Publications by authors named "Tarja Melartin"

53 Publications

Self-invalidation in borderline personality disorder: A content analysis of patients' verbalizations.

Psychother Res 2022 Jan 12:1-14. Epub 2022 Jan 12.

Central Finland Health Care District, Jyväskylä, Finland.

Objective: The ability to trust one's own perceptions is crucial for psychological well-being and growth. The relevance of its opposite, self-invalidation (SI), to the psychopathology of borderline personality disorder (BPD) is emphasized in many contemporary theories of evidence-based treatments for BPD. Empirical research on this topic remains scarce, however. This study aimed to describe manifestations of SI in individuals with BPD during a 40-session psychoeducational intervention based mainly on schema therapy.

Method: Transcripts of videotaped group sessions were analyzed inductively using qualitative content analysis.

Results: SI emerged as a recurrent, ubiquitous phenomenon. The content analysis yielded three core categories of SI: (1) a self-critical and harsh attitude towards the self (subcategories reflected punitive internalizations that could engender fear-based inertia, self-erasing, submissive coping behavior, and temporal fluctuation in SI), (2) a deficient sense of normalcy, and self-doubt, and (3) self-stigma. We also found an association of SI with various dimensions of BPD, including difficulty in the identification of emotions, secondary emotional reactions such as guilt, shame, anger, and resentment, self-related and interpersonal problems, and suicidal urges.

Conclusions: SI is a detrimental cognitive-emotional process relevant to BPD that merits treatment. Efforts to reduce self-stigma, a pernicious aspect of SI, are imperative.
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http://dx.doi.org/10.1080/10503307.2022.2025627DOI Listing
January 2022

"If you don't have a word for something, you may doubt whether it's even real" - how individuals with borderline personality disorder experience change.

Psychother Res 2021 11 10;31(8):1036-1050. Epub 2021 Feb 10.

University of Eastern Finland, Central Finland Health Care District.

This study explored how psychological change was experienced and what treatment-related factors or events were perceived as supporting or hindering their process by individuals with borderline personality disorder.

Eight BPD sufferers attended a 40-session psychoeducational group intervention at a community mental health care center. At intervention end, personal experience of meaningful change was explored in an in-depth interview and data were content-analyzed. Change in BPD symptoms was assessed by the Borderline Personality Disorder Severity Index IV interview.

The qualitative content analysis on subjectively perceived meaningful change yielded three core categories: (1) improved ability to observe and understand mental events, (2) decreased disconnection from emotions, emergence of new or adaptive emotional reactions and decrease in maladaptive ones, and (3) a new, more adaptive experience of self and agency. Accordingly, (1) learning and (2) normalizing emerged as the main categories of helpful treatment factors. In turn, treatment-related factors perceived as obstacles were: (1) aggression in the group, and (2) inflexibility. With respect to symptom change, four participants were considered clinically as remitted, and two showed a reliable change.

Long-term psychoeducational group therapy seems to enhance mentalization / metacognitive functioning and promote self (or personality) integration in BPD patients.
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http://dx.doi.org/10.1080/10503307.2021.1883763DOI Listing
November 2021

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

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

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

Single dose of mirtazapine modulates whole-brain functional connectivity during emotional narrative processing.

Psychiatry Res Neuroimaging 2017 May 22;263:61-69. Epub 2017 Mar 22.

University of Helsinki and Helsinki University Hospital, Psychiatry, Helsinki, Finland; Vaasa Hospital District, Department of Psychiatry, Vaasa, Finland.

The link between neurotransmitter-level effects of antidepressants and their clinical effect remain poorly understood. A single dose of mirtazapine decreases limbic responses to fearful faces in healthy subjects, but it is unknown whether this effect applies to complex emotional situations and dynamic connectivity between brain regions. Thirty healthy volunteers listened to spoken emotional narratives during functional magnetic resonance imaging (fMRI). In an open-label design, 15 subjects received 15mg of mirtazapine two hours prior to fMRI while 15 subjects served as a control group. We assessed the effects of mirtazapine on regional neural responses and dynamic functional connectivity associated with valence and arousal. Mirtazapine attenuated responses to unpleasant events in the right fronto-insular cortex, while modulating responses to arousing events in the core limbic regions and the cortical midline structures (CMS). Mirtazapine decreased responses to unpleasant and arousing events in sensorimotor areas and the anterior CMS implicated in self-referential processing and formation of subjective feelings. Mirtazapine increased functional connectivity associated with positive valence in the CMS and limbic regions. Mirtazapine triggers large-scale changes in regional responses and functional connectivity during naturalistic, emotional stimuli. These span limbic, sensorimotor, and midline brain structures, and may be relevant to the clinical effectiveness of mirtazapine.
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http://dx.doi.org/10.1016/j.pscychresns.2017.03.009DOI Listing
May 2017

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

Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity.

J Affect Disord 2016 Sep 24;202:145-52. Epub 2016 May 24.

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

Background: Primary health care bears the main responsibility for treating depression in most countries. However, few studies have comprehensively investigated provision of pharmacological and psychosocial treatments, their continuity, or patient attitudes and adherence to treatment in primary care.

Methods: In the Vantaa Primary Care Depression Study, 1111 consecutive primary care patients in the City of Vantaa, Finland, were screened for depression with Prime-MD, and 137 were diagnosed with DSM-IV depressive disorders via SCID-I/P and SCID-II interviews. The 100 patients with current major depressive disorder (MDD) or partly remitted MDD at baseline were prospectively followed up to 18 months, and their treatment contacts and the treatments provided were longitudinally followed.

Results: The median number of patients' visits to a general practitioner during the follow-up was five; of those due to depression two. Antidepressant treatment was offered to 82% of patients, but only 50% commenced treatment and adhered to it adequately. Psychosocial support was offered to 49%, but only 29% adhered to the highly variable interventions. Attributed reasons for poor adherence varied, including negative attitude, side effects, practical obstacles, or no perceived need. About one-quarter (23%) of patients were referred to specialized care at some time-point.

Limitations: Moderate sample size. Data collected in 2002-2004.

Conclusions: The majority of depressive patients in primary health care had been offered pharmacotherapy, psychotherapeutic support, or both. However, effectiveness of these efforts may have been limited by lack of systematic follow-up and poor adherence to both pharmacotherapy and psychosocial treatment.
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http://dx.doi.org/10.1016/j.jad.2016.05.035DOI Listing
September 2016

Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity.

J Affect Disord 2016 Sep 24;202:145-52. Epub 2016 May 24.

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

Background: Primary health care bears the main responsibility for treating depression in most countries. However, few studies have comprehensively investigated provision of pharmacological and psychosocial treatments, their continuity, or patient attitudes and adherence to treatment in primary care.

Methods: In the Vantaa Primary Care Depression Study, 1111 consecutive primary care patients in the City of Vantaa, Finland, were screened for depression with Prime-MD, and 137 were diagnosed with DSM-IV depressive disorders via SCID-I/P and SCID-II interviews. The 100 patients with current major depressive disorder (MDD) or partly remitted MDD at baseline were prospectively followed up to 18 months, and their treatment contacts and the treatments provided were longitudinally followed.

Results: The median number of patients' visits to a general practitioner during the follow-up was five; of those due to depression two. Antidepressant treatment was offered to 82% of patients, but only 50% commenced treatment and adhered to it adequately. Psychosocial support was offered to 49%, but only 29% adhered to the highly variable interventions. Attributed reasons for poor adherence varied, including negative attitude, side effects, practical obstacles, or no perceived need. About one-quarter (23%) of patients were referred to specialized care at some time-point.

Limitations: Moderate sample size. Data collected in 2002-2004.

Conclusions: The majority of depressive patients in primary health care had been offered pharmacotherapy, psychotherapeutic support, or both. However, effectiveness of these efforts may have been limited by lack of systematic follow-up and poor adherence to both pharmacotherapy and psychosocial treatment.
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http://dx.doi.org/10.1016/j.jad.2016.05.035DOI Listing
September 2016

Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity.

J Affect Disord 2016 Sep 24;202:145-52. Epub 2016 May 24.

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

Background: Primary health care bears the main responsibility for treating depression in most countries. However, few studies have comprehensively investigated provision of pharmacological and psychosocial treatments, their continuity, or patient attitudes and adherence to treatment in primary care.

Methods: In the Vantaa Primary Care Depression Study, 1111 consecutive primary care patients in the City of Vantaa, Finland, were screened for depression with Prime-MD, and 137 were diagnosed with DSM-IV depressive disorders via SCID-I/P and SCID-II interviews. The 100 patients with current major depressive disorder (MDD) or partly remitted MDD at baseline were prospectively followed up to 18 months, and their treatment contacts and the treatments provided were longitudinally followed.

Results: The median number of patients' visits to a general practitioner during the follow-up was five; of those due to depression two. Antidepressant treatment was offered to 82% of patients, but only 50% commenced treatment and adhered to it adequately. Psychosocial support was offered to 49%, but only 29% adhered to the highly variable interventions. Attributed reasons for poor adherence varied, including negative attitude, side effects, practical obstacles, or no perceived need. About one-quarter (23%) of patients were referred to specialized care at some time-point.

Limitations: Moderate sample size. Data collected in 2002-2004.

Conclusions: The majority of depressive patients in primary health care had been offered pharmacotherapy, psychotherapeutic support, or both. However, effectiveness of these efforts may have been limited by lack of systematic follow-up and poor adherence to both pharmacotherapy and psychosocial treatment.
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http://dx.doi.org/10.1016/j.jad.2016.05.035DOI Listing
September 2016

Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity.

J Affect Disord 2016 Sep 24;202:145-52. Epub 2016 May 24.

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

Background: Primary health care bears the main responsibility for treating depression in most countries. However, few studies have comprehensively investigated provision of pharmacological and psychosocial treatments, their continuity, or patient attitudes and adherence to treatment in primary care.

Methods: In the Vantaa Primary Care Depression Study, 1111 consecutive primary care patients in the City of Vantaa, Finland, were screened for depression with Prime-MD, and 137 were diagnosed with DSM-IV depressive disorders via SCID-I/P and SCID-II interviews. The 100 patients with current major depressive disorder (MDD) or partly remitted MDD at baseline were prospectively followed up to 18 months, and their treatment contacts and the treatments provided were longitudinally followed.

Results: The median number of patients' visits to a general practitioner during the follow-up was five; of those due to depression two. Antidepressant treatment was offered to 82% of patients, but only 50% commenced treatment and adhered to it adequately. Psychosocial support was offered to 49%, but only 29% adhered to the highly variable interventions. Attributed reasons for poor adherence varied, including negative attitude, side effects, practical obstacles, or no perceived need. About one-quarter (23%) of patients were referred to specialized care at some time-point.

Limitations: Moderate sample size. Data collected in 2002-2004.

Conclusions: The majority of depressive patients in primary health care had been offered pharmacotherapy, psychotherapeutic support, or both. However, effectiveness of these efforts may have been limited by lack of systematic follow-up and poor adherence to both pharmacotherapy and psychosocial treatment.
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http://dx.doi.org/10.1016/j.jad.2016.05.035DOI Listing
September 2016

A single dose of mirtazapine attenuates neural responses to self-referential processing.

J Psychopharmacol 2016 Jan 17;30(1):23-32. Epub 2015 Nov 17.

University of Helsinki and Helsinki University Hospital, Psychiatry, Helsinki, Finland Vaasa Hospital District, Department of Psychiatry, Vaasa, Finland

Increased self-focus is a core factor in the psychopathology of depression. Cortical midline structures (CMS) are implicated in the neurobiology of self, depression and antidepressant treatment response. Mirtazapine, an antidepressant that increases serotonin and norepinephrine release, enhances processing of positive and attenuates processing of negative emotional information in healthy volunteers after a single dose. These early changes, which are opposite to the negative information bias in depression, may be important for the therapeutic effect of mirtazapine. It nevertheless remains unresolved whether/how mirtazapine specifically influences processing of self-referential emotional information.Half of the healthy volunteers (n=15/30) received a single dose of mirtazapine, in an open-label design, two hours before functional magnetic resonance imaging (fMRI), and the other half was scanned as a control group without medication. During fMRI the participants categorized positive and negative self-referential adjectives.Mirtazapine attenuated responses to self-referential processing in the medial prefrontal cortex and the anterior cingulate cortex. Mirtazapine further decreased responses to positive self-referential processing in the posterior cingulate cortex and parietal cortex.These decreased responses of the CMS suggest that mirtazapine may rapidly improve the ability of the CMS to down-regulate self-referential processing. In depressed patients, this could lead to decreased self-focus and rumination, contributing to the antidepressant effect.
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http://dx.doi.org/10.1177/0269881115616384DOI Listing
January 2016

The effect of personality on daily life emotional processes.

PLoS One 2014 24;9(10):e110907. Epub 2014 Oct 24.

University of Helsinki, Department of Psychiatry, Helsinki, Finland; Vaasa Hospital District, Department of Psychiatry, Vaasa, Finland.

Personality features are associated with individual differences in daily emotional life, such as negative and positive affectivity, affect variability and affect reactivity. The existing literature is somewhat mixed and inconclusive about the nature of these associations. The aim of this study was to shed light on what personality features represent in daily life by investigating the effect of the Five Factor traits on different daily emotional processes using an ecologically valid method. The Experience Sampling Method was used to collect repeated reports of daily affect and experiences from 104 healthy university students during one week of their normal lives. Personality traits of the Five Factor model were assessed using NEO Five Factor Inventory. Hierarchical linear modeling was used to analyze the effect of the personality traits on daily emotional processes. Neuroticism predicted higher negative and lower positive affect, higher affect variability, more negative subjective evaluations of daily incidents, and higher reactivity to stressors. Conscientiousness, by contrast, predicted lower average level, variability, and reactivity of negative affect. Agreeableness was associated with higher positive and lower negative affect, lower variability of sadness, and more positive subjective evaluations of daily incidents. Extraversion predicted higher positive affect and more positive subjective evaluations of daily activities. Openness had no effect on average level of affect, but predicted higher reactivity to daily stressors. The results show that the personality features independently predict different aspects of daily emotional processes. Neuroticism was associated with all of the processes. Identifying these processes can help us to better understand individual differences in daily emotional life.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0110907PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4208812PMC
December 2015

[How can a doctor meet an anxious patient?].

Duodecim 2014 ;130(5):483-8

A doctor can meet an anxious patient and handle her/his own reactions emerging in the therapeutic relationship. It is especially necessary to focus attention on the phenomena of the therapeutic relationship if the problems are prolonged and the patient and the doctor feel burdened. Mindfulness refers to conscious directing of alertness to the present, and to the approval and permissive perception of both extrinsic and intrinsic events (e.g. thoughts and feelings). The therapeutic relationships of a doctor may be affected by the doctor's presence and willingness to encounter her/his own reactions.
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May 2014

[How can a doctor meet an anxious patient?].

Duodecim 2014 ;130(5):483-8

A doctor can meet an anxious patient and handle her/his own reactions emerging in the therapeutic relationship. It is especially necessary to focus attention on the phenomena of the therapeutic relationship if the problems are prolonged and the patient and the doctor feel burdened. Mindfulness refers to conscious directing of alertness to the present, and to the approval and permissive perception of both extrinsic and intrinsic events (e.g. thoughts and feelings). The therapeutic relationships of a doctor may be affected by the doctor's presence and willingness to encounter her/his own reactions.
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May 2014

Depression and smoking: a 5-year prospective study of patients with major depressive disorder.

Depress Anxiety 2013 Jun 19;30(6):580-8. Epub 2013 Apr 19.

Mood, Depression, and Suicidal Behaviour Unit, National Institute for Health and Welfare, Helsinki, Finland.

Background: Major depressive disorder (MDD) and smoking are major public health problems and epidemiologically strongly associated. However, the relationship between smoking and depression and whether this is influenced by common confounding factors remain unclear, in part due to limited longitudinal data on covariation.

Methods: In the Vantaa Depression Study, psychiatric out- and inpatients with DSM-IV MDD and aged 20-59 years at were followed from baseline to 6 months, 18 months, and 5 years. We investigated course of depression, smoking, and comorbid alcohol-use disorders among the 214 patients (79.6% of 269) participating at least three time points; differences between smoking versus nonsmoking patients, and covariation of MDD, smoking, and alcohol-use disorders.

Results: Overall, 31.3% of the patients smoked regularly, 41.1% intermittently, and 27.6% never. Smokers were younger, had more alcohol-use disorders and Cluster B and C personality disorder symptoms, a higher frequency of lifetime suicide attempts, higher neuroticism, smaller social networks, and lower perceived social support than never smokers. Smoking and depression had limited longitudinal covariation. Depression, smoking, and alcohol-use disorders all exhibited strong autoregressive tendencies.

Conclusions: Among adult psychiatric MDD patients, smoking is strongly associated with substance-use and personality disorders, which may confound research on the impact of smoking. Rather than depression or smoking covarying or predicting each other, depression, smoking, and alcohol-use disorders each have strong autoregressive tendencies. These findings are more consistent with common factors causing their association than either of the conditions strongly predisposing to the other.
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http://dx.doi.org/10.1002/da.22108DOI Listing
June 2013

[Psychiatric evaluation of functional and work capacity--why, when and how?].

Duodecim 2012 ;128(21):2251-9

HYKS, psykiatrian tulosyksikkö, työkyvyntutkimuspoliklinikka Työterveyslaitos, Työ ja mielenterveys.

Evaluation and support of functional capacity are an essential part of treatment and rehabilitation of mental disorders. The evaluation requires objective observations from the examination situation and functional environment and is best effected multi-professionally and in network collaboration. In addition to functional limitations it is important to elucidate the remaining functional capacity, resources, strengths and coping mechanisms of the examined person and the possibilities of the workplace to support continuation in the work. Functional activity, social environment and suitably planned working will support mental health, prevent dropouts and lowering of the quality of life.
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January 2013

Do antidepressants change personality?--a five-year observational study.

J Affect Disord 2012 Dec 28;142(1-3):200-7. Epub 2012 Jul 28.

Department of Mental Health and Substance Use, National Institute of Health and Welfare, Helsinki, Finland.

Background: Whether antidepressants influence personality is a major clinical and societal issue due to their widespread use. In an observational study, we investigated whether depressive patients' neuroticism and extraversion scores covary with antidepressant pharmacotherapy, and if so, whether this remains significant after accounting for depressive or anxiety symptoms.

Methods: Major depressive disorder patients (N=237) were interviewed at up to four time-points in a five-year prospective longitudinal study. Changes in neuroticism plus extraversion scores were compared with changes in antidepressant pharmacotherapies and depressive plus anxiety symptoms to uncover any covariation between them. Autoregressive path models were used to examine this covariation at the sample level. Within-subject change was estimated using a random-effects latent change model.

Results: Significant covariation is present in the change trajectories between personality scores and depressive symptoms; declining depression scores were associated with rising extraversion and declining neuroticism. Although the personality scores of many patients changed significantly over the five-year study, none of these changes were associated with changes in antidepressant pharmacotherapy.

Limitations: The study covered only two dimensions of personality. Single drug-specific analysis could not be done. Antidepressant blood levels were not measured.

Conclusion: No evidence emerged for significant covariation of antidepressant pharmacotherapy with neuroticism or extraversion scores. By contrast, changes in both personality dimensions were associated with changes in depressive symptoms, those in neuroticism also in anxiety symptoms. If antidepressants influence these personality dimensions, the effect size is likely markedly smaller than that of the disorders for which they are prescribed.
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http://dx.doi.org/10.1016/j.jad.2012.04.026DOI Listing
December 2012

Neuroticism mediates the effect of P2RX7 on outcomes of mood disorders.

Depress Anxiety 2012 Sep 23;29(9):816-23. Epub 2012 May 23.

Department of Mental Health and Substance Use, National Institute for Health and Welfare, Helsinki, Finland.

Background: We previously reported an association between P2RX7 variant rs208294, diagnosis, and the longitudinal course of mood disorders. Here, we test whether the personality trait neuroticism mediates the effect of P2RX7 on the course of mood disorders.

Methods: Patients with DSM-IV mood disorder (256 with major depressive disorder and 168 with bipolar disorder [BD]) were diagnosed with semistructured interviews, genotyped, and followed up for a median of 60 (range 6-83) months. The primary outcome was the prospectively assessed proportion of time spent in any DSM-IV mood episode (time ill). Three types of genetic effect were tested in structural equations models: Model 1: genes directly affect outcome independent of neuroticism, Model 2: neuroticism mediates the effect of genes on outcome, and Model 3: neuroticism and the genetic variant interact in their effect on outcome.

Results: Neuroticism mediated the P2RX7 genetic effect on outcome. The T allele of rs208294 was associated with higher neuroticism, which in turn predicted a higher proportion of time spent in mood episodes (the bootstrap-based test of indirect effect, P = .02). There was no significant interaction between neuroticism and the genotype.

Conclusion: Neuroticism is likely to lie on the causal pathway between the rs208294 T variant and the adverse long-term course of major depressive and BDs.
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http://dx.doi.org/10.1002/da.21945DOI Listing
September 2012

Temperament trait Harm Avoidance associates with μ-opioid receptor availability in frontal cortex: a PET study using [(11)C]carfentanil.

Neuroimage 2012 Jul 29;61(3):670-6. Epub 2012 Mar 29.

Department of Psychiatry, University of Turku, Finland.

Harm Avoidance is a temperament trait that associates with sensitivity to aversive and non-rewarding stimuli, higher anticipated threat and negative emotions during stress as well as a higher risk for affective disorders. The neurobiological correlates of interindividual differences in Harm Avoidance are largely unknown. We hypothesized that variability in Harm Avoidance trait would be explained by differences in the activity of μ-opioid system as the opioid system is known to regulate affective states and stress sensitivity. Brain μ-opioid receptor availability was measured in 22 healthy subjects using positron emission tomography and [(11)C]carfentanil, a selective μ-opioid receptor agonist. The subjects were selected from a large Finish population-based cohort (N=2075) on the basis of their pre-existing Temperament and Character Scores. Subjects scoring consistently in the upper (10) and lower (12) quartiles for the Harm Avoidance trait were studied. High Harm Avoidance score associated with high μ-opioid receptor availability (i.e. lower endogenous μ-opioid drive) in anterior cingulate cortex, ventromedial and dorsolateral prefrontal cortices and anterior insular cortex. These associations were driven by two subscales of Harm Avoidance; Shyness with Strangers and Fatigability and Asthenia. In conclusion, higher Harm Avoidance score in healthy subjects is associated with higher μ-opioid availability in regions involved in the regulation of anxiety as well as in the control of emotions, affective component of pain and interoceptive awareness. The results have relevance in the research of vulnerability factors for affective disorders.
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http://dx.doi.org/10.1016/j.neuroimage.2012.03.063DOI Listing
July 2012

P2RX7 gene is associated consistently with mood disorders and predicts clinical outcome in three clinical cohorts.

Am J Med Genet B Neuropsychiatr Genet 2011 Jun 22;156B(4):435-47. Epub 2011 Mar 22.

Public Health Genomics Unit, Institute for Molecular Medicine FIMM, National Institute for Health and Welfare, Helsinki, Finland.

We investigated the effect of nine candidate genes on risk for mood disorders, hypothesizing that predisposing gene variants not only elevate the risk for mood disorders but also result in clinically significant differences in the clinical course of mood disorders. We genotyped 178 DSM-IV bipolar I and II and 272 major depressive disorder patients from three independent clinical cohorts carefully diagnosed with semistructured interviews and prospectively followed up with life charts for a median of 60 (range 6-83) months. Healthy control subjects (n = 1322) were obtained from the population-based national Health 2000 Study. We analyzed 62 genotyped variants within the selected genes (BDNF, NTRK2, SLC6A4, TPH2, P2RX7, DAOA, COMT, DISC1, and MAOA) against the presence of mood disorder, and in post-hoc analyses, specifically against bipolar disorder or major depressive disorder. Estimates for time ill were based on life charts. The P2RX7 gene variants rs208294 and rs2230912 significantly elevated the risk for a familial mood disorder (OR = 1.35, P = 0.0013, permuted P = 0.06, and OR = 1.44, P = 0.0031, permuted P = 0.17, respectively). The results were consistent in all three cohorts. The same risk alleles predicted more time ill in all cohorts (OR 1.3, 95% CI 1.1-1.6, P = 0.0069 and OR 1.7, 95% CI 1.3-2.3, P = 0.0002 with rs208294 and rs2230912, respectively), so that homozygous carriers spent 12 and 24% more time ill. P2RX7 and its risk alleles predisposed to mood disorders consistently in three independent clinical cohorts. The same risk alleles resulted in clinically significant differences in outcome of patients with major depressive and bipolar disorder.
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http://dx.doi.org/10.1002/ajmg.b.31179DOI Listing
June 2011

Family history of psychiatric disorders and the outcome of psychiatric patients with DSM-IV major depressive disorder.

J Affect Disord 2011 Jun 26;131(1-3):251-9. Epub 2011 Jan 26.

Mood, Depression, and Suicidal Behavior Unit, National Institute for Health and Welfare, Helsinki, Finland.

Background: Major Depressive Disorder (MDD) is often comorbid with other heritable disorders. The correlates of a family history (FH) of mood disorders but not of comorbid disorders among MDD patients have been investigated. Since bipolar disorder (BD) is highly heritable, latent BD may bias findings.

Methods: The Vantaa Depression Study included 269 psychiatric out- and in-patients with DSM-IV MDD, diagnosed with semistructured interviews and followed-up for 5 years with a life-chart. The FH of mood, psychotic disorders, and alcoholism among first-degree relatives of 183 patients was investigated.

Results: Three fourths (74.9%) of patients reported a FH of some major mental disorder; 60.7% of mood disorder, 36.6% alcoholism, and 10.9% psychotic disorder. In multivariate regression models, a FH of mood disorder was associated with high neuroticism (OR 1.08 [1.02-1.15], p=0.014); a FH of alcoholism with alcohol dependence, number of cluster B personality disorder symptoms, and dysthymia (OR 2.27 [1.01-5.08], p=0.047; OR=1.11 [1.01-1.23], p=0.030; and OR 4.35 [1.51-12.5], p=0.007), and a FH of psychotic disorder with more time spent with depressive symptoms (OR 1.03 [1.00-1.05], p=0.043). However, after excluding those who later switched to BD, several of the associations abated or lost significance.

Limitations: Family history was ascertained only by an interview of the proband.

Conclusions: The majority of MDD patients have a positive FH besides mood also of other disorders. A mood disorder FH may correlate with higher neuroticism, alcoholism FH with alcoholism or personality disorders. FH studies of MDD should take into account the impact of patients switching to BD.
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http://dx.doi.org/10.1016/j.jad.2010.12.016DOI Listing
June 2011

[A patient with personality disorder on a consultation visit].

Duodecim 2010 ;126(20):2389-98

HUS/HYKS, psykiatria, Jorvin klinikkaryhmä PL 800, 00290 HUS.

Personality disorders are disorders of cerebral function, in which the regulation of emotions or impulse control has become disturbed in a manner that impairs the capacity for reciprocal personal relationships. Persons suffering from unstable personality are exceedingly sensitive in reading emotional states from faces. In a crisis situation it is helpful for the patient, if the physician attempts to catch what is valid in the patient's experience and actively messages such understanding to the patient. Supporting the expressions of grief, loneliness and desire for contact is important in treating narcissistic personality disorder.
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December 2010

Treatment attitudes and adherence of psychiatric patients with major depressive disorder: a five-year prospective study.

J Affect Disord 2010 Dec 23;127(1-3):102-12. Epub 2010 May 23.

Mood, Depression, and Suicidal Behaviour Unit, National Institute for Health and Welfare, Helsinki, Finland.

Background: The prevalence, long-term temporal consistency and factors influencing negative attitudes and poor treatment adherence among psychiatric patients with major depressive disorder (MDD) are not well known.

Methods: In the Vantaa Depression Study (VDS), a prospective 5-year study of psychiatric patients with DSM-IV MDD, 238 (88.5%) patients' attitudes towards and adherence to both antidepressants and psychotherapeutic treatments at baseline, 6 months, 18 months and 5 years was investigated.

Results: Throughout the follow-up, most patients reported positive attitudes towards pharmacotherapy and psychosocial treatments, and good adherence. While attitudes became more critical over time, adherence to psychosocial treatment improved, but remained unchanged for pharmacotherapy. Employment predicted positive attitude (OR=1.97, 95% CI 1.01-3.83, P=0.046), and larger social network good adherence (OR=1.11, 95% CI 1.00-1.23, P=0.042) to pharmacotherapy at the last follow-up. Cluster B personality disorder symptoms predicted negative attitude (OR=0.82, 95% CI 0.70-0.96, P=0.012) and poor adherence (OR=0.83, 95% CI 0.72-0.95, P=0.007), but cluster C symptoms positive attitude (OR=1.30, 95% CI 1.09-1.54, P=0.003), and living alone good adherence (OR=3.13, 95% CI 1.10-9.09, P=0.032) to psychosocial treatment.

Limitations: Patients may exaggerate their adherence to treatments. Attrition from follow-up may occur due to undetected negative change in treatment attitude or adherence.

Conclusions: Among psychiatric MDD patients in long-term follow-up, treatment attitudes and adherence to pharmaco- and psychotherapy were and remained mostly positive. They were significantly predicted by personality features and social support. Attention to adherence of those with cluster B personality disorders, or poor social support, may be needed.
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http://dx.doi.org/10.1016/j.jad.2010.04.022DOI Listing
December 2010

Treatment attitudes and adherence of psychiatric patients with major depressive disorder: a five-year prospective study.

J Affect Disord 2010 Dec 23;127(1-3):102-12. Epub 2010 May 23.

Mood, Depression, and Suicidal Behaviour Unit, National Institute for Health and Welfare, Helsinki, Finland.

Background: The prevalence, long-term temporal consistency and factors influencing negative attitudes and poor treatment adherence among psychiatric patients with major depressive disorder (MDD) are not well known.

Methods: In the Vantaa Depression Study (VDS), a prospective 5-year study of psychiatric patients with DSM-IV MDD, 238 (88.5%) patients' attitudes towards and adherence to both antidepressants and psychotherapeutic treatments at baseline, 6 months, 18 months and 5 years was investigated.

Results: Throughout the follow-up, most patients reported positive attitudes towards pharmacotherapy and psychosocial treatments, and good adherence. While attitudes became more critical over time, adherence to psychosocial treatment improved, but remained unchanged for pharmacotherapy. Employment predicted positive attitude (OR=1.97, 95% CI 1.01-3.83, P=0.046), and larger social network good adherence (OR=1.11, 95% CI 1.00-1.23, P=0.042) to pharmacotherapy at the last follow-up. Cluster B personality disorder symptoms predicted negative attitude (OR=0.82, 95% CI 0.70-0.96, P=0.012) and poor adherence (OR=0.83, 95% CI 0.72-0.95, P=0.007), but cluster C symptoms positive attitude (OR=1.30, 95% CI 1.09-1.54, P=0.003), and living alone good adherence (OR=3.13, 95% CI 1.10-9.09, P=0.032) to psychosocial treatment.

Limitations: Patients may exaggerate their adherence to treatments. Attrition from follow-up may occur due to undetected negative change in treatment attitude or adherence.

Conclusions: Among psychiatric MDD patients in long-term follow-up, treatment attitudes and adherence to pharmaco- and psychotherapy were and remained mostly positive. They were significantly predicted by personality features and social support. Attention to adherence of those with cluster B personality disorders, or poor social support, may be needed.
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http://dx.doi.org/10.1016/j.jad.2010.04.022DOI Listing
December 2010

Differences in neuroticism and extraversion between patients with bipolar I or II and general population subjects or major depressive disorder patients.

J Affect Disord 2010 Sep 19;125(1-3):42-52. Epub 2010 Feb 19.

Department of Mental Health and Substance Use, National Institute of Health and Welfare, Helsinki, Finland.

Background: Whether levels of neuroticism or extraversion differ between patients with bipolar disorder (BD), major depressive disorder (MDD) and subjects from the general population, or between BD I and BD II patients, remains unclear.

Methods: BD patients (n=191) from the Jorvi Bipolar Study, and MDD patients (n=358) from both the Vantaa Depression Study and the Vantaa Primary Care Depression Study cohorts, were interviewed at baseline and at 18 months. A general population comparison group (n=347) was surveyed by mail. BD patients' neuroticism and extraversion scores, measured by Eysenck Personality Inventory, were compared at an index interview, when the levels of depression and mania were lowest, with scores of MDD patients and general population controls. Comparisons were also made between BD I (n=99) and BD II (n=92) patients.

Results: In multinomial logistic regression, BD patients had higher neuroticism (OR=1.17, p<0.001) and lower extraversion (OR=0.92, p=0.003) than the general population. When entered simultaneously into the model, the effect of extraversion disappeared. In logistic regression, the levels of neuroticism and extraversion did not differ between BD and MDD patients, or between BD I and II patients.

Limitations: Patients' personality scores were not pre-morbid.

Conclusions: Levels of neuroticism and extraversion are unlikely to differ between BD and MDD patients, or between BD I and II patients. The overall level of neuroticism is moderately higher and extraversion somewhat lower in BD patients than in the general population. High neuroticism may be an indicator of vulnerability to both bipolar and unipolar mood disorders.
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http://dx.doi.org/10.1016/j.jad.2010.01.068DOI Listing
September 2010

Categorical and dimensional stability of comorbid personality disorder symptoms in DSM-IV major depressive disorder: a prospective study.

J Clin Psychiatry 2010 Mar 12;71(3):287-95. Epub 2010 Jan 12.

Mood, Depression, and Suicidal Behavior Unit, National Institute for Health and Welfare, Helsinki, Finland.

Objective: To investigate the categorical and dimensional temporal stability of Axis II personality disorders among depressive patients, and to determine whether variations in Axis I comorbid disorders or self-reported personality traits predict changes in researcher-assigned personality disorder symptoms.

Method: Patients with DSM-IV major depressive disorder (MDD) in the Vantaa Depression Study (N = 269) were interviewed with the World Health Organization Schedules for Clinical Assessment in Neuropsychiatry, version 2.0, and the Structured Clinical Interview for DSM-III-R Axis II Disorders and were assessed with the 57-item Eysenck Personality Inventory at baseline, 6 months, and 18 months. Baseline interviews occurred between February 1, 1997, and May 31, 1998; follow-up interviews were 6 months and 18 months after baseline for each patient. Of the patients included in the study, 193 remained unipolar and could be interviewed at both follow-ups. The covariation of the severity of depression, anxiety, alcohol use, and reported neuroticism and extraversion with assigned personality disorder symptoms was investigated by using general estimation equations.

Results: The diagnosis of personality disorder persisted at all time points in about half (43%) of the 81 MDD patients diagnosed with personality disorder at baseline. The number of positive personality disorder criteria declined, particularly during the first 6 months, by a mean of 3 criteria. The decline in reported personality disorder symptoms covaried significantly with declines in the severity of depressive and anxiety symptoms (depressive: P = .02 for paranoid, P = .02 for borderline, and P = .01 for avoidant; anxiety: P = .08 for paranoid, P = .01 for borderline, and P < .001 for avoidant). Changes in patients' perceptions of self as measured by neuroticism covaried with changes in paranoid (P = .01) and borderline (P < .001) personality disorder symptoms.

Conclusions: Among MDD patients, the categorical stability of concurrent personality disorder diagnoses assigned while depressed is relatively poor, but the dimensional stability is moderate. The remission of depression as well as variations in Axis I comorbidity, particularly anxiety disorders, influences personality disorder diagnoses. These diagnostic difficulties most likely reflect broader variations in patients' perceptions of self over time, not merely psychometric problems related to the pertinent diagnostic criteria.
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http://dx.doi.org/10.4088/JCP.08m04621bluDOI Listing
March 2010

[Why does a person become depressed?].

Duodecim 2009 ;125(16):1771-9

Terveyden ja hyvinvoinnin laitos, PL 30, 00271 Helsinki.

Genotype, temperament, early traumas, ongoing stress as well as the their mutual, cumulative effects are factors predisposing to depression. Depressed patients often have minor structural lesions of the brain, and during the depressive state they exhibit both neurochemical abnormalities and plasticity, metabolic activity and neuroendocrinological abnormalities of the brain. For the most part, these will return to normal with the convalescence. A temperament predisposing to depression may be reflected in functional imaging studies of the brain. The depressive state is usually triggered by a negative life event.
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December 2009

Influence of personality on objective and subjective social support among patients with major depressive disorder: a prospective study.

J Nerv Ment Dis 2009 Oct;197(10):728-35

Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland.

Personality and social support (SS) influence risk for depression and modify its outcome through multiple pathways. The impact of personality dimensions neuroticism and extraversion on SS among patients with major depressive disorder (MDD) has been little studied. In the Vantaa Depression Study, we assessed neuroticism and extraversion with the Eysenck Personality Inventory, objective SS with the Interview Measure of Social Relationships, and subjective SS with the Perceived Social Support Scale-Revised at baseline, at 6 and 18 months among 193 major depressive disorder patients diagnosed according to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DMS-IV). At all time-points, low neuroticism and high extraversion associated significantly with between-subject differences in levels of objective and subjective SS. Lower neuroticism (beta = 0.213, p = 0.003) and higher extraversion (beta = 0.159, p = 0.038) predicted greater within-subject change of subjective, but not objective SS. Thus, neuroticism and extraversion associated with the size of objective and subjective SS and predicted change of subjective SS. Modification of subjective SS, particularly, may indirectly influence future vulnerability to depression.
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http://dx.doi.org/10.1097/NMD.0b013e3181b97960DOI Listing
October 2009

Screening of psychiatric outpatients for borderline personality disorder with the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD).

Nord J Psychiatry 2009 Nov;63(6):475-9

Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland.

Background: Detecting patients with borderline personality disorder (BPD) is important, and feasible screening instruments are needed.

Aims: To investigate our Finnish translation of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) as a screen for BPD among psychiatric outpatients, its psychometric and screening properties, and feasibility in improving the recognition of BPD.

Methods: We screened 302 consecutive psychiatric outpatients at the Department of Psychiatry at the Helsinki University Central Hospital in Finland for BPD using the Finnish MSI-BPD. Of the patients, 69 (23%) were assigned to a random sample that was stratified according to the number of screens returned to the outpatient clinics, and further stratified into the three strata, high scores deliberately enriched, according to the MSI-BPD scores. Finally, a stratified random sample of 45 patients was interviewed with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) by the interviewers blind to the patients' MSI-BPD scores.

Results: One third (29%) of 302 screened patients had a positive MSI-BPD. The internal consistency of the MSI-BPD was good (Cronbach's alpha = 0.77). Of the 45 patients interviewed with the SCID-II, 11 (24%) were found to have BPD, five (46%) of whom a previously clinical diagnosis. In a ROC analysis, the optimal cut-off score was 7.

Conclusions: The translated MSI-BPD was found to be a feasible screen for BPD in Finnish psychiatric outpatient care. Further studies investigating the clinical utility of MSI-BPD in larger clinical samples are warranted.
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http://dx.doi.org/10.3109/08039480903062968DOI Listing
November 2009
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