychopathy has primarily focused on the problem in men. Only a few studies have examined whether psychopathy even exists in women, and if so, how the disorder manifests itself in them. This paper presents a narrative review of the literature on gender and psychopathy. We briefly discuss why this is an important topic for women and we discuss its causes. The concept of psychopathy is defined and related to the diagnostic systems. The discussion includes a presentation of diagnostic tools, including the Hare Psychology Checklist - Revised, which are examined in relationship to the importance of biological gender. While emphasizing the similarities as well as the differences between the sexes, we discuss the matters of prevalence, behavioral expressions, comorbidity, progression, and treatment of the disorder.