How can we best help this patient? Exploring mental health therapists’ reflections on medication-free care for patients with psychosis in Norway

Background Since 2015, Norwegian Regional Health Authorities have followed new government policy and gradually implemented medication-free services for patients with psychosis. The aim of this qualitative study was to explore the tension between policy and practice, and how health care workers in Bergen reflect on their role in implementing medication-free treatment. Methods We performed three focus group discussions including 17 therapists working within medication free services, asking about their experiences with this new treatment program. We used Systematic Text Condensation for data analysis. The findings were discussed using Michael Lipsky’s theoretical framework on the role public health workers play in policy implementation. Findings Following Norway’s new policy was challenging for the therapists in our study, particularly balancing a patient’s needs with treatment guidelines, the legal framework and available resources. Therapists had an overarching wish to help patients through cooperation and therapeutic alliance, but their alliance was sometimes fragile, and the therapists worried about patients’ conditions worsening. Conclusions Democratization of treatment choices, with the aim of empowering patients in mental health care, challenges the level of professional discretion given that patients and therapists might have conflicting goals. Balancing the desire to help, professional responsibility, the perceived lack of resources, and certain patient choices created conditions that can leave therapists feeling disempowered in and alienated from their work.publishedVersio

Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: protocol for a controversies in psychiatry research project

Objectives: Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry‐ based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency. Methods: By using the natural variation in health providers' preference for compulsory care as a source of quasi‐randomisation we will estimate causal effects of compulsory care on short‐ and long‐term trajectories. Conclusions: This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group

Mitochondrial physiology

As the knowledge base and importance of mitochondrial physiology to evolution, health and disease expands, the necessity for harmonizing the terminology concerning mitochondrial respiratory states and rates has become increasingly apparent. The chemiosmotic theory establishes the mechanism of energy transformation and coupling in oxidative phosphorylation. The unifying concept of the protonmotive force provides the framework for developing a consistent theoretical foundation of mitochondrial physiology and bioenergetics. We follow the latest SI guidelines and those of the International Union of Pure and Applied Chemistry (IUPAC) on terminology in physical chemistry, extended by considerations of open systems and thermodynamics of irreversible processes. The concept-driven constructive terminology incorporates the meaning of each quantity and aligns concepts and symbols with the nomenclature of classical bioenergetics. We endeavour to provide a balanced view of mitochondrial respiratory control and a critical discussion on reporting data of mitochondrial respiration in terms of metabolic flows and fluxes. Uniform standards for evaluation of respiratory states and rates will ultimately contribute to reproducibility between laboratories and thus support the development of data repositories of mitochondrial respiratory function in species, tissues, and cells. Clarity of concept and consistency of nomenclature facilitate effective transdisciplinary communication, education, and ultimately further discovery

Mitochondrial physiology

As the knowledge base and importance of mitochondrial physiology to evolution, health and disease expands, the necessity for harmonizing the terminology concerning mitochondrial respiratory states and rates has become increasingly apparent. The chemiosmotic theory establishes the mechanism of energy transformation and coupling in oxidative phosphorylation. The unifying concept of the protonmotive force provides the framework for developing a consistent theoretical foundation of mitochondrial physiology and bioenergetics. We follow the latest SI guidelines and those of the International Union of Pure and Applied Chemistry (IUPAC) on terminology in physical chemistry, extended by considerations of open systems and thermodynamics of irreversible processes. The concept-driven constructive terminology incorporates the meaning of each quantity and aligns concepts and symbols with the nomenclature of classical bioenergetics. We endeavour to provide a balanced view of mitochondrial respiratory control and a critical discussion on reporting data of mitochondrial respiration in terms of metabolic flows and fluxes. Uniform standards for evaluation of respiratory states and rates will ultimately contribute to reproducibility between laboratories and thus support the development of data repositories of mitochondrial respiratory function in species, tissues, and cells. Clarity of concept and consistency of nomenclature facilitate effective transdisciplinary communication, education, and ultimately further discovery

Hva kan tungen fortelle oss? : En litteraturstudie om tungeforandringer

I vår litteraturstudie ”Hva kan tungen fortelle oss?”, ønsker vi å få oversikt over forskjellige tilstander som kan affisere tungen. Vi har sett på ulik litteratur; bøker og artikler, og valgt å klassifisere tungeforandringer etter etiologisk årsak. Det er få av våre referanser som tar for seg denne inndelingen, men vi har likevel kommet til at dette vil være den mest hensiktmessige og oversiktlige klassifikasjonen. En artikkel av Dr. Alison Rich ved University of Otago, “Tongue Lesions: What can it be?” (14), benytter klassifikasjon basert på etiologi. I boken “Orofacial Disease”, skrevet av C.Scully og S.Porter (34), finnes lignende inndeling, og disse kildene har vært utgangspunkt i vår oppgave. Munnslimhinnens reaksjon på ulike typer sykdomstilstander, kan arte seg som farge-, formog konsistensavvik eller som sår. Ved jernmangelanemi vil f.eks. tungens spesialiserte slimhinne kunne rammes på lik linje med keratinisert og ikke-keratinisert slimhinne, og reaksjonen vil da kunne være noe annerledes på tungen enn ellers i munnslimhinnen. Å gjenkjenne en unormal tunge som tegn på systemisk sykdom, er av stor klinisk verdi. Det er viktig for oss som klinikere å vite om, og gjenkjenne det store spekter av sykdommer som affiserer tungen. Det må presiseres at mange av forandringene ikke bare er lokalisert på tungen, men kan også ses ellers i munnslimhinnen. I tillegg til normalvariasjoner som kan sees på tungen, har vi også tatt for oss ulike tumores, maligne og benigne. Plateepitelcarcinom (OPC) er den vanligste typen oral cancer, og 25 % av tilfeller med OPC er lokalisert på tungen. Allmenntannlegens rolle i diagnostiseringsarbeidet kan være avgjørende for pasienten. Vi ønsker med denne oppgaven både å få – og gi – en oversikt over ulike tilstander/ forandringer som kan forekomme på tungen, for å lettere kunne skille det farlige fra det ufarlige

Mellom kunst og dokument - Representasjoner av nød i fotografi og tegneserier

Denne oppgaven diskuterer representasjonen av nød gjennom fotografi og tegneserier. Jonas Bendiksens prosjekt, Steder der vi bor og Andrea Gjestvangs prosjekt En dag i historien - 22. juli er begge fotografiske prosjekter som består av portretter av mennesker i vanskelige situasjoner og begge bruker tekst for å forankre konteksten nødvendig for en forståelse, men de skiller seg fra hverandre ved at mens Bendiksens prosjekt omhandler slummer i tredje verden, skildrer Gjestvangs prosjekt norske ungdommer som overlevde massakren på Utøya i 2011. De fordrer derfor en diskusjon om resepsjonen av den nøden som rammer nært og den nøden som rammer fjernt. Joe Sacco bruker sin journalistiske bakgrunn til å skildre Gazas trøblete historie i tegneserieform. I Footnotes in Gaza undersøker to massakrer som ble begått i Khan Younis og i Rafah i 1956. Denne tegneserieboken settes opp mot Art Spiegelmans tegneseriebok Maus. I sistnevnte forteller Spiegelman om sin far opplevelser i Auschwitch og sin egen historie ved å vokse opp under dette traumet han selv ikke var en del av. Mens Sacco har en viss distanse fra traumet er det dypt personlig for Spiegelman. Et annet skille mellom disse tegneseriebøkene er at mens Holocaust er grundig dokumentert og skrevet inn i verdenshistorien, er overgrepene i Gaza udokumentert og dermed forvist til fotnotene. Dette fremmer et spørsmål om tillit: Kan tegneserien fungere som et dokument på noe virkelig? Fotografiet har et visst objektivt preg. Dette har vært skriver Roland Barthes. Denne indeksikaliteten er ikke til stede i en tegning, men som postmodernistisk fototeori påpeker, fotografen gjør et utvalg i hva som kommer innenfor billedflaten og redaktøren gjør et valg om hva som kommer på trykk. Dette er begge subjektive valg. Fotografier er et produkt av kulturen som har skapt det og det er avhengig av en tekstlig forankring for å gi den nødvendige konteksten for å kunne tolkes. Så er egentlig en tegneserie så mye mer subjektiv enn en fotoserie med tekst? Vi gir fotografen tilliten om at han/hun forteller noe sant, på samme måte som vi må stole på tegneserieskaperen. I den samtidsdokumentarfotografiske teorien blir det sagt at dokumentarfotografiet av grusomheter er i krise. Denne krisen baserer seg på en videreføring av postmodernistenes kritikk fra 1960- og 1970-tallet. Behovet for kontekst, etiske problemstillinger og tilliten til fotografen. Kan fotografiet formidle det vi trenger å vite om begivenhetene? Alle representasjoner av lidelse forholder seg til denne krisen og har utviklet en form for strategi som svar på den, inkludert mine eksempler. Avslutningsvis undersøker jeg disse strategiene

Evaluering av norsk skogvern i 2016. Dekning av mål for skogvernet og behov for supplerende vern

Framstad, E. (red.), Blindheim, T., Granhus, A., Nowell, M. og Sverdrup-Thygeson, A. 2017. Evaluering av norsk skogvern i 2016. Dekning av mål for skogvernet og behov for supplerende vern. – NINA Rapport 1352. 149 s. Vernet av skog har økt betydelig i Norge de siste 20 årene, men fremdeles er dagens skogvern bare knapt halvparten av målet om 10% skogvern som Stortinget har vedtatt. I denne rapporten har vi evaluert hvor godt dagens skogvern dekker skogens naturvariasjon, vern av store sammenhengende skogområder, viktige naturtyper og leveområder for arter. Vi påpeker mangler og gir anbefaling om innretningen på nytt skogvern. Andel vernet skogareal i Norge er i dag 5,0% basert på data fra kartserien N50 og 4,0% basert på Landsskogtakseringens data. Det inngår ca 114 flere verneområder i beregningen basert på N50, og skogarealet er definert litt videre enn i Landsskogtakseringen. Andel vernet skog varierer mellom fylkene, med minst andel (1,4%-2,7%) for fylkene rundt Oslofjorden, Vest-Agder og på Vestlandet, og størst andel (6,3%-8,3%) for fylkene fra Nord-Trøndelag og nordover. Ifølge Landsskogtakseringens data er det mindre andel vernet produktiv skog (2,9%) enn skog generelt og særlig lav andel for skog på høy og svært høy bonitet (0,7%). Det er også lavere andel vernet skog i lavlandet (2,8% under 300 moh) og for «varme» vegetasjonssoner (boreonemoral, sørboreal) (1,9%). Andel vernet skog er nokså lik for skog med ulike dominerende treslag. Vernet skog inneholder vesentlig større mengder død ved og har høyere andeler med gammel skog enn skog som ikke er vernet. I vernet skog er hele 75% av antall sammenhengende skogområder små og uten kjerneareal, men det er også 140 slike skogområder på mer enn 10 km2, de fleste i fylkene med mest vernet skog. Analyse av 20 viktige skogtyper for naturmangfoldet viser at 32% av arealet av kjente forekomster finnes i verneområder. Det er stor variasjon mellom naturtypene (fra knapt 12% for gammel blandingslauvskog til 53% for kalkbjørkeskog) og mellom fylkene (fra 12% i Hordaland til 49% i Finnmark). Det er imidlertid stor variasjon i hvor systematisk slike naturtyper er kartlagt, både i og utenfor verneområder. Andelen funn av skoglevende arter som er registrert i skog i verneområder, varierer forholdsvis lite mellom artsgruppene insekter, karplanter, lav og sopp på landsbasis, fra 12% for karplanter til 18% for sopp. Det er imidlertid betydelig forskjell mellom fylkene i andelen av fylkets artsfunn som ligger i verneområder, fra 1,2% i Finnmark til 44% i Troms. Som for naturtyper er det stor variasjon mellom fylkene i kartlegging av ulike arter i og utenfor verneområder. Det er dermed betydelig usikkerhet knyttet til vurderingen av verneområdenes dekning av skogtyper og arter. Basert på målene for skogvernet, analysen av manglene ved dagens skogvern og fylkenes potensial for å dekke disse manglene, anbefaler vi følgende prioritering av nytt skogvern i årene framover: 1. Prioritering av kjente forekomster av viktige skogtyper med høy naturverdi og med lav dekning i dagens skogvern, spesielt i fylker med generelt lav dekning av skogvern og høyt press på skogarealene, samt arealer i lavlandet, i boreonemoral eller sørboreal sone. 2. Kjente verdifulle forekomster av andre viktige skogtyper, særlig arealer i lavlandet, i boreonemoral eller sørboreal sone. 3. Øvrig skog på produktiv mark uten stor påvirkning av intensivt skogbruk eller inngrep, særlig arealer i lavlandet, i boreonemoral eller sørboreal sone, eller andre områder med stor verdi for naturmangfoldet. 4. Store sammenhengende skogområder eller arealer som kan bidra til å skape større grad av økologisk sammenheng mellom eksisterende områder med vernet skog.Framstad, E. (ed.), Blindheim, T., Granhus, A., Nowell, M. and Sverdrup-Thygeson, A. 2017. Evaluation of Norwegian forest protection in 2016. Fulfilment of objectives for forest protection and needs for additional forest conservation. – NINA Report 1352. 148 pp. Forest protection has advanced considerably in Norway over the last 20 year. Still, current forest protection is barely half of the Parliament’s objective of 10% forest protection. In this report, we evaluate how well current forest protection covers the natural variety in forests, large contiguous forest areas, important forest types and habitats for species. We indicate gaps in forest protection and recommend priorities for new forest protection. The proportion of protected forest in Norway is currently 5.0% based on land cover data in the map series N50 and 4.0% based on the national forest inventory. The N50 estimate includes about 114 additional protected areas and has a wider definition of forest area than the forest inventory. The proportion of protected forest varies among counties, from 1.4%-2.7% for the counties around the Oslo fjord, Vest-Agder and in West-Norway to 6.3%-8.3% for the counties north of Sør-Trøndelag. There is a smaller proportion of protected productive forest (2.9%), especially of highly productive forest (0.7%), than of forest in general. There is also a smaller proportion of protected forest in the lowlands (2.8% below 300 m asl) and for “warm” vegetation zones (boreonemoral, south boreal) (1.9%). The proportion of protected forest is rather similar for forest of various dominating tree species. Compared to forest in general, protected forest contains considerably more old forest and dead wood. Most (75%) contiguous patches of protected forest tend to be small and without a core area, although there are also 140 such patches larger than 10 km2. For 20 forest types considered important for biodiversity, 32% of the area of known sites is in protected forest. This varies between forest types (from 12% for old mixed deciduous forest to 53% for calcareous birch forest) and counties (from 12% in Hordaland to 49% in Finnmark). However, sampling intensity varies greatly within and outside protected areas between counties and forest types. The proportions of records of forest-living insects, vascular plants, lichens and fungi in protected forest vary only between 14% and 18% at the national level. However, there is considerable variation in the proportion of species records per county found in protected forest, from 1.2% in Finnmark to 44% in Troms. Counties vary greatly in sampling of various species within and outside protected forest. Hence, there is considerable uncertainty in the assessment of how well protected forests cover forest types and species of national management concern. Based on the objectives for forest protection, the analysis of gaps in current forest protection, and the potential of counties to cover these gaps, we recommend the following priorities for new forest protection for the next few years: 1. Known occurrences of important forest types with high nature value and low coverage in current forest protection, especially in counties with overall low degree of forest protection and high land use intensity, as well as lowland forest in boreonemoral and south boreal zones. 2. Known valuable occurrences of other important forest types, especially lowland forest in boreonemoral and south boreal zones. 3. Other forest on productive ground, without major influences from intensive forestry or technical development, particularly lowland forest in boreonemoral and south boreal zones, or other areas of high value to biodiversity. 4. Large contiguous forest areas or areas that may contribute to create a higher degree of ecological connectivity between existing areas of protected forest

Health care workers’ perspectives on the challenges and possibilities of music therapy within medication-free treatment services

Introduction In 2015, the Norwegian Regional Health Authorities introduced the possibility for people with psychotic disorders to choose medication-free services, with music therapy as a treatment option. This study aimed to explore the health care workers’ perspectives on challenges and possibilities of music therapy within these services. Method This is a qualitative study by an interdisciplinary research team, including experts by experience. Ethnographic notes provide data from participant observation with one patient using music therapy, describing what music therapy can be “a case of”. Focus group discussions (FGDs) with health care workers, including music therapists, explore their experiences with music therapy and medication-free treatment. These were transcribed and analyzed using systematic text condensation in a stepwise, iterative process involving co-authors to ensure reflexivity. Results The summary from the participant observation provides the reader with background information on how music therapy can unfold in mental health care. The informants from the FGDs described music therapy as having a high degree of treatment flexibility providing a continuous process of choices. The collaborative choices both among staff members as well as between patient and staff were experienced as important for treatment outcome. Patients worsening or stagnating increased the significance of contingent choices. Discussion The strengths of music therapy, such as its acceptability and flexibility, also represent challenges, including dilemmas of prioritization, challenges when ending therapy, and the need for close collaboration when assessing a patient’s worsening. There is a potential for improving the implementation of music therapy into the existing health care teams.publishedVersio

Clinical insight among persons with schizophrenia spectrum disorders treated with amisulpride, aripiprazole or olanzapine: a semi-randomised trial

Background Antipsychotic treatment may improve clinical insight. However, previous studies have reported inconclusive findings on whether antipsychotics improve insight over and above the reduction in symptoms of psychosis. These studies assessed homogeneous samples in terms of stage of illness. Randomised studies investigating a mixed population of first- and multiepisode schizophrenia spectrum disorders might clarify this disagreement. Methods Our data were derived from a pragmatic, rater-blinded, semi-randomised trial that compared the effectiveness of amisulpride, aripiprazole and olanzapine. A sample of 144 patients with first- or multiepisode schizophrenia spectrum disorders underwent eight assessments during a 1-year follow-up. Clinical insight was assessed by item General 12 from the Positive and Negative Syndrome Scale (PANSS). We analysed latent growth curve models to test if the medications had a direct effect on insight that was over and above the reduction in total psychosis symptoms. Furthermore, we investigated whether there were differences between the study drugs in terms of insight. Results Based on allocation analysis, all three drugs were associated with a reduction in total psychosis symptoms in the initial phase (weeks 0–6). Amisulpride and olanzapine were associated with improved insight over and above what was related to the reduction in total psychosis symptoms in the long-term phase (weeks 6–52). However, these differential effects were lost when only including the participants that chose the first drug in the randomisation sequence. We found no differential effect on insight among those who were antipsychotic-naïve and those who were previously medicated with antipsychotics. Conclusions Our results suggest that antipsychotic treatment improves insight, but whether the effect on insight surpasses the effect of reduced total psychosis symptoms is more uncertain.publishedVersio

How can we best help this patient? Exploring mental health therapists’ reflections on medication-free care for patients with psychosis in Norway

Background Since 2015, Norwegian Regional Health Authorities have followed new government policy and gradually implemented medication-free services for patients with psychosis. The aim of this qualitative study was to explore the tension between policy and practice, and how health care workers in Bergen reflect on their role in implementing medication-free treatment. Methods We performed three focus group discussions including 17 therapists working within medication free services, asking about their experiences with this new treatment program. We used Systematic Text Condensation for data analysis. The findings were discussed using Michael Lipsky’s theoretical framework on the role public health workers play in policy implementation. Findings Following Norway’s new policy was challenging for the therapists in our study, particularly balancing a patient’s needs with treatment guidelines, the legal framework and available resources. Therapists had an overarching wish to help patients through cooperation and therapeutic alliance, but their alliance was sometimes fragile, and the therapists worried about patients’ conditions worsening. Conclusions Democratization of treatment choices, with the aim of empowering patients in mental health care, challenges the level of professional discretion given that patients and therapists might have conflicting goals. Balancing the desire to help, professional responsibility, the perceived lack of resources, and certain patient choices created conditions that can leave therapists feeling disempowered in and alienated from their work