Publications by authors named "Grigori Joffe"

52 Publications

Measurement Invariant but Non-Normal Treatment Responses in Guided Internet Psychotherapies for Depressive and Generalized Anxiety Disorders.

Assessment 2021 Dec 14:10731911211062500. Epub 2021 Dec 14.

University of Helsinki, Finland.

Assessment of treatment response in psychotherapies can be undermined by lack of longitudinal measurement invariance (LMI) in symptom self-report inventories, by measurement error, and/or by wrong model assumptions. To understand and compare these threats to validity of outcome assessment in psychotherapy research, we studied LMI, sum scores, and Davidian Curve Item Response Theory models in a naturalistic guided internet psychotherapy treatment register of 2,218 generalized anxiety disorder (GAD) patients and 3,922 depressive disorder (DD) patients (aged ≥16 years). Symptoms were repeatedly assessed by Generalized Anxiety Disorder Assessment-7 (GAD-7) or Beck Depression Inventory. The symptom self-reports adhered to LMI under equivalence testing, suggesting sum scores are reasonable proxies for disorder status. However, the standard LMI assumption of normally distributed latent factors did not hold and inflated treatment response estimates by 0.2 to 0.3 standard deviation units compared with sum scores. Further methodological research on non-normally distributed latent constructs holds promise in advancing LMI and mental health assessment.
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http://dx.doi.org/10.1177/10731911211062500DOI Listing
December 2021

Scheduled Telephone Support for Internet Cognitive Behavioral Therapy for Depression in Patients at Risk for Dropout: Pragmatic Randomized Controlled Trial.

J Med Internet Res 2020 07 23;22(7):e15732. Epub 2020 Jul 23.

Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland.

Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient.

Objective: This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression.

Methods: Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a ≥14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)-measured depressive symptoms and time spent in treatment.

Results: Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ.

Conclusions: Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice.

Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 55123131; http://www.isrctn.com/ISRCTN55123131.
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http://dx.doi.org/10.2196/15732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413288PMC
July 2020

Reducing health inequalities trough digital options in mental health: A physician's perspective.

Health Mark Q 2019 Apr-Jun;36(2):93-106. Epub 2019 Mar 23.

d Social Marketing @ Griffith , Griffith University , Nathan , Australia.

This article explores the physicians' perspective regarding the potential of computerized cognitive behavioral therapies (cCBTs) to overcome inequalities in the context of mental health care provision. The main benefits were related to the ability of cCBTs to provide care in a convenient and efficient manner, enhancing its accessibility. These aspects were perceived more important than cost-effectivity of treatment, which is often claimed to be the key benefit of cCBTs. Age and general acceptance of CBT were the most significant individual-level separators of perceptions, while the sector in which the physician works was seen as the main structural-level separator.
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http://dx.doi.org/10.1080/07359683.2019.1575059DOI Listing
August 2019

Self-reported treatment adherence among psychiatric in- and outpatients.

Nord J Psychiatry 2018 Oct 16;72(7):526-533. Epub 2018 Nov 16.

d Department of Psychiatry , Institute of Clinical Medicine , Helsinki , Finland.

Background: Poor adherence to psychiatric treatment is a common clinical problem, leading to unfavourable treatment outcome and increased healthcare costs.

Aim: The aim of this study was to investigate the self-reported adherence and attitudes to outpatient visits and pharmacotherapy in specialized care psychiatric patients.

Methods: Within the Helsinki University Psychiatric Consortium (HUPC) pilot study, in- and outpatients with schizophrenia or schizoaffective disorder (SSA, n  =  113), bipolar disorder (BD, n  =  99), or depressive disorder (DD, n  =  188) were surveyed about their adherence and attitudes towards outpatient visits and pharmacotherapy. Correlates of self-reported adherence to outpatient and drug treatment were investigated using regression analysis.

Results: The majority (78.5%) of patients reported having attended outpatient visits regularly or only partly irregularly. Most patients (79.2%) also reported regular use of pharmacotherapy. Self-reported non-adherence to preceding outpatient visits was consistently and significantly more common among inpatients than outpatients across all diagnostic groups (p < .001). Across all groups, hospital setting was the strongest independent correlate of poor adherence to outpatient visits (SSA β = -2.418, BD β = -3.417, DD β = -2.766; p < .001 in all). Another independent correlate of non-adherence was substance use disorder (SSA β = -1.555, p = .001; BD β = -1.535, p = .006; DD β = -2.258, p < .000). No other socio-demographic or clinical factor was significantly associated with poor adherence in multivariate regression models.

Conclusions: Irrespective of diagnosis, self-reported adherence to outpatient care among patients with schizophrenia or schizoaffective disorder, bipolar disorder, and depression is associated strongly with two factors: hospital setting and substance use disorders. Thus, detection of adherence problems among former inpatients and recognition and treatment of substance misuse are important to ensure proper outpatient care.
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http://dx.doi.org/10.1080/08039488.2018.1538387DOI Listing
October 2018

Therapeutic alliance in guided internet therapy programs for depression and anxiety disorders - A systematic review.

Internet Interv 2018 Mar 17;11:1-10. Epub 2017 Nov 17.

Hospital District of Helsinki and Uusimaa, Department of Psychiatry, University of Helsinki and Helsinki University Hospital, P.O. Box 590, 00029 HUS, Finland.

Objective: The role of internet therapy programs for mental disorders is growing. Those programs employing human support yield better outcomes than do those with no such support. Therapeutic alliance may be a critical element in this support. Currently, the significance of therapeutic alliance in guided, internet-delivered cognitive behavioral therapy programs (iCBT) remains unknown. This review aims to determine whether the therapeutic alliance influences outcome of iCBTs and if it does, what plausible factors underlie this association.

Method: Towards that goal searches were made in PubMed, PsycINFO, SCOPUS, The Cochrane Library and CINAHL in May 2016 and January 2017.

Results: From the 1658 relevant studies, only six studied the relationship of therapeutic alliance and outcome. All six studies showed a high level of client-therapist alliance; in the three most recent studies, the alliance was directly associated with outcome. No studies reported alliance-adherence associations.

Conclusions: Alliance research in iCBT for mental disorders is scarce. Therapeutic alliance seems to associate with outcomes. More studies are necessary to define the optimal support to strengthen alliance. iCBT is a feasible environment for alliance research both practically and theoretically. The impact of alliance on adherence to iCBT requires study.
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http://dx.doi.org/10.1016/j.invent.2017.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6084872PMC
March 2018

A Comparison of Mental Health Care Systems in Northern and Southern Europe: A Service Mapping Study.

Int J Environ Res Public Health 2018 05 31;15(6). Epub 2018 May 31.

VIDEA Lab, Centre for Mental Health Research, Australian National University, 63 Eggleston Rd, Acton ACT 2601, Australia.

Mental health services (MHS) have gone through vast changes during the last decades, shifting from hospital to community-based care. Developing the optimal balance and use of resources requires standard comparisons of mental health care systems across countries. This study aimed to compare the structure, personnel resource allocation, and the productivity of the MHS in two benchmark health districts in a Nordic welfare state and a southern European, family-centered country. The study is part of the REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care) project. The study areas were the Helsinki and Uusimaa region in Finland and the Girona region in Spain. The MHS were mapped by using the DESDE-LTC (Description and Evaluation of Services and Directories for Long Term Care) tool. There were 6.7 times more personnel resources in the MHS in Helsinki and Uusimaa than in Girona. The resource allocation was more residential-service-oriented in Helsinki and Uusimaa. The difference in mental health personnel resources is not explained by the respective differences in the need for MHS among the population. It is important to make a standard comparison of the MHS for supporting policymaking and to ensure equal access to care across European countries.
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http://dx.doi.org/10.3390/ijerph15061133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024953PMC
May 2018

Identifying Local and Centralized Mental Health Services-The Development of a New Categorizing Variable.

Int J Environ Res Public Health 2018 05 31;15(6). Epub 2018 May 31.

Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, FI-20520 Turku, Finland.

The challenges of mental health and substance abuse services (MHS) require shifting of the balance of resources from institutional care to community care. In order to track progress, an instrument that can describe these attributes of MHS is needed. We created a coding variable in the European Service Mapping Schedule-Revised (ESMS-R) mapping tool using a modified Delphi panel that classified MHS into centralized, local services with gatekeeping and local services without gatekeeping. For feasibility and validity, we tested the variable on a dataset comprising MHS in Southern Finland, covering a population of 2.3 million people. There were differences in the characteristics of services between our study regions. In our data, 41% were classified as centralized, 37% as local without gatekeeping and 22% as local services with gatekeeping. The proportion of resources allocated to local services varied from 20% to 43%. Reclassifying ESMS-R is an easy way to compare the important local vs. centralized balance of MHS systems globally, where such data exists. Further international studies comparing systems and validating this approach are needed.
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http://dx.doi.org/10.3390/ijerph15061131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6025394PMC
May 2018

Features of borderline personality disorder as a mediator of the relation between childhood traumatic experiences and psychosis-like experiences in patients with mood disorder.

Eur Psychiatry 2018 03 30;49:9-15. Epub 2018 Jan 30.

Department of Psychiatry, University of Helsinki and Helsinki University Hospital, P.O. Box 22, 00014, Finland. Electronic address:

Background: Psychosis-like experiences (PEs) are common in patients with non-psychotic disorders. Several factors predict reporting of PEs in mood disorders, including mood-associated cognitive biases, anxiety and features of borderline personality disorder (BPD). Childhood traumatic experiences (CEs), often reported by patients with BPD, are an important risk factor for mental disorders. We hypothesized that features of BPD may mediate the relationship between CEs and PEs. In this study, we investigated the relationships between self-reported PEs, CEs and features of BPD in patients with mood disorders.

Methods: As part of the Helsinki University Psychiatric Consortium study, McLean Screening Instrument (MSI), Community Assessment of Psychic Experiences (CAPE-42) and Trauma and Distress Scale (TADS) were filled in by patients with mood disorders (n = 282) in psychiatric care. Correlation coefficients between total scores of scales and their dimensions were estimated, multiple regression and mediation analyses were conducted.

Results: Total scores of MSI correlated strongly with scores of the CAPE-42 dimension "frequency of positive symptoms" (rho = 0.56; p ≤ 0.001) and moderately with scores of TADS (rho = 0.4; p ≤ 0.001). Total score of MSI and its dimension "cognitive symptoms", including identity disturbance, distrustfulness and dissociative symptoms, fully mediated the relation between TADS and CAPE-42. Each cognitive symptom showed a partial mediating role (dissociative symptoms 43% (CI = 25-74%); identity disturbance 40% (CI = 30-73%); distrustfulness 18% (CI = 12-50%)).

Conclusions: Self-reported cognitive-perceptual symptoms of BPD fully mediate, while affective, behavioural and interpersonal symptoms only partially mediate the relationships between CEs and PEs. Recognition of co-morbid features of BPD in patients with mood disorders reporting PEs is essential.
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http://dx.doi.org/10.1016/j.eurpsy.2017.12.005DOI Listing
March 2018

Should patients with schizophrenia receive antidepressants?

Duodecim 2017;133(5):465-71

Antipsychotics play a key role in the pharmacological treatment of schizophrenia, and monotherapy is effective for most patients. Achieving an optimal treatment response is, however, often difficult. Combining an antidepressant drug to the antipsychotic regimen could potentially improve treatment outcomes, although the evidence supporting the use of such combinations is limited and contradictory. Positive evidence has mostly been obtained from the efficacy of antidepressants acting on monoamine receptors on the negative symptoms of schizophrenia. These receptor-active drugs may also improve cognition in schizophrenic patients. In the light of current knowledge, antidepressants do not appear to potentiate the psychotic symptoms of schizophrenic patients. However, there is no robust evidence of the efficacy of antidepressants in the treatment of schizophrenia-related depression, and thus monotherapy with an antipsychotic drug is recommended for treating it. If using antidepressants in addition to antipsychotics is deemed necessary, the risk of pharmacodynamic and pharmacokinetic interactions should be kept in mind.
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January 2018

Psychoactive substance use in specialized psychiatric care patients.

Int J Psychiatry Med 2017 Jul-Sep;52(4-6):399-415

1 Department of Psychiatry, 159841 HYKS sairaanhoitopiiri , University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Objective Life expectancy of psychiatric patients is markedly shorter compared to the general population, likely partly due to smoking or misuse of other substances. We investigated prevalence and correlates of substance use among psychiatric patients. Methods Within the Helsinki University Psychiatric Consortium Study, data were collected on substance use (alcohol, smoking, and illicit drugs) among patients with schizophrenia or schizoaffective disorder (n = 113), bipolar (n = 99), or depressive disorder (n = 188). Clinical diagnoses of substance use were recorded, and information on smoking, hazardous alcohol use, or misuse of other substances was obtained using questionnaires. Results One-fourth (27.7%) of the patients had clinical diagnoses of substance use disorders. In addition, in the Alcohol Use Disorders Identification Test, 43.1% had hazardous alcohol use and 38.4% were daily smokers. All substance use was more common in men than in women. Bipolar patients had the highest prevalence of alcohol use disorders and hazardous use, whereas those with schizophrenia or schizoaffective disorder were more often daily smokers. In regression analyses, self-reported alcohol consumption was associated with symptoms of anxiety and borderline personality disorder and low conscientiousness. No associations emerged for smoking. Conclusions The vast majority of psychiatric care patients have a diagnosed substance use disorder, hazardous alcohol use, or smoke daily, males more often than females. Bipolar patients have the highest rates of alcohol misuse, schizophrenia or schizoaffective disorder patients of smoking. Alcohol use may associate with symptoms of anxiety, borderline personality disorder, and low conscientiousness. Preventive and treatment efforts specifically targeted at harmful substance use among psychiatric patients are necessary.
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http://dx.doi.org/10.1177/0091217417738937DOI Listing
June 2018

Relationships between self-reported childhood traumatic experiences, attachment style, neuroticism and features of borderline personality disorders in patients with mood disorders.

J Affect Disord 2017 Mar 14;210:82-89. Epub 2016 Dec 14.

Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Mental Health Unit, National Institute for Health and Welfare, Helsinki, Finland. Electronic address:

Background: Co-occurring borderline personality disorder (BPD) features have a marked impact on treatment of patients with mood disorders. Overall, high neuroticism, childhood traumatic experiences (TEs) and insecure attachment are plausible aetiological factors for BPD. However, their relationship with BPD features specifically among patients with mood disorders remains unclear. We investigated these relationships among unipolar and bipolar mood disorder patients.

Methods: As part of the Helsinki University Psychiatric Consortium study, the McLean Screening Instrument (MSI), the Experiences in Close Relationships-Revised (ECR-R), the Short Five (S5) and the Trauma and Distress Scale (TADS) were filled in by patients with mood disorders (n=282) in psychiatric care. Correlation coefficients between total scores of scales and their dimensions were estimated, and multivariate regression (MRA) and mediation analyses were conducted.

Results: Spearman's correlations were strong (rho=0.58; p<0.001) between total scores of MSI and S5 Neuroticism and moderate (rho=0.42; p<0.001) between MSI and TADS as well as between MSI and ECR-R Attachment Anxiety. In MRA, young age, S5 Neuroticism and TADS predicted scores of MSI (p<0.001). ECR-R Attachment Anxiety mediated 33% (CI=17-53%) of the relationships between TADS and MSI.

Limitations: Cross-sectional questionnaire study.

Conclusions: We found moderately strong correlations between self-reported BPD features and concurrent high neuroticism, reported childhood traumatic experiences and Attachment Anxiety also among patients with mood disorders. Independent predictors for BPD features include young age, frequency of childhood traumatic experiences and high neuroticism. Insecure attachment may partially mediate the relationship between childhood traumatic experiences and borderline features among mood disorder patients.
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http://dx.doi.org/10.1016/j.jad.2016.12.004DOI Listing
March 2017

Regional Correlates of Psychiatric Inpatient Treatment.

Int J Environ Res Public Health 2016 12 5;13(12). Epub 2016 Dec 5.

Unit for Mental Health, National Institute for Health and Welfare (T.H.L.); Mannerheimintie 168, Helsinki FI-00270, Finland.

Current reforms of mental health and substance abuse services (MHS) emphasize community-based care and the downsizing of psychiatric hospitals. Reductions in acute and semi-acute hospital beds are achieved through shortened stays or by avoiding hospitalization. Understanding the factors that drive the current inpatient treatment provision is essential. We investigated how the MHS service structure (diversity of services and balance of personnel resources) and indicators of service need (mental health index, education, single household, and alcohol sales) correlated with acute and semi-acute inpatient treatment provision. The European Service Mapping Schedule-Revised (ESMS-R) tool was used to classify the adult MHS structure in southern Finland (population 1.8 million, 18+ years). The diversity of MHS in terms of range of outpatient and day care services or the overall personnel resourcing in inpatient or outpatient services was not associated with the inpatient treatment provision. In the univariate analyses, sold alcohol was associated with the inpatient treatment provision, while in the multivariate modeling, only a general index for mental health needs was associated with greater hospitalization. In the dehospitalization process, direct resource re-allocation and substituting of inpatient treatment with outpatient care per se is likely insufficient, since inpatient treatment is linked to contextual factors in the population and the health care system. Mental health services reforms require both strategic planning of service system as a whole and detailed understanding of effects of societal components.
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http://dx.doi.org/10.3390/ijerph13121204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5201345PMC
December 2016

Regional Correlates of Psychiatric Inpatient Treatment.

Int J Environ Res Public Health 2016 12 5;13(12). Epub 2016 Dec 5.

Unit for Mental Health, National Institute for Health and Welfare (T.H.L.); Mannerheimintie 168, Helsinki FI-00270, Finland.

Current reforms of mental health and substance abuse services (MHS) emphasize community-based care and the downsizing of psychiatric hospitals. Reductions in acute and semi-acute hospital beds are achieved through shortened stays or by avoiding hospitalization. Understanding the factors that drive the current inpatient treatment provision is essential. We investigated how the MHS service structure (diversity of services and balance of personnel resources) and indicators of service need (mental health index, education, single household, and alcohol sales) correlated with acute and semi-acute inpatient treatment provision. The European Service Mapping Schedule-Revised (ESMS-R) tool was used to classify the adult MHS structure in southern Finland (population 1.8 million, 18+ years). The diversity of MHS in terms of range of outpatient and day care services or the overall personnel resourcing in inpatient or outpatient services was not associated with the inpatient treatment provision. In the univariate analyses, sold alcohol was associated with the inpatient treatment provision, while in the multivariate modeling, only a general index for mental health needs was associated with greater hospitalization. In the dehospitalization process, direct resource re-allocation and substituting of inpatient treatment with outpatient care per se is likely insufficient, since inpatient treatment is linked to contextual factors in the population and the health care system. Mental health services reforms require both strategic planning of service system as a whole and detailed understanding of effects of societal components.
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http://dx.doi.org/10.3390/ijerph13121204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5201345PMC
December 2016

How size matters: exploring the association between quality of mental health services and catchment area size.

BMC Psychiatry 2016 08 12;16:289. Epub 2016 Aug 12.

Mental Health Unit, National Institute for Health and Welfare (THL), Mannerheimintie 170, FI-00270, Helsinki, Finland.

Background: The diversity of mental health and substance abuse services (MHS) available to service users is seen as an indicator of the quality of the service system. In most countries MHS are provided by a mix of public, private and third sector providers. In Finland, officially, the municipalities are responsible for organizing the services needed, but the real extent and roles of private and third sector service providers are not known. Our previous study showed that the catchment area population size was strongly associated with diversity of mental health services. It is not known whether this was due to some types of services or some provider types being more sensitive to the size effect than others. The aim of this study was to investigate the association between area population size and diversity of mental health services, i.e. which types of services and which service providers' contributions are sensitive to population size.

Methods: To map and classify services, we used the ESMS-R. The diversity of services was defined as the count of main types of care. Providers were classified as public, private or third sectors.

Results: The diversity of outpatient, residential and voluntary services correlated positively with catchment area population size. The strongest positive correlation between the size of population and services available was found in third sector activities followed by public providers, but no correlation was found for diversity of private services. The third sector and public corporations each provided 44 % of the service units. Third sector providers produced all self-help services and most of the day care services. Third sector and private companies provided a significant part (59 %) of the residential care service units.

Conclusions: Significant positive correlations were found between size of catchment area population and diversity of residential, outpatient and voluntary services, indicating that these services concentrate on areas with larger population bases. The third sector seems to significantly complement the public sector in providing different services. Thus the third sector be needs to be functionally integrated with other MHS services to achieve a diversified and integrated service system.
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http://dx.doi.org/10.1186/s12888-016-0992-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4983042PMC
August 2016

Short report: self-reported psychopathic traits in Finnish and Dutch samples of non-referred adolescents: exploration of cultural differences.

Child Adolesc Psychiatry Ment Health 2016 8;10. Epub 2016 Feb 8.

Forensic Psychiatry, Helsinki University and Helsinki University Hospital, 04500 Kellokoski, Finland.

Background: Culture-related differences in psychopathic traits have been reported for adults, but for adolescents such knowledge is lacking. The aim of this cross-national study was to compare self-reported psychopathic traits between Finnish and Dutch samples of mid-adolescent community youth.

Methods: The Youth Psychopathic traits Inventory (YPI) was filled in by 372 Finnish and 474 Dutch 15- to 16-year-old pupils. As gender-specific differences exist in psychopathic traits, we analyzed the data separately for boys and girls.

Results: Dutch boys scored significantly higher than Finnish boys on total and all dimensional scores of the YPI as well as on most sub-dimensional scores. Dutch girls scored significantly higher than Finnish girls on the Affective dimension and on the two corresponding sub-dimensions: remorselessness and callousness. Finnish girls scored significantly higher on grandiosity, which loads to the Interpersonal dimension of the YPI.

Conclusions: Our findings suggest that culture influences the manifestation of psychopathic traits already in adolescence and that this relation is more prominent in boys.
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http://dx.doi.org/10.1186/s13034-015-0090-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4745156PMC
February 2016

Short report: self-reported psychopathic traits in Finnish and Dutch samples of non-referred adolescents: exploration of cultural differences.

Child Adolesc Psychiatry Ment Health 2016 8;10. Epub 2016 Feb 8.

Forensic Psychiatry, Helsinki University and Helsinki University Hospital, 04500 Kellokoski, Finland.

Background: Culture-related differences in psychopathic traits have been reported for adults, but for adolescents such knowledge is lacking. The aim of this cross-national study was to compare self-reported psychopathic traits between Finnish and Dutch samples of mid-adolescent community youth.

Methods: The Youth Psychopathic traits Inventory (YPI) was filled in by 372 Finnish and 474 Dutch 15- to 16-year-old pupils. As gender-specific differences exist in psychopathic traits, we analyzed the data separately for boys and girls.

Results: Dutch boys scored significantly higher than Finnish boys on total and all dimensional scores of the YPI as well as on most sub-dimensional scores. Dutch girls scored significantly higher than Finnish girls on the Affective dimension and on the two corresponding sub-dimensions: remorselessness and callousness. Finnish girls scored significantly higher on grandiosity, which loads to the Interpersonal dimension of the YPI.

Conclusions: Our findings suggest that culture influences the manifestation of psychopathic traits already in adolescence and that this relation is more prominent in boys.
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http://dx.doi.org/10.1186/s13034-015-0090-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4745156PMC
February 2016

Is there an interrelationship between the effects of antipsychotics on psychopathology and on metabolism?

Nord J Psychiatry 2016 8;70(3):190-4. Epub 2015 Oct 8.

a Department of Psychiatry , Helsinki University Central Hospital , Finland.

Background: Increased body weight and hyperlipidemia caused by antipsychotics may be associated with improved antipsychotic efficacy in schizophrenia. If this association has a causal interrelationship via a genuine pathophysiological mechanism, then body weight loss in antipsychotic-treated patients would be accompanied by worsened psychopathology. This could have clinical implications.

Aim: To explore whether the decreased body weight in these patients is associated with a worsened psychopathology.

Methods: In our previously published study, a 16 week treatment period with add-on orlistat (but not placebo) resulted in body weight loss in male (but not female) clozapine- or olanzapine-treated overweight or obese patients. In the current study, we investigated whether body weight loss in those male patients could worsen psychosis. Changes in the Positive and Negative Syndrome Scale (PANSS) scores within groups and body weight changes and lipid profiles over the treatment period were analysed by the paired samples t-test. Between-group comparisons were analysed by the independent samples t-test.

Results: Over the treatment period body weight decreased by 2.56 ± 3.25 kg from initial 106.02 ± 12.61 kg (p = 0.04) for the orlistat group, with no statistically significant changes for the placebo group. Lipid levels did not change in either group. The orlistat-induced weight decrease was not associated with worsening in the PANSS scores.

Conclusions: Weight loss was not associated with a worsening of psychosis. The interrelationship between the antipsychotic-induced weigh gain and improved schizophrenia psychopathology observed in earlier studies appears to be indirect. Orlistat treatment in our study did not worsen psychopathology in this population.
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http://dx.doi.org/10.3109/08039488.2015.1074283DOI Listing
October 2016

Is there an interrelationship between the effects of antipsychotics on psychopathology and on metabolism?

Nord J Psychiatry 2016 8;70(3):190-4. Epub 2015 Oct 8.

a Department of Psychiatry , Helsinki University Central Hospital , Finland.

Background: Increased body weight and hyperlipidemia caused by antipsychotics may be associated with improved antipsychotic efficacy in schizophrenia. If this association has a causal interrelationship via a genuine pathophysiological mechanism, then body weight loss in antipsychotic-treated patients would be accompanied by worsened psychopathology. This could have clinical implications.

Aim: To explore whether the decreased body weight in these patients is associated with a worsened psychopathology.

Methods: In our previously published study, a 16 week treatment period with add-on orlistat (but not placebo) resulted in body weight loss in male (but not female) clozapine- or olanzapine-treated overweight or obese patients. In the current study, we investigated whether body weight loss in those male patients could worsen psychosis. Changes in the Positive and Negative Syndrome Scale (PANSS) scores within groups and body weight changes and lipid profiles over the treatment period were analysed by the paired samples t-test. Between-group comparisons were analysed by the independent samples t-test.

Results: Over the treatment period body weight decreased by 2.56 ± 3.25 kg from initial 106.02 ± 12.61 kg (p = 0.04) for the orlistat group, with no statistically significant changes for the placebo group. Lipid levels did not change in either group. The orlistat-induced weight decrease was not associated with worsening in the PANSS scores.

Conclusions: Weight loss was not associated with a worsening of psychosis. The interrelationship between the antipsychotic-induced weigh gain and improved schizophrenia psychopathology observed in earlier studies appears to be indirect. Orlistat treatment in our study did not worsen psychopathology in this population.
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http://dx.doi.org/10.3109/08039488.2015.1074283DOI Listing
October 2016

Randomized Controlled Trials of Add-On Antidepressants in Schizophrenia.

Int J Neuropsychopharmacol 2015 May 19;18(9). Epub 2015 May 19.

Kellokoski Hospital, Kellokoski, Finland (Dr Terevnikov); Department of Psychiatry, Helsinki University Central Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland (Drs Joffe and Stenberg).

Background: Despite adequate treatment with antipsychotics, a substantial number of patients with schizophrenia demonstrate only suboptimal clinical outcome. To overcome this challenge, various psychopharmacological combination strategies have been used, including antidepressants added to antipsychotics.

Methods: To analyze the efficacy of add-on antidepressants for the treatment of negative, positive, cognitive, depressive, and antipsychotic-induced extrapyramidal symptoms in schizophrenia, published randomized controlled trials assessing the efficacy of adjunctive antidepressants in schizophrenia were reviewed using the following parameters: baseline clinical characteristics and number of patients, their on-going antipsychotic treatment, dosage of the add-on antidepressants, duration of the trial, efficacy measures, and outcomes.

Results: There were 36 randomized controlled trials reported in 41 journal publications (n=1582). The antidepressants used were the selective serotonin reuptake inhibitors, duloxetine, imipramine, mianserin, mirtazapine, nefazodone, reboxetin, trazodone, and bupropion. Mirtazapine and mianserin showed somewhat consistent efficacy for negative symptoms and both seemed to enhance neurocognition. Trazodone and nefazodone appeared to improve the antipsychotics-induced extrapyramidal symptoms. Imipramine and duloxetine tended to improve depressive symptoms. No clear evidence supporting selective serotonin reuptake inhibitors' efficacy on any clinical domain of schizophrenia was found. Add-on antidepressants did not worsen psychosis.

Conclusions: Despite a substantial number of randomized controlled trials, the overall efficacy of add-on antidepressants in schizophrenia remains uncertain mainly due to methodological issues. Some differences in efficacy on several schizophrenia domains seem, however, to exist and to vary by the antidepressant subgroups--plausibly due to differences in the mechanisms of action. Antidepressants may not worsen the course of psychosis. Better designed, larger, and longer randomized controlled trials are needed.
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http://dx.doi.org/10.1093/ijnp/pyv049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4576515PMC
May 2015

Does primary care mental health resourcing affect the use and costs of secondary psychiatric services?

Int J Environ Res Public Health 2014 Aug 26;11(9):8743-54. Epub 2014 Aug 26.

Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Mannerheimintie 170, FI-00270 Helsinki, Finland.

Collaborative care models for treatment of depression and anxiety disorders in primary care have been shown to be effective. The aim of this study was to investigate at the municipal level to what extent investment in mental health personnel at primary care health centres in the study area is reflected in the costs and use of secondary psychiatric services. Furthermore, we analysed whether the service provision and use of secondary psychiatric care correlates with the socioeconomic indicators of need. We found significant variation in the amount of mental health personnel provided at the health centres, uncorrelated with the indicators of need nor with the costs of secondary psychiatric care. The amount of mental health nurses at the health centres correlated inversely with the number of secondary psychiatric outpatient visits, whereas its relation to inpatient days and admission was positive. The costs of secondary psychiatric care correlated with level of psychiatric morbidity and socioeconomic indicators of need. The results suggest that when aiming at equal access of care and cost-efficiency, the primary and secondary care should be organized and planned with integrative collaboration.
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http://dx.doi.org/10.3390/ijerph110908743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4198988PMC
August 2014

Size matters - determinants of modern, community-oriented mental health services.

Int J Environ Res Public Health 2014 Aug 19;11(8):8456-74. Epub 2014 Aug 19.

Department of Mental Health and Substance Abuse Service, National Institute for Health and Welfare, Mannerheimintie 170, FI-00270 Helsinki, Finland.

Governances, structures and contents of mental health services are being reformed across countries. There is a need for data to support those changes. The aim of this study was to explore the quality, i.e., diversity and community orientation, and quantity, i.e., personnel resources, of mental health and substance abuse services (MHS) and evaluate correlation between population needs and quality and quantity of MHS. The European Service Mapping Schedule-Revised (ESMS-R) was used to classify mental health and substance abuse services in southern Finland. Municipal-level aggregate data, local data on unemployment rate, length of education, age of retirement, proportion of single households, alcohol sales and a composite mental health index were used as indicators of population mental health needs. Population size correlated strongly with service diversity, explaining 84% of the variance. Personnel resources did not associate with diversity or community orientation. The indicators of mental health services need did not have the expected association with quality and quantity of services. In terms of service organization, the results may support larger population bases, at least 150,000 adult inhabitants, when aiming for higher diversity.
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http://dx.doi.org/10.3390/ijerph110808456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4143871PMC
August 2014

Methodological and ethical challenges in studying patients' perceptions of coercion: a systematic mixed studies review.

BMC Psychiatry 2014 Jun 4;14:162. Epub 2014 Jun 4.

Department of Nursing Science, University of Turku, Turku, Finland.

Background: Despite improvements in psychiatric inpatient care, patient restrictions in psychiatric hospitals are still in use. Studying perceptions among patients who have been secluded or physically restrained during their hospital stay is challenging. We sought to review the methodological and ethical challenges in qualitative and quantitative studies aiming to describe patients' perceptions of coercive measures, especially seclusion and physical restraints during their hospital stay.

Methods: Systematic mixed studies review was the study method. Studies reporting patients' perceptions of coercive measures, especially seclusion and physical restraints during hospital stay were included. Methodological issues such as study design, data collection and recruitment process, participants, sampling, patient refusal or non-participation, and ethical issues such as informed consent process, and approval were synthesized systematically. Electronic searches of CINALH, MEDLINE, PsychINFO and The Cochrane Library (1976-2012) were carried out.

Results: Out of 846 initial citations, 32 studies were included, 14 qualitative and 18 quantitative studies. A variety of methodological approaches were used, although descriptive and explorative designs were used in most cases. Data were mainly collected in qualitative studies by interviews (n = 13) or in quantitative studies by self-report questionnaires (n = 12). The recruitment process was explained in 59% (n = 19) of the studies. In most cases convenience sampling was used, yet five studies used randomization. Patient's refusal or non-participation was reported in 37% (n = 11) of studies. Of all studies, 56% (n = 18) had reported undergone an ethical review process in an official board or committee. Respondents were informed and consent was requested in 69% studies (n = 22).

Conclusions: The use of different study designs made comparison methodologically challenging. The timing of data collection (considering bias and confounding factors) and the reasons for non-participation of eligible participants are likewise methodological challenges, e.g. recommended flow charts could aid the information. Other challenges identified were the recruitment of large and representative samples. Ethical challenges included requesting participants' informed consent and respecting ethical procedures.
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http://dx.doi.org/10.1186/1471-244X-14-162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051960PMC
June 2014

Psychiatric staff on the wards does not share attitudes on aggression.

Int J Ment Health Syst 2014 22;8:14. Epub 2014 Apr 22.

Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Area, Tuusula, Finland.

Background: The concept of ward culture has been proposed as a reason for the often reported differences in treatment decisions when managing inpatient aggression. We therefore studied whether staff on wards actually shares similar perceptions and attitudes about aggression and whether the specialty of the ward on which the staff members work influences these opinions.

Methods: The Attitudes Towards Aggression Scale was used to assess attitudes towards aggression in 31 closed psychiatric wards. Altogether 487 staff members working on the study wards were asked to fill in the scale. Respondent's gender, age, educational level, working experience on the current ward, and specialty of this ward (acute, forensic, rehabilitation) served as background variables.

Results: Most of the variance found was due to differences between individuals. Belonging to the personnel of a particular ward did not explain much of the variance.

Conclusions: Psychiatric staff on the wards does not share attitudes on aggression. As each staff member has his/her own opinion about aggression, training for dealing with aggression or violent incidents should be done, at least partly, on an individual level. We also suggest caution in using the concept of ward culture as an explanation for the use of restrictive measures on psychiatric wards.
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http://dx.doi.org/10.1186/1752-4458-8-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4002577PMC
April 2014

Toward a safer working environment on psychiatric wards: service users' delayed perspectives of aggression and violence-related situations and development ideas.

Perspect Psychiatr Care 2014 Oct 10;50(4):271-9. Epub 2014 Jan 10.

Department of Psychiatry, Hospital District of Helsinki and Uusimaa, Kellokoski, Tuusula, Finland.

Purpose: To explore service users' (n = 9) delayed perceptions of and suggestions for improvement of management of aggression/violence in psychiatry.

Design And Method: Focus group interviews, inductive content analysis.

Findings: Participants reported aggression/violence-related negative perceptions (including loneliness, boredom, excessive control, and fear) but also memories of humane and caring personnel. The suggestions included meaningful activities and humane, interactive nursing.

Practice Implications: Delayed perceptions and proposals resembled the proximate ones. Perceptions may persist for years. Such perceptions and proposals, if taken into account from the beginning of treatment, may prevent negative long-term consequences of witnessed or experienced aggression/violence. Humane, interactive nursing models should be studied and disseminated.
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http://dx.doi.org/10.1111/ppc.12054DOI Listing
October 2014

Does experienced seclusion or restraint affect psychiatric patients' subjective quality of life at discharge?

Int J Ment Health Syst 2013 Dec 5;7(1):28. Epub 2013 Dec 5.

Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Area, Tuusula, Finland.

Background: In Finland major effort has been invested in reducing the use of coercion in psychiatric treatment, and the goal is to diminish the use of coercion by 40% by 2015. Improving patients' quality of life (QoL) has gained prominence in psychiatric treatment during the past decade. Numerous studies have shown that most secluded or restrained patients (S/R patients) would prefer not to have had this experience. Experience of S/R could affect negatively patients' QoL, but empirical data on this issue are lacking.

Aim: The study aimed to explore the effect of experienced S/R on the subjective QoL of psychiatric in-patients.

Method: This study explored subjective QoL of the S/R patients. At discharge, S/R patients completed the Short Form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF).

Results: We found that S/R patients' (n = 36) subjective QoL was significantly better than that of non-S/R patients' (n = 228). Most non-S/R patients were diagnosed with mood disorders (mostly depression). Most of S/R patients were diagnosed with schizophrenia, schizotypal and delusional disorders. The mean duration of S/R was 2.3 days, median was one day and mean length of the hospitalization after S/R episode was 2.5 months.

Conclusion: Our cross-sectional findings suggest that S/R does not considerably influence patients' QoL or that the influence is short-lived. Because baseline QoL was not measured this remains uncertain. There are also many other factors, such as negative mood, which decrease the patients' QoL ratings. These factors may either mask the influence of S/R on QoL or modify the experience of QoL to such an extent that no independent association can be found at the time of discharge.
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http://dx.doi.org/10.1186/1752-4458-7-28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174906PMC
December 2013

eLearning course may shorten the duration of mechanical restraint among psychiatric inpatients: a cluster-randomized trial.

Nord J Psychiatry 2014 Oct 25;68(7):443-9. Epub 2013 Nov 25.

Raija Kontio, Ph.D., Assistant Chief of Department of Psychiatry, Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Region, Kellokoski Hospital , Finland.

Background: The management of psychiatric inpatients exhibiting severely disturbed and aggressive behaviour is an important educational topic. Well structured, IT-based educational programmes (eLearning) often ensure quality and may make training more affordable and accessible.

Aims: The aim of this study was to explore the impact of an eLearning course for personnel on the rates and duration of seclusion and mechanical restraint among psychiatric inpatients.

Methods: In a cluster-randomized intervention trial, the nursing personnel on 10 wards were randomly assigned to eLearning (intervention) or training-as-usual (control) groups. The eLearning course comprised six modules with specific topics (legal and ethical issues, behaviour-related factors, therapeutic relationship and self-awareness, teamwork and integrating knowledge with practice) and specific learning methods. The rates (incidents per 1000 occupied bed days) and durations of the coercion incidents were examined before and after the course.

Results: A total of 1283 coercion incidents (1143 seclusions [89%] and 140 incidents involving the use of mechanical restraints [11%]) were recorded on the study wards during the data collection period. On the intervention wards, there were no statistically significant changes in the rates of seclusion and mechanical restraint. However, the duration of incidents involving mechanical restraints shortened from 36.0 to 4.0 h (median) (P < 0.001). No statistically significant changes occurred on the control wards.

Conclusions: After our eLearning course, the duration of incidents involving the use of mechanical restraints decreased. However, more studies are needed to ensure that the content of the course focuses on the most important factors associated with the seclusion-related elements. The eLearning course deserves further development and further studies. The duration of coercion incidents merits attention in future research.
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http://dx.doi.org/10.3109/08039488.2013.855254DOI Listing
October 2014

Influence of patient characteristics on duration of seclusion/restrain in acute psychiatric settings in Japan.

Psychiatry Clin Neurosci 2013 Sep 13;67(6):405-11. Epub 2013 Aug 13.

Department of Social Psychiatry, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan.

Aim: The aim of this study was to investigate the current state of duration of seclusion/restraint in acute psychiatric settings in Japan and the effect of patient characteristics on duration of seclusion/restraint.

Methods: During an 8-month period starting from November 2008, duration of seclusion/restraint and patient characteristics were investigated in 694 psychiatric inpatients who experienced seclusion/restraint in three emergency and three acute wards at four psychiatric hospitals. Reasons for starting seclusion/restraint were also assessed. Analysis was performed using generalized linear models, with the duration of seclusion/restraint as the dependent variable and patient characteristics and reasons for starting seclusion/restraint as independent variables.

Results: Of the patients secluded/restrained, 58.6% had a primary diagnosis of schizophrenia (F20-F29) and a large proportion (37.9%) were secluded/restrained due to hurting others. Median hours ofseclusion/restraint were 204 and 82 h, respectively. The duration of seclusion was longer for patients with F20-F29 than those with disorders due to psychoactive substance use (F10-F19) or other diagnoses (F40-F99), and when the reason was danger of hurting others. In contrast, the duration of restraint in female patients and in patients with F10-F19 diagnosis was shorter.

Conclusion: The duration of seclusion/restraint at acute psychiatric care wards in Japan are much longer than those reported by previous overseas studies. Although Japanese structure issues such as more patients per ward and a lower ratio of nurses need to be considered, skills for dealing with patients with primary diagnosis of F20-F29 secluded due to danger posed to others should be improved.
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http://dx.doi.org/10.1111/pcn.12078DOI Listing
September 2013

Relationships between pharmacotherapy-induced metabolic changes and improved psychopathology in schizophrenia: data from a mirtazapine and first-generation antipsychotics combination trial.

Int J Neuropsychopharmacol 2013 Aug 10;16(7):1661-6. Epub 2012 Dec 10.

Kellokoski Hospital, Kellokoski, Finland.

Clinical efficacy and metabolic side-effects of antipsychotics seem to correlate with each other. In this study, interrelationship of similar metabolic effects of mirtazapine and its earlier reported desirable effects on psychopathology in first-generation antipsychotics (FGAs)-treated schizophrenia were explored. Symptomatic FGAs-treated patients with schizophrenia received a 6-wk double-blind treatment with add-on mirtazapine (n = 20) or placebo (n = 16), followed by a 6-wk open-label mirtazapine treatment. Mirtazapine (but not placebo) induced an increase in body weight and cholesterol levels. The latter was associated with a clinical improvement in all (sub)scales of the Positive and Negative Syndrome Scale [PANSS; an increase of cholesterol by 1 mmol/l predicted 7 points reduction on the PANSS total score (r = 0.85, p = 0.001)]. In schizophrenia, mirtazapine-induced weight gain and increase of total cholesterol are associated with the improved efficacy of mirtazapine-FGAs combination--a novel observation with possible clinical and theoretical implications.
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http://dx.doi.org/10.1017/S146114571200137XDOI Listing
August 2013

In a randomized placebo-controlled add-on study orlistat significantly reduced clozapine-induced constipation.

Int Clin Psychopharmacol 2013 Mar;28(2):67-70

Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland.

Constipation is a common and potentially fatal side effect of clozapine treatment. Another important side effect of clozapine may also be significant weight gain. Orlistat is a weight-control medication that is known to induce loose stools as a common side effect. This study aimed to explore whether orlistat used to control clozapine-induced weight gain can simultaneously tackle clozapine-related constipation. In this 16-week randomized-controlled study, clozapine-treated patients received add-on orlistat (n=30) or add-on placebo (n=24). Colonic function was measured using the Bristol Stool Form Scale. There was a significant (P=0.039) difference in the prevalence of constipation in favor of orlistat over placebo in completers (n=40) at the endpoint. A decrease in the prevalence of constipation within the orlistat group (P=0.035) was observed (vs. no statistically significant changes in the placebo group). In clozapine-treated patients, orlistat may be beneficial not only for weight control but also as a laxative. As no established treatments for clozapine-induced constipation exist, orlistat can be considered for this population, although more studies are required.
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http://dx.doi.org/10.1097/YIC.0b013e32835b08d2DOI Listing
March 2013

Underaged patients' opinions toward different containment measures: a questionnaire survey in Finnish adolescent psychiatry.

J Child Adolesc Psychiatr Nurs 2012 Nov 11;25(4):219-23. Epub 2012 Oct 11.

Department of Nursing Science, University of Turku and Hospital District of Southwest Finland, Turku, Finland.

Problem: The current literature does not provide an understanding of adolescent patients' opinions toward various containment measures and how these are related to the opinions of the staff who are caring for them.

Methods: The study population comprised 81 inpatients and 128 staff members in an inpatient setting in Finland. Their opinions were studied using the Attitude to Containment Measures Questionnaire.

Findings: The adolescents were more critical toward most containment measures compared to the staff. Exactly as reported in previous studies among adult service users, the containment measures most accepted by the adolescents were as-needed medication, intermittent observation, and time out. They were considered as helpful, safe, and respectful methods. Net bed, which has never been used in Finland, was most disapproved. It was considered as a distressing, inhuman, and cruel method. Opinions toward mechanical restraint, which is commonly used in Finnish adolescent psychiatry, were noticeable: adolescents rated mechanical restraint among the three least accepted, staff among the three most accepted containment methods. Adolescents considered it as distressing and not consistent of human dignity.

Conclusions: Adolescents disapprove of containment measures some of which are widely used in psychiatric practice. Their opinions differ significantly from those of the staff. New ways to manage crisis situations should be developed. Where containment cannot be avoided, information, explanation about the procedures involved, and debriefing should be offered to an underaged patient in a manner which takes account of his/her developmental level.
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http://dx.doi.org/10.1111/jcap.12006DOI Listing
November 2012
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