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

Personality Disorder: What Predicts Acute Psychiatric Readmissions?

Individuals diagnosed with borderline personality disorder (BPD) often struggle with chronic suicidal thoughts and behaviors and have frequent acute psychiatric admissions. Prevention of serial admissions and disruptions in long-term treatment strategies is needed. This study explored predictors of how frequently and how quickly patients diagnosed with BPD are readmitted after an index psychiatric admission. The authors identified self-harming behavior as a predictor of readmission frequency, whereas depression and hallucinations and delusions predicted time elapsed between the index admission and the first readmission. The authors recommend that predictors of readmissions should be carefully monitored and treated following index admission

Beskrivelser, forståelse og definisjoner av selvskading fra antikken til i dag

Det finnes beskrivelser av at mennesker har skadet seg selvmed hensikt langt tilbake i tid, men hvordan det som i dag kallesselvskading har blitt forstått og definert, har variert. Denne artikkelentar for seg beskrivelser og definisjoner av selvpåførte skaderfra antikken og frem til i dag. Den er avgrenset til å handle omden vestlige verden, og hovedfokuset er på selvskading som ikkeer motivert av et ønske om å dø. Selvmordsforsøk og selvmorder likevel med i bildet, da nettopp overlapp mellom ulike formerfor selvskading har vært noe av utfordringen for fagfolk som harforsøkt å forstå og definere hva dette handler om. Den historiskegjennomgangen viser at i tidsspennet fra antikken og frem tili dag har synet på selvskading endret seg fra å være religiøstog kulturelt akseptert fenomen til å bli sett på som symptom påpsykisk lidelse. Det siste tiårets diskusjoner omkring definisjonerog diagnostikk blir omtalt til slutt i artikkelen

Predictors of suicidality and self-harm related admissions to psychiatric and general hospitals

Background and aims: Although suicide risk is a frequent reason for acute psychiatric admissions, there is a lack of knowledge on the prevalence and characteristics of such admissions and very little is known about the short- and long-term outcome in relation to severe self-harm after psychiatric discharge. The overall aim of this thesis was to describe the prevalence of suicide risk, suicidal ideation, non-suicidal self-harm, and suicide attempt as the main or contributing reasons for acute psychiatric admissions: as well as to study these variables together with other clinical, sociodemographic, diagnostic, and treatment related variables as predictors of acute psychiatric readmissions and self-harm induced somatic admissions. Methods: This thesis is based on the results from two prospective, observational and longitudinal cohort studies, and one interview study. The studies are based on data from patients admitted to a psychiatric acute unit at a hospital, which has a catchment area of about 400 000 inhabitants. Papers I (n=1245) and II (n=2827) used data obtained by the standardised assessments of all consecutive admissions during one and three years respectively. Study I examined the data assessed at the index admission (each patient’s first admission to the psychiatric acute unit during the inclusion period) as predictors of readmission due to any cause, and readmissions due to suicide risk, within a mean follow-up time of 1.5 years. Study II analysed data assessed at index admission and possible readmissions, as well as follow-up data on psychiatric outpatient treatment as predictors of selfharm induced somatic admissions within a mean follow-up time of 2.3 years. Paper III included 308 patients who were randomly selected from non-psychotic patients consecutively admitted to the psychiatric acute unit, due to suicide risk. A multiple regression model was used to examine if post-traumatic stress disorder (PTSD) predicted the number of self-harm induced somatic admissions within 6 months, when adjusted for borderline personality disorder (BPD). Secondly, a structural model comprising two latent BPD factors, ‘dysregulation’ and ‘relationship problems’, as well as PTSD and several other diagnostic variables was applied to examine the associations between these variables and the number of post-discharge self-harm induced somatic admissions. Results: Suicide risk was the main or contributing reason for 54% of the total index admissions and 62% of the total readmissions. In the most frequently admitted patients, 80% of the admissions were related to suicide risk. Of the total cohort, about one in ten patients had at least one self-harm induced somatic admission during follow-up. The proportion of patients having their first such admission within the first six months after psychiatric discharge was 48%, while 42% of the patients had their first self-harm induced somatic admission within the subsequent six months. Important predictors of self-harm induced somatic admission, were having had the most recent psychiatric admission related to nonsuicidal self-harm or to a suicide attempt. Other significant predictors were having a history of psychiatric hospitalisation before the index admission, psychiatric readmissions during follow-up, an increasing number of psychiatric outpatient consultations during follow-up, and having a diagnosis of recurrent depression, BPD, substance use disorders, or PTSD. Only about half of the somatic hospital admissions identified by the researchers as caused by self-harm, received an ICD-10 diagnosis of intentional self-harm. In the subgroup of patients with suicide risk related acute psychiatric admissions one in five patients had at least one self-harm induced somatic admission within 6 months after discharge. Among these patients, PTSD and BPD predicted the number of self-harm induced somatic admissions with nearly the same estimates. An emotional dysregulation factor based on the BPD criteria was significantly associated both directly and indirectly, via PTSD, with the number of somatic self-harm admissions; even when controlled for other relevant psychiatric disorders and symptoms. Conclusions: Suicide risk is a frequent reason for acute psychiatric admissions, and about one in ten patients have at least one self-harm induced somatic admission during the year following psychiatric discharge. The risk of such severe self-harm is high over an extended period after discharge. Treatment of the underlying disorder(s) may not be sufficient to prevent self-harm, and the repetition of self-harm in particular. In addition, there is a need for evidencebased psychosocial and behavioural interventions that may directly and transdiagnostically address suicidal thoughts and behaviours. Treatments that help patients to better deal with problems related to emotional dysregulation may contribute to preventing or reducing self-harm behaviour in several subgroups of patients admitted to psychiatric acute units

Selvmordsrelaterte innleggelser i psykiatri og somatikk: Disputas for Liv Mellesdal

Liv Mellesdal disputerte for ph.d.-graden 22.11.17. ved UiB med avhandlingen: «Predictors of suicidality and self-harm related admissions to psychiatric and general hospitals»

The suicide assessment scale: Psychometric properties of a Norwegian language version

BACKGROUND: Rating scales are valuable tools in suicide research and can also be useful supplements to the clinical interview in suicide risk assessments. This study describes the psychometric properties of a Norwegian language version of the Suicide Assessment Scale Self-report version (SUAS-S). METHODS: Participants were fifty-two patients (mean age = 39.3 years, SD = 10.7) with major depression (53.8%), bipolar disorder (25.0%) and/or a personality disorder (63.5%) referred to a psychiatric outpatient clinic. The SUAS-S, the screening section of the Beck Scale for Suicidal Ideation (BSS-5), the Beck Depression Inventory (BDI), Beck’s Hopelessness Scale (BHS), the Symptom Check-List-90 R (SCL-90R) and the Clinical Global Impression for Severity of Suicidality (CGI-SS) were administered. One week later, the patients completed the SUAS-S a second time. RESULTS: Cronbach’s alpha for SUAS-S was 0.88 and the test–retest reliability was 0.95 (95% CI: 0.93– 0.97). SUAS-S was positively correlated with the BSS-5 (r = 0.66; 95% CI: 0.47–0.85) for the study sample as a whole and for the suicidal (r = 0.52) and non-suicidal groups (r = 0.50) respectively. There was no difference between the SUAS-S and the BSS-5 in the ability to identify suicidality. This ability was more pronounced when the suicide risk was high. There was a substantial intercorrelation between the score on the SUAS-S and the BDI (0.81) and the BHS (0.76). The sensitivity and specificity of the SUAS-S was explored and an appropriate clinical cut-off value was assessed. CONCLUSIONS: The study revealed good internal consistency, test–retest reliability and concurrent validity for the Suicide Assessment Scale Self-report version. The discriminatory ability for suicidality was comparable to that of the BSS-5

The suicide assessment scale: Psychometric properties of a Norwegian language version

Abstract Background Rating scales are valuable tools in suicide research and can also be useful supplements to the clinical interview in suicide risk assessments. This study describes the psychometric properties of a Norwegian language version of the Suicide Assessment Scale Self-report version (SUAS-S). Methods Participants were fifty-two patients (mean age = 39.3 years, SD = 10.7) with major depression (53.8%), bipolar disorder (25.0%) and/or a personality disorder (63.5%) referred to a psychiatric outpatient clinic. The SUAS-S, the screening section of the Beck Scale for Suicidal Ideation (BSS-5), the Beck Depression Inventory (BDI), Beck’s Hopelessness Scale (BHS), the Symptom Check-List-90 R (SCL-90R) and the Clinical Global Impression for Severity of Suicidality (CGI-SS) were administered. One week later, the patients completed the SUAS-S a second time. Results Cronbach’s alpha for SUAS-S was 0.88 and the test–retest reliability was 0.95 (95% CI: 0.93– 0.97). SUAS-S was positively correlated with the BSS-5 (r = 0.66; 95% CI: 0.47–0.85) for the study sample as a whole and for the suicidal (r = 0.52) and non-suicidal groups (r = 0.50) respectively. There was no difference between the SUAS-S and the BSS-5 in the ability to identify suicidality. This ability was more pronounced when the suicide risk was high. There was a substantial intercorrelation between the score on the SUAS-S and the BDI (0.81) and the BHS (0.76). The sensitivity and specificity of the SUAS-S was explored and an appropriate clinical cut-off value was assessed. Conclusions The study revealed good internal consistency, test–retest reliability and concurrent validity for the Suicide Assessment Scale Self-report version. The discriminatory ability for suicidality was comparable to that of the BSS-5.</p

Den sårbare tiden etter utskrivelse fra psykiatrisk sykehus – selvmordsrisiko og dokumentasjonspraksis

Tiden like etter utskrivelse fra psykiatrisk døgnenhet innebærerforhøyet selvmordsrisiko. Nasjonale retningslinjer for selvmordsforebyggingi psykisk helsevern anbefaler at når selvmordsrisiko harvært en problemstilling under oppholdet eller tidligere skal pasienterselvmordsrisikovurderes og det er en fordel med timeavtale hosoppfølgende instans. Hensikten med denne studien var å kartleggedokumentert etterlevelse av disse anbefalingene og identifisering avprediktorer for manglende timeavtale.En journalstudie i Divisjon psykisk helsevern, Haukeland Universitetssykehus,ble gjennomført for å vurdere i hvilken grad dokumentasjonspraksisi epikriser og overføringsnotat samsvarte medretningslinjeanbefalingene. Opplysninger om selvmordsrisikovurderingog timeavtale ble kartlagt sammen med kjønn, alder, tidligereselvmordsforsøk, andre risikofaktorer og mulige beskyttende faktorerfor selvmord, hoveddiagnoser, henvisnings- og mottaksformalitet.Analyser var deskriptiv statistikk og Generalized Estimating Equation.Selvmordsrisikovurdering var dokumentert i nesten alle epikriser/overføringsnotat. Begrunnelser for selvmordsrisikovurderingene vari liten grad dokumentert. Lavere sannsynlighet for dokumentasjon avtimeavtale var knyttet til utskrivelser med rus som hoveddiagnose,schizofrenidiagnose for kvinner, samt å bli henvist til tvangsinnleggelsemen mottatt til frivillig sykehusopphold for kvinner.Dokumentasjonspraksis vedrørende selvmordsrisikovurdering vargod, men vurderingene inneholdt i liten grad utdypende beskrivelserslik retningslinjen anbefaler. Gode beskrivelser gir oppfølgendeinstans viktig informasjon for videre pasientbehandling. Bedret dokumentasjonspraksis kan bidra til økt kontinuitet i helsetjenestetilbudetfor pasientene

Mortality and non-use of antipsychotic drugs after acute admission in schizophrenia: A prospective total-cohort study

Background In society at large, it is debated whether use of antipsychotic drugs is associated with increased or decreased mortality among patients with schizophrenia. Large register studies have demonstrated an increased mortality risk associated with non-use of antipsychotic drugs, but prospective studies are missing. Aims To investigate the association between mortality and non-use of antipsychotics in patients with schizophrenia. Method An open cohort study included and followed all patients with a discharge-diagnosis of schizophrenia consecutively admitted to a psychiatric acute unit at Haukeland University Hospital, Bergen, Norway during a 10 year period (n = 696). Cox multiple regression analyses were conducted with use of antipsychotic drugs as a time dependent variable, and periods of use and non-use were compared within individual patients. Adjustments were made for gender, age at index admission, number of acute psychiatric hospital admissions, excessive use of alcohol and illicit substances and use of benzodiazepines and antidepressants. Results A total of 68 (9.8%) deaths were registered during follow-up. Of these, 40 (59%) had natural causes, whereas 26 (38%) had unnatural causes. Non-use of antipsychotics was associated with 2.15 (p = .01, CI: 1.24–3.72) times higher mortality risk compared to use of antipsychotics. The difference in mortality risk between use and non-use of antipsychotic drugs was age dependent, with the largest risk difference in young patients. Conclusions Non-use of antipsychotic drugs was associated with twofold increased mortality risk in patients with schizophrenia