Suomen Lääkärilehti [Finnish Medical Journal], Jun 2, 2017
[English abstract at end]
Lähtökohdat: Psykiatrian sairaansijojen vähetessä mielenterveyskuntoutu... more [English abstract at end] Lähtökohdat: Psykiatrian sairaansijojen vähetessä mielenterveyskuntoutujille suunnatut asumispalvelut ovat lisääntyneet.
Aineisto ja menetelmät: Helsingin ja Uudenmaan sairaanhoitopiirin (HUS) kunnissa tehtiin v. 2012 ja 2014 selvitys aikuisväestön mielenterveys- ja päihdepalveluista ESMS-R-työkalulla (European Service Mapping Schedule, revised).
Tulokset: Psykiatrian sairaansijat vähenivät kahdessa vuodessa sairaalaosastojen sulkemisen takia 15 % ja mielenterveyskuntoutujien asumispalvelut lisääntyivät 4 %. Päihdekuntoutujien asumispalvelut lisääntyivät 67 % pitkäaikaisasunnottomuuden vähentämisohjelman ansiosta. Julkisten tuottajien osuus mielenterveys- ja päihdekuntoutujien asumispalveluista kasvoi tarkastelujaksona. Ympärivuorokautisten paikkojen yhteismäärä vaihteli suuresti sairaanhoitoalueittain. Psykiatrian sairaansijojen määrän ja mielenterveyskuntoutujien asumispalvelujen paikkamäärän väliltä ei löytynyt yhteyttä. Asumispalveluissa havaittiin lievää siirtymistä vähemmän tuettuihin asumismuotoihin ja kohti kotiin tuotua tukea.
Päätelmät: Alueen palvelujen järjestäminen on valtakunnallisten linjausten mukaisesti kehittynyt laitosmaisista olosuhteista tuettuun asumiseen. Ympärivuorokautisten paikkojen suuri alueellinen vaihtelu sekä psykiatrian sairaansijojen ja asumispalvelujen paikkamäärän väliltä puuttuva yhteys kuitenkin viittaavat siihen, ettei palvelukokonaisuus ole kehittynyt ohjatusti. Ryhmämuotoisia asumispalveluja painotettaessa on vaara, ettei aito itsenäinen asuminen lisäänny, vaan hoiva siirtyy osastoilta asumispalveluihin.
ENGLISH: Background: While there has been a decrease in inpatient psychiatric care, supported housing services for people with mental health problems have increased.
Methods: Adult mental health and substance abuse services in the Hospital District of Helsinki and Uusimaa (HUS) were systematically mapped and classified using the revised European Service Mapping Schedule (ESMS-R) tool in 2012 and again in 2014.
Results: As a result of the closure of psychiatric hospital wards and despite population growth, psychiatric inpatient beds decreased by 15% and mental health supported housing services increased by 4% over the two-year period. Also, beds in supported housing relating to substance abuse increased significantly (67%) as a result of a national programme aimed at reducing long term homelessness. These factors led to an increase in publicly provided supported housing services for people with mental health and substance abuse problems during this time period.
Variation between hospital districts in the total number of beds used, i.e. hospital beds and beds in housing services, was high, ranging from a total of 21 beds per 10 000 adults to 68 beds per 10 000 adults. No association between the number of psychiatric hospital beds and the number of beds in mental health housing services was found. Our results show a transition towards less intensively supported housing in the HUS district during the period studied. Also, a slight trend towards providing more home based support can be seen.
Conclusions: Services in the HUS area have been developed in accordance with national mental health and housing policies, i.e. moving away from traditional institution-based services towards home-based services. The total use of beds varies considerably between different geographical areas in the district and, taken together with the absence of an association between the number of psychiatric hospital beds and beds in supported housing services, it appears that the mental health service system as a whole has not been developed in a planned and strategic manner. Emphasis on supported housing services in the form of group homes contrasts with the Western European model which has a stronger focus on home-based services. This focus on group-based housing services increases the risk of transinstitutionalisation, where the reduction in hospital beds leads to service users being transferred from psychiatric inpatient wards to supported housing services without this resulting in a genuine increase in autonomy. Strategic governance of psychiatric services as well as supported housing is necessary in order to further develop home-based services, improve quality of services, and increase social inclusion and participation, as well as to facilitate cost control.
Social psychiatry and psychiatric epidemiology, Jan 9, 2017
To review psychosocial and policy interventions which mitigate the effects of poverty and inequal... more To review psychosocial and policy interventions which mitigate the effects of poverty and inequality on mental health. Systematic reviews, controlled trials and realist evaluations of the last 10 years are reviewed, without age or geographical restrictions. Effective psychosocial interventions on individual and family level, such as parenting support programmes, exist. The evidence for mental health impact of broader community-based interventions, e.g. community outreach workers, or service-based interventions, e.g. social prescribing and debt advice is scarce. Likewise, the availability of evidence for the mental health impact of policy level interventions, such as poverty alleviation or youth guarantee, is quite restricted. The social, economic, and physical environments in which people live shape mental health and many common mental disorders. There are effective early interventions to promote mental health in vulnerable groups, but it is necessary to both initiate and facilitate...
Background
Psychiatric readmissions have been studied at length. However, knowledge about how e... more Background
Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.
Methods
Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.
Results
Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.
Conclusion
This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.
Background: Psychiatric services have undergone profound changes over the last decades. CEPHOS-LI... more Background: Psychiatric services have undergone profound changes over the last decades. CEPHOS-LINK is an EU-funded study project with the aim to compare readmission of patients discharged with psychiatric diagnoses using a registry-based observational record linkage study design and to analyse differences in the findings for five different countries. A range of different approaches is available for analysis of the available data. Although there are some studies that compare selected methods for evaluating questions on readmission, there are to our knowledge no published systematic literature reviews on commonly used methods and their comparison. This work shall therefore provide an overview of the methods in use, their evolution throughout history and new developments which can further improve the research quality in this area. Methods: Based on systematic literature reviews realized in the course of the CEPHOS-LINK study, this work is a systematic evaluation of mathematical (statistical and modelling) methods used in studies examining psychiatric readmission. The starting point were 502 papers, of which 407 were analysed in detail; Methods used were assigned to one of five categories with subcategories and analysed accordingly. Our particular interest next to survival analysis and regression models is modelling and simulation. Results: As population sizes and follow-up times in the included studies varied widely, a range of methods was applied. Studies with bigger sample sizes conducted survival and regression analysis more often than studies with fewer patients did. These latter relied more on classical statistical tests (e.g. t-tests and Student Newman Keuls). Statistical strategies were often insufficiently described, posing a major problem for the evaluation. Almost all cases failed to provide and explanation of the rationale behind using certain methods.
Background: Readmission rate is considered an indicator of the mental health care quality. Previo... more Background: Readmission rate is considered an indicator of the mental health care quality. Previous studies have examined a number of factors that are likely to influence readmission. The main objective of this systematic review is to identify the studied pre-discharge variables and describe their relevance to readmission among psychiatric patients.
Background: Comorbidity between mental and physical disorder conditions is the rule rather than t... more Background: Comorbidity between mental and physical disorder conditions is the rule rather than the exception. It is estimated that 25% of adult population have mental health condition and 68% of them suffer from comorbid medical condition. Readmission rates in psychiatric patients are high and we still lack understanding potential predictors of recidivism. Physical comorbidity could be one of important risk factors for psychiatric readmission. The aim of the present study was to review the impact of physical comorbidity variables on readmission after discharge from psychiatric or general inpatient care among patients with co-occurring psychiatric and medical conditions. Methods: A comprehensive database search from January 1990 to June 2014 was performed in the following bibliographic databases: Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. An integrative research review was conducted on 23 observational studies.
(Article in Finnish) Obesity is associated with insomnia symptoms, but the contribution of weight... more (Article in Finnish) Obesity is associated with insomnia symptoms, but the contribution of weight changes to insom¬nia symptoms is poorly known. We examined the associations between weight changes and insom¬nia symptoms by baseline weight. The phase 1 questionnaire survey was conducted in 2000–2002 among employees of the City of Helsinki (n=8960) and phase 2 in 2007 (n=7332). Insom¬nia symptoms, weight, height, and covariates were available for 6929 participants. Weight change (≥5%) during the follow-up was examin¬ed among normal weight (BMI 18.5-24.9), over¬weight (BMI 25.0-29.9) and obese (BMI 30 or more) participants. Insomnia symptoms were trouble falling or staying asleep, nocturnal awa¬kenings, and non-restorative sleep for at least 15 nights over previous four weeks. Logistic regres¬sion was used, adjusting first for age, second also for baseline insomnia symptoms, and third, in addition to the previous covariates, for marital status, education, employment status, alcohol consumption, smoking, physical activity, and self-rated health. Among men, overweight (OR 2.28, 95% CI 1.43–3.63) and obese (OR, 2.98, 95% CI, 1.55–5.75) weight gainers and persistently obese (OR 2.23, 95% CI 1.29–3.84) were more likely to report insomnia symptoms at follow-up. These associations remained after adjustments. Among women, obese weight gainers were more likely to report insomnia symptoms (OR 1.64, 95% CI 1.24–2.18), but the association reduced after adjustments. In conclusion, preventing weight gain among the overweight or obese could help prevent insomnia symptoms particularly among men.
Social psychiatry and psychiatric epidemiology, 2014
Purpose This study examined the associations of insomnia symptoms with subsequent psychotropic me... more Purpose This study examined the associations of insomnia symptoms with subsequent psychotropic medication, reflecting mental health. Methods Postal baseline surveys among 40- to 60-year-old employees of the city of Helsinki, Finland, were collected in 2000–2002 (N = 6,227, response rate 67 %, 78 % women) and longitudinally linked with national register data on prescribed reimbursed medication. Insomnia symptoms at baseline comprised difficulties in initiating and maintaining sleep, and non-restorative sleep. All purchased psychotropic medication 5–7 years prior to and 5 years after baseline was included. Outcomes were any psychotropic medication; antidepressants; and anxiolytics, hypnotics, and sedatives. Covariates included socio-demographic and work-related factors, health behaviors, lifetime mental disorders, and prior psychotropic medication. Logistic regression analysis was used to calculate odds ratios (OR) and their 95 % confidence intervals (CI). Results Insomnia symptoms were associated with higher frequency of subsequent psychotropic medication prescriptions. The associations were strongest for frequent insomnia symptoms (women OR 3.55, 95 % CI 2.64–4.77; men OR 4.64, 95 % CI 2.49–8.66, adjusted for age and prior medication), but also rare and occasional symptoms were associated with psychotropic medication. Further adjustments had negligible effects. Conclusions Insomnia symptoms were associated with prescribed psychotropic medication during follow-up in a dose–response manner. Attention should be given to the prevention of insomnia symptoms to curb subsequent mental problems.
BackgroundPain and insomnia are both independently associated with work disability. Although pain... more BackgroundPain and insomnia are both independently associated with work disability. Although pain and insomnia often co-occur, their joint associations with subsequent sickness absence and disability retirement have not been studied. We aimed to examine these associations in two prospective occupational cohorts while considering key covariates.Pain and insomnia are both independently associated with work disability. Although pain and insomnia often co-occur, their joint associations with subsequent sickness absence and disability retirement have not been studied. We aimed to examine these associations in two prospective occupational cohorts while considering key covariates.MethodsNorwegian Hordaland Health Study (n = 6892, 59% women) and Finnish Helsinki Health Study (n = 6060, 78% women) data were used. Those with only pain, only insomnia or both conditions at baseline were compared with those with no pain and no insomnia. Work disability outcomes were derived from national and employers' register data. Medically certified sickness absence spells lasting 2 weeks or more and all-cause disability retirement were examined. Register-based follow-up was 4 years for sickness absence and 5 years for disability retirement. Covariates were sex, age, marital status, education, smoking, alcohol use, body mass index and blood pressure. Poisson and Cox regression models were fitted.Norwegian Hordaland Health Study (n = 6892, 59% women) and Finnish Helsinki Health Study (n = 6060, 78% women) data were used. Those with only pain, only insomnia or both conditions at baseline were compared with those with no pain and no insomnia. Work disability outcomes were derived from national and employers' register data. Medically certified sickness absence spells lasting 2 weeks or more and all-cause disability retirement were examined. Register-based follow-up was 4 years for sickness absence and 5 years for disability retirement. Covariates were sex, age, marital status, education, smoking, alcohol use, body mass index and blood pressure. Poisson and Cox regression models were fitted.ResultsBoth pain and insomnia were associated with subsequent sickness absence and disability retirement, but the associations were stronger for those reporting co-morbid pain and insomnia with support for a synergistic interaction effect, particularly regarding disability retirement. The associations were largely similar in both cohorts and remained after full adjustments.Both pain and insomnia were associated with subsequent sickness absence and disability retirement, but the associations were stronger for those reporting co-morbid pain and insomnia with support for a synergistic interaction effect, particularly regarding disability retirement. The associations were largely similar in both cohorts and remained after full adjustments.ConclusionsThis study is the first to report the separate and combined effects of pain and insomnia on objective health outcomes. Common patterns observed in two separate cohorts suggest that the combination of pain and insomnia might be particularly relevant for subsequent disability retirement.This study is the first to report the separate and combined effects of pain and insomnia on objective health outcomes. Common patterns observed in two separate cohorts suggest that the combination of pain and insomnia might be particularly relevant for subsequent disability retirement.
Sleep disturbances have been associated with an increased risk of cardiovascular disease outcomes... more Sleep disturbances have been associated with an increased risk of cardiovascular disease outcomes. The associations of insomnia with hypertension and dyslipidaemia, the main modifiable cardiovascular risk factors, are less studied. We especially lack understanding on the longitudinal effects of insomnia on dyslipidaemia. We aimed to examine the associations of insomnia symptoms with subsequent prescribed medication for hypertension and dyslipidaemia using objective register-based follow-up data. Baseline questionnaire surveys among 40–60-year-old employees of the City of Helsinki, Finland, were conducted in 2000–2002 (n = 6477, response rate 67%, 78% women) and linked to a national register on prescribed reimbursed medication 5–7 years prior to and 5 years after baseline. Associations between the frequency of insomnia symptoms (difficulties in initiating and maintaining sleep, non-restorative sleep) and hypertension and dyslipidaemia medication during the follow-up were analysed using logistic regression analysis (odds ratios with 95% confidence intervals). Analyses were adjusted for pre-baseline medication, sociodemographic and work-related factors, health behaviours, mental health, and diabetes. Frequent insomnia symptoms were reported by 20%. During the 5-year follow-up, 32% had hypertension medication and 15% dyslipidaemia medication. Adjusting for age, gender and pre-baseline medication, frequent insomnia symptoms were associated with hypertension medication (odds ratio 1.57, 95% confidence interval 1.23–2.00) and dyslipidaemia medication (odds ratio 1.59, 95% confidence interval 1.19–2.12). Occasional insomnia symptoms were also associated with cardiovascular medication, though less strongly. Further adjustments had negligible effects. To conclude, insomnia should be taken into account in the prevention and management of cardiovascular disease and related risk factors.
Clinical assessment of object relations is essential when evaluating treatability by different ty... more Clinical assessment of object relations is essential when evaluating treatability by different types of psychotherapy. The Quality of Object Relations Scale (QORS) is an established interview measure used for assessing object relations, but the validity of the QORS in relation to its theoretical constituents has not been examined. Our aim was to study the concurrent validity of the QORS. Trained interviewers assessed 263 outpatients seeking psychotherapy due to mood or anxiety disorder, with the QORS and with selected proxy criterion measures representing constituents of object-relational maturity. Discontinuity in relationships and the use of devaluation in relationships were the main determinants of low Quality of Object Relations (low-QOR). Patients with discontinuity in relationships had a four-fold and patients with devaluation in relationships a three-fold risk of belonging to the low-QOR group (p = 0.001) in comparison to those without these relational characteristics. Also poor self-confidence and major separations in childhood predicted the low- versus high-QOR category. The results indicate adequate concurrent validity of the QORS and support its credibility in assessing personality pathology, beyond axis II diagnosis, by trained clinicians.
Scandinavian journal of work, environment & health, 2012
The aim of this study was to examine the joint association of sleep duration and insomnia symptom... more The aim of this study was to examine the joint association of sleep duration and insomnia symptoms with subsequent disability retirement. Baseline survey data were collected in 2000-2002 from 40-60-year-old employees of the City of Helsinki, all working at baseline. Baseline data were linked with disability retirement data until the end of 2010, obtained from the Finnish Centre for Pensions registers (N=6042). Sleep duration and self-reported insomnia symptoms (non-restorative sleep and difficulties in initiating and maintaining sleep) were derived from the baseline surveys. All-cause disability retirement (N=561) and the most prevalent diagnostic groups - musculoskeletal diseases (43%) and mental disorders (26%) - were examined. Cox regression analysis was used to yield hazard ratios (HR) with 95% confidence intervals (95% CI). A joint association of sleep duration and insomnia symptoms with disability retirement was found, implying a higher risk for those with frequent insomnia symptoms. HR for all-cause disability retirement ranged among those with frequent symptoms from 2.02 (95% CI 1.53-2.68, sleeping 7 hours) to 3.92 (95% CI 2.57-5.97, sleeping ≤ 5 hours). Adjusting for sociodemographic, work, and health-related factors attenuated the associations, which nevertheless remained. The associations were similar for the two diagnostic groups, although stronger for those with mental disorders. Frequent insomnia symptoms dominate the joint association of sleep duration and insomnia symptoms with subsequent disability retirement. Examining exclusively sleep duration would provide an incomplete understanding of the consequences of poor sleep.
Suomen Lääkärilehti [Finnish Medical Journal], Jun 2, 2017
[English abstract at end]
Lähtökohdat: Psykiatrian sairaansijojen vähetessä mielenterveyskuntoutu... more [English abstract at end] Lähtökohdat: Psykiatrian sairaansijojen vähetessä mielenterveyskuntoutujille suunnatut asumispalvelut ovat lisääntyneet.
Aineisto ja menetelmät: Helsingin ja Uudenmaan sairaanhoitopiirin (HUS) kunnissa tehtiin v. 2012 ja 2014 selvitys aikuisväestön mielenterveys- ja päihdepalveluista ESMS-R-työkalulla (European Service Mapping Schedule, revised).
Tulokset: Psykiatrian sairaansijat vähenivät kahdessa vuodessa sairaalaosastojen sulkemisen takia 15 % ja mielenterveyskuntoutujien asumispalvelut lisääntyivät 4 %. Päihdekuntoutujien asumispalvelut lisääntyivät 67 % pitkäaikaisasunnottomuuden vähentämisohjelman ansiosta. Julkisten tuottajien osuus mielenterveys- ja päihdekuntoutujien asumispalveluista kasvoi tarkastelujaksona. Ympärivuorokautisten paikkojen yhteismäärä vaihteli suuresti sairaanhoitoalueittain. Psykiatrian sairaansijojen määrän ja mielenterveyskuntoutujien asumispalvelujen paikkamäärän väliltä ei löytynyt yhteyttä. Asumispalveluissa havaittiin lievää siirtymistä vähemmän tuettuihin asumismuotoihin ja kohti kotiin tuotua tukea.
Päätelmät: Alueen palvelujen järjestäminen on valtakunnallisten linjausten mukaisesti kehittynyt laitosmaisista olosuhteista tuettuun asumiseen. Ympärivuorokautisten paikkojen suuri alueellinen vaihtelu sekä psykiatrian sairaansijojen ja asumispalvelujen paikkamäärän väliltä puuttuva yhteys kuitenkin viittaavat siihen, ettei palvelukokonaisuus ole kehittynyt ohjatusti. Ryhmämuotoisia asumispalveluja painotettaessa on vaara, ettei aito itsenäinen asuminen lisäänny, vaan hoiva siirtyy osastoilta asumispalveluihin.
ENGLISH: Background: While there has been a decrease in inpatient psychiatric care, supported housing services for people with mental health problems have increased.
Methods: Adult mental health and substance abuse services in the Hospital District of Helsinki and Uusimaa (HUS) were systematically mapped and classified using the revised European Service Mapping Schedule (ESMS-R) tool in 2012 and again in 2014.
Results: As a result of the closure of psychiatric hospital wards and despite population growth, psychiatric inpatient beds decreased by 15% and mental health supported housing services increased by 4% over the two-year period. Also, beds in supported housing relating to substance abuse increased significantly (67%) as a result of a national programme aimed at reducing long term homelessness. These factors led to an increase in publicly provided supported housing services for people with mental health and substance abuse problems during this time period.
Variation between hospital districts in the total number of beds used, i.e. hospital beds and beds in housing services, was high, ranging from a total of 21 beds per 10 000 adults to 68 beds per 10 000 adults. No association between the number of psychiatric hospital beds and the number of beds in mental health housing services was found. Our results show a transition towards less intensively supported housing in the HUS district during the period studied. Also, a slight trend towards providing more home based support can be seen.
Conclusions: Services in the HUS area have been developed in accordance with national mental health and housing policies, i.e. moving away from traditional institution-based services towards home-based services. The total use of beds varies considerably between different geographical areas in the district and, taken together with the absence of an association between the number of psychiatric hospital beds and beds in supported housing services, it appears that the mental health service system as a whole has not been developed in a planned and strategic manner. Emphasis on supported housing services in the form of group homes contrasts with the Western European model which has a stronger focus on home-based services. This focus on group-based housing services increases the risk of transinstitutionalisation, where the reduction in hospital beds leads to service users being transferred from psychiatric inpatient wards to supported housing services without this resulting in a genuine increase in autonomy. Strategic governance of psychiatric services as well as supported housing is necessary in order to further develop home-based services, improve quality of services, and increase social inclusion and participation, as well as to facilitate cost control.
Social psychiatry and psychiatric epidemiology, Jan 9, 2017
To review psychosocial and policy interventions which mitigate the effects of poverty and inequal... more To review psychosocial and policy interventions which mitigate the effects of poverty and inequality on mental health. Systematic reviews, controlled trials and realist evaluations of the last 10 years are reviewed, without age or geographical restrictions. Effective psychosocial interventions on individual and family level, such as parenting support programmes, exist. The evidence for mental health impact of broader community-based interventions, e.g. community outreach workers, or service-based interventions, e.g. social prescribing and debt advice is scarce. Likewise, the availability of evidence for the mental health impact of policy level interventions, such as poverty alleviation or youth guarantee, is quite restricted. The social, economic, and physical environments in which people live shape mental health and many common mental disorders. There are effective early interventions to promote mental health in vulnerable groups, but it is necessary to both initiate and facilitate...
Background
Psychiatric readmissions have been studied at length. However, knowledge about how e... more Background
Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.
Methods
Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.
Results
Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.
Conclusion
This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.
Background: Psychiatric services have undergone profound changes over the last decades. CEPHOS-LI... more Background: Psychiatric services have undergone profound changes over the last decades. CEPHOS-LINK is an EU-funded study project with the aim to compare readmission of patients discharged with psychiatric diagnoses using a registry-based observational record linkage study design and to analyse differences in the findings for five different countries. A range of different approaches is available for analysis of the available data. Although there are some studies that compare selected methods for evaluating questions on readmission, there are to our knowledge no published systematic literature reviews on commonly used methods and their comparison. This work shall therefore provide an overview of the methods in use, their evolution throughout history and new developments which can further improve the research quality in this area. Methods: Based on systematic literature reviews realized in the course of the CEPHOS-LINK study, this work is a systematic evaluation of mathematical (statistical and modelling) methods used in studies examining psychiatric readmission. The starting point were 502 papers, of which 407 were analysed in detail; Methods used were assigned to one of five categories with subcategories and analysed accordingly. Our particular interest next to survival analysis and regression models is modelling and simulation. Results: As population sizes and follow-up times in the included studies varied widely, a range of methods was applied. Studies with bigger sample sizes conducted survival and regression analysis more often than studies with fewer patients did. These latter relied more on classical statistical tests (e.g. t-tests and Student Newman Keuls). Statistical strategies were often insufficiently described, posing a major problem for the evaluation. Almost all cases failed to provide and explanation of the rationale behind using certain methods.
Background: Readmission rate is considered an indicator of the mental health care quality. Previo... more Background: Readmission rate is considered an indicator of the mental health care quality. Previous studies have examined a number of factors that are likely to influence readmission. The main objective of this systematic review is to identify the studied pre-discharge variables and describe their relevance to readmission among psychiatric patients.
Background: Comorbidity between mental and physical disorder conditions is the rule rather than t... more Background: Comorbidity between mental and physical disorder conditions is the rule rather than the exception. It is estimated that 25% of adult population have mental health condition and 68% of them suffer from comorbid medical condition. Readmission rates in psychiatric patients are high and we still lack understanding potential predictors of recidivism. Physical comorbidity could be one of important risk factors for psychiatric readmission. The aim of the present study was to review the impact of physical comorbidity variables on readmission after discharge from psychiatric or general inpatient care among patients with co-occurring psychiatric and medical conditions. Methods: A comprehensive database search from January 1990 to June 2014 was performed in the following bibliographic databases: Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. An integrative research review was conducted on 23 observational studies.
(Article in Finnish) Obesity is associated with insomnia symptoms, but the contribution of weight... more (Article in Finnish) Obesity is associated with insomnia symptoms, but the contribution of weight changes to insom¬nia symptoms is poorly known. We examined the associations between weight changes and insom¬nia symptoms by baseline weight. The phase 1 questionnaire survey was conducted in 2000–2002 among employees of the City of Helsinki (n=8960) and phase 2 in 2007 (n=7332). Insom¬nia symptoms, weight, height, and covariates were available for 6929 participants. Weight change (≥5%) during the follow-up was examin¬ed among normal weight (BMI 18.5-24.9), over¬weight (BMI 25.0-29.9) and obese (BMI 30 or more) participants. Insomnia symptoms were trouble falling or staying asleep, nocturnal awa¬kenings, and non-restorative sleep for at least 15 nights over previous four weeks. Logistic regres¬sion was used, adjusting first for age, second also for baseline insomnia symptoms, and third, in addition to the previous covariates, for marital status, education, employment status, alcohol consumption, smoking, physical activity, and self-rated health. Among men, overweight (OR 2.28, 95% CI 1.43–3.63) and obese (OR, 2.98, 95% CI, 1.55–5.75) weight gainers and persistently obese (OR 2.23, 95% CI 1.29–3.84) were more likely to report insomnia symptoms at follow-up. These associations remained after adjustments. Among women, obese weight gainers were more likely to report insomnia symptoms (OR 1.64, 95% CI 1.24–2.18), but the association reduced after adjustments. In conclusion, preventing weight gain among the overweight or obese could help prevent insomnia symptoms particularly among men.
Social psychiatry and psychiatric epidemiology, 2014
Purpose This study examined the associations of insomnia symptoms with subsequent psychotropic me... more Purpose This study examined the associations of insomnia symptoms with subsequent psychotropic medication, reflecting mental health. Methods Postal baseline surveys among 40- to 60-year-old employees of the city of Helsinki, Finland, were collected in 2000–2002 (N = 6,227, response rate 67 %, 78 % women) and longitudinally linked with national register data on prescribed reimbursed medication. Insomnia symptoms at baseline comprised difficulties in initiating and maintaining sleep, and non-restorative sleep. All purchased psychotropic medication 5–7 years prior to and 5 years after baseline was included. Outcomes were any psychotropic medication; antidepressants; and anxiolytics, hypnotics, and sedatives. Covariates included socio-demographic and work-related factors, health behaviors, lifetime mental disorders, and prior psychotropic medication. Logistic regression analysis was used to calculate odds ratios (OR) and their 95 % confidence intervals (CI). Results Insomnia symptoms were associated with higher frequency of subsequent psychotropic medication prescriptions. The associations were strongest for frequent insomnia symptoms (women OR 3.55, 95 % CI 2.64–4.77; men OR 4.64, 95 % CI 2.49–8.66, adjusted for age and prior medication), but also rare and occasional symptoms were associated with psychotropic medication. Further adjustments had negligible effects. Conclusions Insomnia symptoms were associated with prescribed psychotropic medication during follow-up in a dose–response manner. Attention should be given to the prevention of insomnia symptoms to curb subsequent mental problems.
BackgroundPain and insomnia are both independently associated with work disability. Although pain... more BackgroundPain and insomnia are both independently associated with work disability. Although pain and insomnia often co-occur, their joint associations with subsequent sickness absence and disability retirement have not been studied. We aimed to examine these associations in two prospective occupational cohorts while considering key covariates.Pain and insomnia are both independently associated with work disability. Although pain and insomnia often co-occur, their joint associations with subsequent sickness absence and disability retirement have not been studied. We aimed to examine these associations in two prospective occupational cohorts while considering key covariates.MethodsNorwegian Hordaland Health Study (n = 6892, 59% women) and Finnish Helsinki Health Study (n = 6060, 78% women) data were used. Those with only pain, only insomnia or both conditions at baseline were compared with those with no pain and no insomnia. Work disability outcomes were derived from national and employers' register data. Medically certified sickness absence spells lasting 2 weeks or more and all-cause disability retirement were examined. Register-based follow-up was 4 years for sickness absence and 5 years for disability retirement. Covariates were sex, age, marital status, education, smoking, alcohol use, body mass index and blood pressure. Poisson and Cox regression models were fitted.Norwegian Hordaland Health Study (n = 6892, 59% women) and Finnish Helsinki Health Study (n = 6060, 78% women) data were used. Those with only pain, only insomnia or both conditions at baseline were compared with those with no pain and no insomnia. Work disability outcomes were derived from national and employers' register data. Medically certified sickness absence spells lasting 2 weeks or more and all-cause disability retirement were examined. Register-based follow-up was 4 years for sickness absence and 5 years for disability retirement. Covariates were sex, age, marital status, education, smoking, alcohol use, body mass index and blood pressure. Poisson and Cox regression models were fitted.ResultsBoth pain and insomnia were associated with subsequent sickness absence and disability retirement, but the associations were stronger for those reporting co-morbid pain and insomnia with support for a synergistic interaction effect, particularly regarding disability retirement. The associations were largely similar in both cohorts and remained after full adjustments.Both pain and insomnia were associated with subsequent sickness absence and disability retirement, but the associations were stronger for those reporting co-morbid pain and insomnia with support for a synergistic interaction effect, particularly regarding disability retirement. The associations were largely similar in both cohorts and remained after full adjustments.ConclusionsThis study is the first to report the separate and combined effects of pain and insomnia on objective health outcomes. Common patterns observed in two separate cohorts suggest that the combination of pain and insomnia might be particularly relevant for subsequent disability retirement.This study is the first to report the separate and combined effects of pain and insomnia on objective health outcomes. Common patterns observed in two separate cohorts suggest that the combination of pain and insomnia might be particularly relevant for subsequent disability retirement.
Sleep disturbances have been associated with an increased risk of cardiovascular disease outcomes... more Sleep disturbances have been associated with an increased risk of cardiovascular disease outcomes. The associations of insomnia with hypertension and dyslipidaemia, the main modifiable cardiovascular risk factors, are less studied. We especially lack understanding on the longitudinal effects of insomnia on dyslipidaemia. We aimed to examine the associations of insomnia symptoms with subsequent prescribed medication for hypertension and dyslipidaemia using objective register-based follow-up data. Baseline questionnaire surveys among 40–60-year-old employees of the City of Helsinki, Finland, were conducted in 2000–2002 (n = 6477, response rate 67%, 78% women) and linked to a national register on prescribed reimbursed medication 5–7 years prior to and 5 years after baseline. Associations between the frequency of insomnia symptoms (difficulties in initiating and maintaining sleep, non-restorative sleep) and hypertension and dyslipidaemia medication during the follow-up were analysed using logistic regression analysis (odds ratios with 95% confidence intervals). Analyses were adjusted for pre-baseline medication, sociodemographic and work-related factors, health behaviours, mental health, and diabetes. Frequent insomnia symptoms were reported by 20%. During the 5-year follow-up, 32% had hypertension medication and 15% dyslipidaemia medication. Adjusting for age, gender and pre-baseline medication, frequent insomnia symptoms were associated with hypertension medication (odds ratio 1.57, 95% confidence interval 1.23–2.00) and dyslipidaemia medication (odds ratio 1.59, 95% confidence interval 1.19–2.12). Occasional insomnia symptoms were also associated with cardiovascular medication, though less strongly. Further adjustments had negligible effects. To conclude, insomnia should be taken into account in the prevention and management of cardiovascular disease and related risk factors.
Clinical assessment of object relations is essential when evaluating treatability by different ty... more Clinical assessment of object relations is essential when evaluating treatability by different types of psychotherapy. The Quality of Object Relations Scale (QORS) is an established interview measure used for assessing object relations, but the validity of the QORS in relation to its theoretical constituents has not been examined. Our aim was to study the concurrent validity of the QORS. Trained interviewers assessed 263 outpatients seeking psychotherapy due to mood or anxiety disorder, with the QORS and with selected proxy criterion measures representing constituents of object-relational maturity. Discontinuity in relationships and the use of devaluation in relationships were the main determinants of low Quality of Object Relations (low-QOR). Patients with discontinuity in relationships had a four-fold and patients with devaluation in relationships a three-fold risk of belonging to the low-QOR group (p = 0.001) in comparison to those without these relational characteristics. Also poor self-confidence and major separations in childhood predicted the low- versus high-QOR category. The results indicate adequate concurrent validity of the QORS and support its credibility in assessing personality pathology, beyond axis II diagnosis, by trained clinicians.
Scandinavian journal of work, environment & health, 2012
The aim of this study was to examine the joint association of sleep duration and insomnia symptom... more The aim of this study was to examine the joint association of sleep duration and insomnia symptoms with subsequent disability retirement. Baseline survey data were collected in 2000-2002 from 40-60-year-old employees of the City of Helsinki, all working at baseline. Baseline data were linked with disability retirement data until the end of 2010, obtained from the Finnish Centre for Pensions registers (N=6042). Sleep duration and self-reported insomnia symptoms (non-restorative sleep and difficulties in initiating and maintaining sleep) were derived from the baseline surveys. All-cause disability retirement (N=561) and the most prevalent diagnostic groups - musculoskeletal diseases (43%) and mental disorders (26%) - were examined. Cox regression analysis was used to yield hazard ratios (HR) with 95% confidence intervals (95% CI). A joint association of sleep duration and insomnia symptoms with disability retirement was found, implying a higher risk for those with frequent insomnia symptoms. HR for all-cause disability retirement ranged among those with frequent symptoms from 2.02 (95% CI 1.53-2.68, sleeping 7 hours) to 3.92 (95% CI 2.57-5.97, sleeping ≤ 5 hours). Adjusting for sociodemographic, work, and health-related factors attenuated the associations, which nevertheless remained. The associations were similar for the two diagnostic groups, although stronger for those with mental disorders. Frequent insomnia symptoms dominate the joint association of sleep duration and insomnia symptoms with subsequent disability retirement. Examining exclusively sleep duration would provide an incomplete understanding of the consequences of poor sleep.
Uploads
Lähtökohdat: Psykiatrian sairaansijojen vähetessä mielenterveyskuntoutujille suunnatut asumispalvelut ovat lisääntyneet.
Aineisto ja menetelmät: Helsingin ja Uudenmaan sairaanhoitopiirin (HUS) kunnissa tehtiin v. 2012 ja 2014 selvitys aikuisväestön mielenterveys- ja päihdepalveluista ESMS-R-työkalulla (European Service Mapping Schedule, revised).
Tulokset: Psykiatrian sairaansijat vähenivät kahdessa vuodessa sairaalaosastojen sulkemisen takia 15 % ja mielenterveyskuntoutujien asumispalvelut lisääntyivät 4 %. Päihdekuntoutujien asumispalvelut lisääntyivät 67 % pitkäaikaisasunnottomuuden vähentämisohjelman ansiosta. Julkisten tuottajien osuus mielenterveys- ja päihdekuntoutujien asumispalveluista kasvoi tarkastelujaksona. Ympärivuorokautisten paikkojen yhteismäärä vaihteli suuresti sairaanhoitoalueittain. Psykiatrian sairaansijojen määrän ja mielenterveyskuntoutujien asumispalvelujen paikkamäärän väliltä ei löytynyt yhteyttä. Asumispalveluissa havaittiin lievää siirtymistä vähemmän tuettuihin asumismuotoihin ja kohti kotiin tuotua tukea.
Päätelmät: Alueen palvelujen järjestäminen on valtakunnallisten linjausten mukaisesti kehittynyt laitosmaisista olosuhteista tuettuun asumiseen. Ympärivuorokautisten paikkojen suuri alueellinen vaihtelu sekä psykiatrian sairaansijojen ja asumispalvelujen paikkamäärän väliltä puuttuva yhteys kuitenkin viittaavat siihen, ettei palvelukokonaisuus ole kehittynyt ohjatusti. Ryhmämuotoisia asumispalveluja painotettaessa on vaara, ettei aito itsenäinen asuminen lisäänny, vaan hoiva siirtyy osastoilta asumispalveluihin.
ENGLISH:
Background: While there has been a decrease in inpatient psychiatric care, supported housing services for people with mental health problems have increased.
Methods: Adult mental health and substance abuse services in the Hospital District of Helsinki and Uusimaa (HUS) were systematically mapped and classified using the revised European Service Mapping Schedule (ESMS-R) tool in 2012 and again in 2014.
Results: As a result of the closure of psychiatric hospital wards and despite population growth, psychiatric inpatient beds decreased by 15% and mental health supported housing services increased by 4% over the two-year period. Also, beds in supported housing relating to substance abuse increased significantly (67%) as a result of a national programme aimed at reducing long term homelessness. These factors led to an increase in publicly provided supported housing services for people with mental health and substance abuse problems during this time period.
Variation between hospital districts in the total number of beds used, i.e. hospital beds and beds in housing services, was high, ranging from a total of 21 beds per 10 000 adults to 68 beds per 10 000 adults. No association between the number of psychiatric hospital beds and the number of beds in mental health housing services was found. Our results show a transition towards less intensively supported housing in the HUS district during the period studied. Also, a slight trend towards providing more home based support can be seen.
Conclusions: Services in the HUS area have been developed in accordance with national mental health and housing policies, i.e. moving away from traditional institution-based services towards home-based services. The total use of beds varies considerably between different geographical areas in the district and, taken together with the absence of an association between the number of psychiatric hospital beds and beds in supported housing services, it appears that the mental health service system as a whole has not been developed in a planned and strategic manner. Emphasis on supported housing services in the form of group homes contrasts with the Western European model which has a stronger focus on home-based services. This focus on group-based housing services increases the risk of transinstitutionalisation, where the reduction in hospital beds leads to service users being transferred from psychiatric inpatient wards to supported housing services without this resulting in a genuine increase in autonomy. Strategic governance of psychiatric services as well as supported housing is necessary in order to further develop home-based services, improve quality of services, and increase social inclusion and participation, as well as to facilitate cost control.
Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.
Methods
Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.
Results
Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.
Conclusion
This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.
Lähtökohdat: Psykiatrian sairaansijojen vähetessä mielenterveyskuntoutujille suunnatut asumispalvelut ovat lisääntyneet.
Aineisto ja menetelmät: Helsingin ja Uudenmaan sairaanhoitopiirin (HUS) kunnissa tehtiin v. 2012 ja 2014 selvitys aikuisväestön mielenterveys- ja päihdepalveluista ESMS-R-työkalulla (European Service Mapping Schedule, revised).
Tulokset: Psykiatrian sairaansijat vähenivät kahdessa vuodessa sairaalaosastojen sulkemisen takia 15 % ja mielenterveyskuntoutujien asumispalvelut lisääntyivät 4 %. Päihdekuntoutujien asumispalvelut lisääntyivät 67 % pitkäaikaisasunnottomuuden vähentämisohjelman ansiosta. Julkisten tuottajien osuus mielenterveys- ja päihdekuntoutujien asumispalveluista kasvoi tarkastelujaksona. Ympärivuorokautisten paikkojen yhteismäärä vaihteli suuresti sairaanhoitoalueittain. Psykiatrian sairaansijojen määrän ja mielenterveyskuntoutujien asumispalvelujen paikkamäärän väliltä ei löytynyt yhteyttä. Asumispalveluissa havaittiin lievää siirtymistä vähemmän tuettuihin asumismuotoihin ja kohti kotiin tuotua tukea.
Päätelmät: Alueen palvelujen järjestäminen on valtakunnallisten linjausten mukaisesti kehittynyt laitosmaisista olosuhteista tuettuun asumiseen. Ympärivuorokautisten paikkojen suuri alueellinen vaihtelu sekä psykiatrian sairaansijojen ja asumispalvelujen paikkamäärän väliltä puuttuva yhteys kuitenkin viittaavat siihen, ettei palvelukokonaisuus ole kehittynyt ohjatusti. Ryhmämuotoisia asumispalveluja painotettaessa on vaara, ettei aito itsenäinen asuminen lisäänny, vaan hoiva siirtyy osastoilta asumispalveluihin.
ENGLISH:
Background: While there has been a decrease in inpatient psychiatric care, supported housing services for people with mental health problems have increased.
Methods: Adult mental health and substance abuse services in the Hospital District of Helsinki and Uusimaa (HUS) were systematically mapped and classified using the revised European Service Mapping Schedule (ESMS-R) tool in 2012 and again in 2014.
Results: As a result of the closure of psychiatric hospital wards and despite population growth, psychiatric inpatient beds decreased by 15% and mental health supported housing services increased by 4% over the two-year period. Also, beds in supported housing relating to substance abuse increased significantly (67%) as a result of a national programme aimed at reducing long term homelessness. These factors led to an increase in publicly provided supported housing services for people with mental health and substance abuse problems during this time period.
Variation between hospital districts in the total number of beds used, i.e. hospital beds and beds in housing services, was high, ranging from a total of 21 beds per 10 000 adults to 68 beds per 10 000 adults. No association between the number of psychiatric hospital beds and the number of beds in mental health housing services was found. Our results show a transition towards less intensively supported housing in the HUS district during the period studied. Also, a slight trend towards providing more home based support can be seen.
Conclusions: Services in the HUS area have been developed in accordance with national mental health and housing policies, i.e. moving away from traditional institution-based services towards home-based services. The total use of beds varies considerably between different geographical areas in the district and, taken together with the absence of an association between the number of psychiatric hospital beds and beds in supported housing services, it appears that the mental health service system as a whole has not been developed in a planned and strategic manner. Emphasis on supported housing services in the form of group homes contrasts with the Western European model which has a stronger focus on home-based services. This focus on group-based housing services increases the risk of transinstitutionalisation, where the reduction in hospital beds leads to service users being transferred from psychiatric inpatient wards to supported housing services without this resulting in a genuine increase in autonomy. Strategic governance of psychiatric services as well as supported housing is necessary in order to further develop home-based services, improve quality of services, and increase social inclusion and participation, as well as to facilitate cost control.
Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.
Methods
Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.
Results
Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.
Conclusion
This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.