Non-suicidal self-injury (NSSI) in adult psychiatric outpatients – A nationwide study

Background: Non-suicidal self-injury (NSSI) is a highly prevalent behavioural problem among people with mental illness, yet many fundamental aspects of NSSI remain unknown. We studied the prevalence of NSSI, and its relationship with suicide ideation (SI) and suicide attempts (SA) among adult psychiatric outpatients, with a special focus on patients with personality disorders compared with patients with other disorders. Method: During a 14-day period, data were collected on all available patients in all outpatient psychiatric clinics in Norway. This national clinical unselected cross-sectional dataset from 23,124 outpatients was used to generate proportional Venn diagrams of the prevalence of NSSI, SI and SA and their co-occurrence over the last four weeks. Differences in the risk for these behaviours across diagnoses were tested, both with and without adjustments for demographic and socio-demographic characteristics. Results: Over the previous four-week period, 8.1% of the patients had experienced at least one episode of NSSI, 17.3% had SI and 0.6% had made at least one SA. Among patients with NSSI, 27.8% had co-occurring SI, and among patients with SI, 13% had co-occurring NSSI. The prevalence of SA was more than seven times higher among patients with NSSI behaviour than among patients without NSSI behaviour. Patients with a diagnosis of personality disorder had a significantly higher prevalence of SI, NSSI, and NSSI with co-occurring SI, than all other diagnostic groups; however, they were not systematically different from patients with other diagnoses in their prevalence of NSSI without co-occurring SI. These findings remained statistically significant even when controlling for socio-demographic variables. Conclusions: The prevalence of recent NSSI is high in patients receiving outpatient psychiatric treatment in Norway. NSSI is significantly more prevalent in patients with personality disorders than in patients with other diagnoses, mainly due to the significantly higher prevalence of NSSI with co-occurring SI in patients with personality disorders. The co-occurrence of NSSI and SI is also prevalent in all diagnostic groups, but both NSSI and SI appear alone more often than together. The strong association between NSSI and SA calls for a more proactive focus on NSSI behaviour in mental health clinical settings as an important suicide preventive measure.publishedVersio

Collaboration between general hospitals and community health services in the care of suicide attempters in Norway: a longitudinal study

<p>Abstract</p> <p>Background</p> <p>The aim of this paper was to study the collaboration between emergency departments (EDs) in general hospitals and community health services (CHS) in Norway when providing psychosocial care and aftercare to patients treated in EDs following a suicide attempt. We wanted to explore the extent to which quality indicators at the hospital level measured in 1999 and 2006 could predict the presence or absence of a chain of care structure in the CHS in 2006.</p> <p>Methods</p> <p>Data were collected through structured interviews with informants from 95% of all general hospitals in Norway in 1999 and 2006, and informants from CHS, in a stratified sample of Norwegian municipalities in 2006 (n = 47).</p> <p>Results</p> <p>In 15 of the 47 municipalities (32%), the CHS reported having a chain of care structure in 2006. A discriminant function analysis revealed that the hospitals that in 1999 had: (a) a collaboration agreement with aftercare providers, and (b) written guidelines, including a quality assurance system, were significantly more likely to have municipalities with a chain of care structure in their catchment area in 2006.</p> <p>Conclusions</p> <p>Hospitals' and municipalities' self-reported provision of aftercare services for patients treated after a suicide attempt was markedly below the recommendations given in national standards. Systems at the hospital level for the management and care of patients admitted after a suicide attempt and systematic collaboration between hospitals and aftercare providers seem to be important elements in the long-term maintenance of continuity of care for suicide attempters.</p

Trajectories of Service Contact before Suicide in People with Substance Use Disorders—A National Register Study

Objective: This study aimed to identify trajectories of service use during the last year before suicide death and the characteristics associated with the trajectories in patients with substance use disorders. Methods: This study used a national registry data linkage, which included all patients with substance use disorders who died by suicide in Norway between 2010 and 2018. In- and outpatient contacts with mental health or substance use services during the last year before suicide death was analyzed by week using Sequence State Analysis and cluster analysis to identify trajectories. Logistic regression was used to measure the association between the characteristics and the trajectories. Results: We identified four trajectories of service contact. A brief contact trajectory (n ¼ 366) with a low proportion of weeks in contact (M weeks ¼ 8.3), associated with less psychosis or bipolar disorder (aOR ¼ 0.13 (0.08–0.22)) and higher age. A regular contact trajectory (n ¼ 160), with a higher proportion of contact (M weeks ¼ 47.9), associated with psychosis or bipolar disorder (aOR ¼ 3.66 (2.10–6.47)) and depressive or anxiety disorder (aOR ¼ 3.11 (1.93–5.13)). An intermittent contact trajectory (n ¼ 195) with most contacts with outpatient substance use disorder services (M weeks ¼ 9.7). A continuous contact trajectory (n ¼ 109) with a high proportion of inpatient contact (M weeks ¼ 44.5), strongly associated with psychosis or bipolar disorder (aOR ¼ 6.08 (3.26–11.80)). Conclusion: Longitudinal descriptions of service use reveal different trajectories that are important to consider when developing policies or interventions to reduce the risk of suicide death in patients with substance use disorders

The temporal association between suicide and comorbid mental disorders in people treated for substance use disorders: a National registry study

Background The time after contact with specialized health services for mental health and substance use is associated with an increased risk of suicide, where temporal aspects of suicide and comorbid mental disorders in patients with substance use disorders could be associated. This study aimed to examine the temporal association between time from last treatment contact to suicide and comorbid mental disorders in patients with substance use disorders. Methods This study is a historical prospective case series using nationwide registry data. It included 946 individuals registered the year before suicide with a substance use disorder (F10-F19) in Norway’s specialized health services for treating substance use and mental health disorders between 2010 and 2020. The outcome was the number of weeks from the last contact with services to suicide. The exposure was comorbid mental disorders divided into ’no comorbid mental disorder’; ‘psychosis or bipolar disorders’ (F20−F31), ‘depressive or anxiety disorders’ (F32−F49); and ’personality disorders’ (F60-F69). Covariates included gender, age, last diagnosed substance use disorder, registered deliberate self-harm last year, and the number of in- and outpatient contacts the previous year. Results The number of weeks from last service contact to suicide difered (p= <0.001) between patients with no comorbid mental disorders (Median=7; IQR 2–23), psychosis or bipolar disorders (Median=2; IQR=1–7), depressive or anxiety disorders (Median=3; IQR=1–11) and personality disorders (Median=1; IQR=1–5.5). Signifcantly decreased adjusted incidence rate ratios (aIRR) were found for psychosis or bipolar disorders [aIRR=0.67 (95% CI 0.53–0.85)] and personality disorders [aIRR=0.56 (0.42–0.77)] compared to no comorbid mental disorder when adjusted for individual characteristics and service contact. For depressive and anxiety disorders compared to no comorbid mental disorder, the association was signifcant when adjusted for individual characteristics [aIRR=0.55 (0.46–0.66)]. Conclusions While patients with substance use disorders generally died by suicide a short time after contact with services, patients with comorbid mental disorders died an even shorter time after such contact and signifcantly shorter than patients without such comorbidities

Suicide and other Violent Death Cases in Norwegian Peacekeeping Forces

U populaciji bivših norveških jedinica u sklopu UN-a koje su služile u UNIFIL-u (United Nations Interim Forces in Lebanon = Privremene snage UN-a u Libanonu) u razdoblju 1978.-1991. utvrđen je 43 postotni porast smrtnosti zbog samoubojstva i 28 postotni porast smrtnosti zbog drugih načina nasilne smrti. Ovi su nalazi pridonijeli razvoju strategija za sprečavanje samoubojstva u norveškim jedinicama pri UN-u. Strategije sprečavanja samoubojstva u norveškim jedinicama pri UN-u prije misije usmjerene su na samopomoć, pomoć drugovima i odgovornost vođa. Na ratištu u središtu su pažnje krizne intervencije. Po završetku misije, identificirane su grupe visokog rizika u svrhu postupaka sustavnog praćenja. Sadašnji planovi za poboljšanje postojeće strategije sprečavanja samoubojstva usmjereni su na razvoj postupaka individualnog snimanja prilagođenijih muškoj simptomatologiji, a sadašnje istraživanje usmjereno je na ispitivanje počinjenih samoubojstava i drugih načina nasilne smrti norveških veterana UN-a.In a population of former Norwegian UN personnel serving in UNIFIL (United Nations Interim Forces in Lebanon) in the period 1978-1991, was found a 43% increased mortality of suicide and a 28% increase in the mortality of other violent death. These findings have contributed to the development of suicide prevention strategies targeting Norwegian UN personnel. Suicide prevention strategies in the Norwegian UN forces before the mission focus on self-help, buddy aid and leader responsibilities. In theatre focus is put on crisis interventions. After completing the mission, high risk groups are identified for systematic follow-up procedures. Current plans for improvement of the existing suicide prevention strategy focus on development of individual screening procedures better adapted to male symptomatology, and current research targets investigations of committed suicides and other violent deaths amongst Norwegian UN veterans

Overactive, aggressive, disruptive and agitated behavior associated with the use of psychotropic medications in schizophrenia

Background Evidence is limited for the associations between use of psychotropic medications and overactive, aggressive, disruptive or agitated behavior (OADA)1 in clinical practice. Aims To investigate the associations between risk of readmission with OADA and use of antipsychotics, antidepressants, mood stabilizers and benzodiazepines in patients with schizophrenia. Method A consecutive total cohort diagnosed with schizophrenia (N = 663) after admission to the Haukeland University Hospital psychiatric acute unit in Bergen, Norway, was followed from discharge over a 10-year period. At every following readmission, the level of OADA was assessed using the first item of the Health of the Nation Outcome Scale (HoNOS). Periods of use versus non-use of antipsychotics, antidepressants, mood stabilizers and benzodiazepines were recorded as time-dependent variables in each patient and compared using Cox multiple regression analyses. Results A total of 161 (24.3 %) patients were readmitted with OADA, and the mean (SD) and median times in years to readmission with OADA were 2.8 (2.6) and 2.1, respectively. We found that the risk of readmission with OADA was negatively associated with use of antipsychotics (adjusted hazard ratio (AHR) = 0.33, p < 0.01, CI: 0.24–0.46) and antidepressants (AHR = 0.57, p = 0.03, CI: 0.34–0.95), positively associated with use of benzodiazepines (AHR = 1.95, p < 0.01, CI: 1.31–2.90) and not significantly associated with use of mood stabilizers. Conclusions Use of antipsychotics and antidepressants is associated with reduced risk of readmission with OADA whereas benzodiazepines are associated with an increased risk of readmission with OADA in patients with schizophrenia.publishedVersio

Future Challenges in Psychotherapy Research for Personality Disorders

Purpose of Review Individuals with personality disorders are frequently seen in mental health settings. Their symptoms typically reflect a high level of suffering and burden of disease, with potentially harmful societal consequences, including costs related to absenteeism at work, high use of health services, ineffective or harmful parenting, substance use, suicidal and non-suicidal self-harming behavior, and aggressiveness with legal consequences. Psychotherapy is currently the first-line treatment for patients with personality disorders, but the study of psychotherapy in the domain of personality disorders faces specific challenges. Recent Findings Challenges include knowing what works for whom, identifying which putative mechanisms of change explain therapeutic effects, and including the social interaction context of patients with a personality disorder. By following a dimensional approach, psychotherapy research on personality disorders may serve as a model for the development and study of innovative psychotherapeutic interventions. Summary We recommend developing the following: (a) an evidence base to make treatment decisions based on individual features; (b) a data-driven approach to predictors, moderators, and mechanisms of change in psychotherapy; (c) methods for studying the interaction between social context and psychotherapy

Use of Benzodiazepines and Antipsychotic Drugs Are Inversely Associated with Acute Readmission Risk in Schizophrenia

Purpose: Little is known about the impact of different psychotropic drugs on acute readmission risk, when used concomitantly in a real-life setting. We aimed to investigate the association between acute readmission risk and use of antipsychotic drugs, antidepressants, mood stabilizers, and benzodiazepines in patients with schizophrenia. Methods: A cohort study included all patients diagnosed with schizophrenia admitted to a psychiatric acute unit at Haukeland University Hospital in Bergen, Norway, during a 10-year period (N = 663). Patients were followed from discharge until first readmission or censoring. Cox multiple regression analyses were conducted using antipsychotic drugs, antidepressants, mood stabilizers, and benzodiazepines as time-dependent variables, and periods of use and nonuse were compared within individual patients. Adjustments were made for sex, age at index admission, and excessive use of alcohol and illicit substances. Results: A total of 410 patients (61.8%) were readmitted during follow-up, and the mean and median times in days to readmission were 709 and 575, respectively. Compared with nonuse, the use of antipsychotic drugs was associated with reduced risk of readmission (adjusted hazards ratio, 0.20; P < 0.01; confidence interval, 0.16–0.24), and the use of benzodiazepines was associated with increased risk of readmission (adjusted hazards ratio, 1.51; P < 0.01; confidence interval, 1.13–2.02). However, no relation to readmission risk was found for the use of antidepressants and mood stabilizers. Conclusions: We found that use of benzodiazepines and antipsychotic drugs are inversely associated with acute readmission risk in schizophrenia.publishedVersio

Associations between insecure attachment styles to parents and suicidal ideation in adolescents with depression

Objective: Suicidal ideation and depressive symptoms are often interrelated in clinical settings. Insecure attachment may be a risk factor for suicidal ideation in depressed adolescents. To our knowledge, this study is the first to examine the association between self-reported insecure attachment styles to both parents and suicidal ideation in a clinical sample of adolescents with depression. Methods: Fifty clinically depressed adolescents (13-17 years, 84% girls) completed self-reported measures of suicidal ideation, depressive symptoms, and attachment style to parents. Results: There was a statistically significant bivariate association between higher levels of attachment anxiety in relation to mothers and fathers and higher levels of suicidal ideation. When attachments to both parents were included in the same multivariate model, only attachment anxiety to the mother was significantly associated with the level of suicidal ideation. Self-reported depressive symptoms remained significantly associated with the level of suicidal ideation in all analyses. Younger adolescents with attachment anxiety reported higher levels of suicidal ideation than older adolescents. Conclusion: Conclusions about directionality and causality of associations between insecure attachment and suicidal ideation are limited due to the cross-sectional design. Our findings suggest that attachment anxiety in relation to the mother and father is associated with increased levels of suicidal ideation. Implication of these findings for treatment selection is discussed

Building a strong European alliance for personality disorder research and intervention

People with personality disorders frequently face stigma, ignorance and pessimism regarding the treatability of their disorders. This is despite substantial progress that has been made in developing a number of effective evidence based psychotherapeutic treatments. However, expertise in how to systematically deliver these treatments in a sustainable way throughout Europe is largely lacking. To bridge the gap between evidence based treatments and their implementation in health services, the European Society for the Study of Personality Disorders is currently building a new alliance of experts to promote personality disorder scholarship, and to support the development of clinical expertise and systematic treatment implementation throughout Europe. The aim of this paper is to describe how the Society is currently using its interdisciplinary and international roster of experts to address the specific treatment and research needs of the European personality disorder field, particularly to countries in which expertise in the field is less developed