Finnish Adolescents Treated in Psychiatric Inpatient Care from 1980 to 2010 and Their Long-term Life Situations

Nuoruusiän mielenterveyshäiriöt ovat usein hyvin monimuotoisia ja muuttuvia sekä usein ne jatkuvat aikuisuuteen tai uusiutuvat myöhemmin. Niillä voi olla myös huomattava vaikutus nuoren tulevaisuuteen, kun aiemmissa tutkimuksissa ne on liitetty esimerkiksi alhaisempaan koulutustasoon ja sosioekonomiseen asemaan sekä lisääntyneeseen rikollisuuteen, kuolleisuuteen ja sairaalahoidon käyttöön. Suomessa on etenkin 1980-luvulta lähtien rakennettu ainutlaatuista, ikävaihespesifillä tavalla mielenterveyshäiriöitä hoitavaa nuorisopsykiatrisen palvelujärjestelmää, jonka on odotettu parantavan nuoruusiän mielenterveyshäiriöiden ennustetta. Mielenterveyshäiriöiden ennusteen sekä siten esim. syrjäytymisen ehkäisemiseksi tarvitaan laaja-alaisia seurantatutkimuksia. Tässä väitöskirjatutkimuksessa selvitettiin rekisteritutkimuksen keinoin Suomessa vuosien 1980–2010 aikana nuoruusiässä (13– 17 v) ensimmäistä kertaa psykiatriseen sairaalahoitoon joutuneiden (N 17112) myöhempää psykiatrisen sairaalahoidon käyttöä, rikollisuutta, koulutusta, kuolleisuutta sekä skitsofrenian esiintyvyyttä ja ilmaantuvuutta. Tutkimuksessa tutkittavia seurattiin Terveyden ja hyvinvoinnin laitoksen, Eläketurvakeskuksen sekä Tilastokeskuksen rekistereissä vuoden 2014 loppuun saakka. Tutkimuksessa havaittiin nuorisopsykiatrisen sairaalahoidon määrän lisääntyneen 1990-luvun puolivälistä lähtien kasvun ollessa erityisen voimakasta 2000-luvun loppupuolella ikäryhmästään yhä useamman nuoren, erityisesti tyttöjen, oltua hoidettavana nuorisopsykiatrisella osastolla. Mielialahäiriödiagnoosin osuus hoidon syynä kasvoi merkittävästi, mutta tämä ei ole selitettävissä epidemiologisin syin vaan todennäköisesti taustalla on yhteiskunnan muutokset ja terveyspoliittiset tekijät. Sairaalahoitojaksot lyhenivät erityisesti 80- ja 90-luvuilla, mutta tämä ei näytä huonontaneen ennustetta tai lisänneen uudelleen sairaalahoitoon joutumisen riskiä. Nuorisopsykiatrista sairaalahoitoa edellyttävillä mielenterveyshäiriöllä oli havaittavissa negatiivinen vaikutus hoidossa olleiden nuorten tulevaisuuteen. Sairaalahoidossa olleiden koulutustaso jäi muuta samanikäistä väestöä huonommaksi, kun vain 50% hoidossa olleista oli suorittanut peruskoulun jälkeisen koulutuksen verrattuna 85% vastaavan ikäisestä väestöstä. Erityisessä riskissä alhaiseen koulutustasoon olivat externalisoivan häiriön (päihdehäiriö, käytöshäiriö, persoonallisuushäiriö) tai skitsofreniaryhmän psykoosin vuoksi sairaalahoidossa olleet., minkä lisäksi eksternalisoivan häiriön vuoksi sairaalahoidossa olleet olivat myös kohonneessa riskissä syyllistyä rikoksiin. Nuorisopsykiatrisessa sairaalahoidossa olleilla oli myös suuri riski saada myöhemmin skitsofreniadiagnoosi. Vaikka viimeisten vuosikymmenten aikana nuorisopsykiatristen palveluita ja muita tukimuotoja onkin kehitetty aktiivisesti sekä niiden saatavuus on parantunut huomattavasti, kuitenkaan nuoruusiässä sairaalahoitoa edellyttäneiden mielenterveyshäiriöiden ennuste ei näytä silti parantuneen huomattavasti. Vakavat mielenterveyden häiriöt vaarantavat normaalia nuoruusiän kehitystä, lisäävät riskiä antisosiaaliselle kehityssuunnalle sekä syrjäytymiselle vaikuttamalla negatiivisesti mm. kouluttautumiseen. Sen vuoksi on syytä kiinnittää huomiota riittävään arjen tukeen, psykiatriseen hoitoon, opiskelun tukemiseen erityisesti nuorisopsykiatrisessa sairaalahoidossa olleiden kohdalla. Hyödyllistä olisi pyrkiä mahdollisimman lyhyisiin osastojaksoihin ja siirtää nuoren hoidon ja kuntoutuksen fokus mahdollisimman lähelle nuoren normaalia arjen toimintaympäristöä.Mental disorders during adolescence are often diverse and variable. They often recur in or continue into adulthood and have a significant impact on adolescents’ future. Earlier research has shown that adolescent-onset mental disorders are associated, for example, with less education, lower socioeconomic status, increased criminality and also increased hospitalization and mortality. Since the 1980s the adolescent psychiatric services in Finland have undergone developments aiming to treat mental disorders by taking account of the developmental stage of the patient. These exceptional services are expected to improve the outcomes of early onset mental disorders. Comprehensive follow-up studies are crucial for the prognosis of mental disorders during adolescence and therefore in preventing marginalization. This register-based study examined subsequent use of psychiatric inpatient care, criminality, education and mortality among those Finnish adolescents aged 13-17 who had their first psychiatric inpatient care during adolescence between 1980 and 2010. Incidence and prevalence of schizophrenia was also studied. Subjects (N 17112) were followed up in the registers of the Finnish Institute of Health and Welfare, the Finnish Centre for Pensions and Statistics Finland until end of 2014. An increase in adolescent psychiatric inpatient care was observed from the mid- 1990s, the growth being especially prominent in the late 2000s. An increasing proportion of adolescents were hospitalized in psychiatric inpatient care, the growth being especially prominent in girls. The proportion of mood disorders as the primary diagnostic reason for inpatient care increased significantly, but this could not be explained by epidemiological reasons, but instead by changes in society and healthcare policies. There was a decrease in length of stay, especially in the 1980s and 1990s, but this seemed not to impair the the prognoses of mental disorders nor to increase the risk for rehospitalization. Mental disorders requiring adolescent psychiatric inpatient care were observed to have a negative effect on adolescents’ future. The educational level of those adolescents who had been psychiatric inpatients was generally lower than that in general population; only 50% of those had completed post-comprehensive school education compared to 85% of general population. Those needing inpatient care due to externalizing disorder (conduct, personality or substance use disorder) or schizophrenia spectrum psychoses diagnoses were at risk for lower educational attainment. Those with externalizing disorder diagnoses were also at the higher risk for criminal behaviour. Also, those adolescents undergoing psychiatric inpatient care had a high risk for later receiving a diagnosis of schizophrenia diagnosis. Despite the development and increased availability of outpatient and other support services in recent decades, the outcomes of mental disorders requiring inpatient care during adolescence have not shown any marked improvement. Severe mental disorders compromise normal adolescent development, increase the risk of antisocial development and of marginalization due to the negative effect, for example on the educational pathway. Therefore, it is important to focus on adequate support in everyday life, availability of psychiatric care and school welfare especially in those adolescents with episodes of psychiatric inpatient care. It is beneficial to aim at keeping the duration of inpatient care is as short as possible and keeping adolescents’ care and rehabilitation as close as possible to their environment in everyday life

Subsequent criminal participation among young people first admitted to psychiatric inpatient care during early and middle adolescence

Adolescents brought before court suffer excessively of mental disorders. Less is known about subsequent criminal participation of adolescent psychiatric inpatients. Our register study comprised all subjects that had between 1980 and 2010 been admitted to psychiatric inpatient care in Finland for the first time in their lives at ages 13-17 (n = 16 842), identified in the Care Register for Health Care and followed up for up to 10 years in the Register of Prosecutions, Sentences and Punishments. Incidence of register entry for any crime was 2.4/100 person-years, 4.0 in males and 1.9 in females. Incidence of violent crime was 0.9/100 person-years, 1.5 in males and 0.3 in females. Greatest risk for subsequent crime was associated with diagnoses of conduct, personality and substance use disorders (F90-92, F60-69, F10-19). Schizophrenia group diagnoses (F20-29) were associated with lowest risk. Later criminality was manifold among those who already had a crime register entry before the index treatment. Need for psychiatric inpatient care during adolescence associates with a great risk of antisocial development. Treatment needs to address this risk by systematically implementing evidence-based interventions. Health and social policies need to ensure resources and skills to these treatments.Peer reviewe

Schizophrenia among young people first admitted to psychiatric inpatient care during early and middle adolescence

OBJECTIVE: This study explored the incidence and stability of schizophrenia in a large national register data of all adolescents first admitted to psychiatric inpatient care at ages 13-17 in Finland 1980-2010. METHODS: The study population (N 17,112) comprised all Finnish citizens aged 13-17 receiving their first ever psychiatric inpatient treatment between 1980 and 2010 in Finland. To explore incidence and stability of schizophrenia, the diagnostic information on inpatient care or disability pension was obtained from the appropriate registers. RESULTS: The incidence of schizophrenia disorders (F20 + F25) during adolescence was higher in the study population for those admitted to psychiatric inpatient care 1980-1989 than in other decades examined. Overall, psychiatric inpatient care during adolescence was a risk factor for subsequent schizophrenia, especially if a diagnosis of F20-29 was set although a considerable share of those with psychotic disorders other than schizophrenia diagnosis did not subsequently convert to schizophrenia. The stability of adolescent onset schizophrenia diagnosis was high. CONCLUSION: Adolescents requiring psychiatric inpatient care have a higher later rate of schizophrenia diagnosis than prevalence at community level. Whereas adolescent onset schizophrenia diagnosis is a fairly stable diagnosis, there are other adolescent psychotic disorders which are more transient in nature.publishedVersionPeer reviewe

Sex offending among adolescents and young men with history of psychiatric inpatient care in adolescence

Background: Some mental disorders have been associated with increased likelihood of sexual offending in adolescents (and adults), but relevant studies tend to be of established sex offenders. Aims: To examine relationships between adolescent mental disorders and subsequent involvement in sex offending and to explore any predictive value of primary diagnoses for subsequent interpersonal offending, whether sexual or violent. Methods: We analyse national register-based longitudinal data on males in Finland admitted for their first psychiatric inpatient treatment between the ages of 13–17 in the period 1980–2010 (N = 6749). Cox regression was used for the analysis of multivariate associations. Results: A subsequent criminal record for sex crime in the 10-year follow up was rare among former child and adolescent psychiatric (CAP) inpatient males (1.5%). Having a subsequent criminal record for non-sex-related violent crime was more common (25%). Time to either sex crimes or non-sex-related violent crimes after a first CAP inpatient treatment was 3–4 years. Whilst the risk of committing non-sex-related violent crimes was elevated in all diagnostic groups compared to those with schizophrenia spectrum disorders, the risk of committing subsequent sex crimes was elevated only in the group with substance use, conduct or personality disorders. Among those with pre-existing criminal history of sex crime, the risk of a subsequent criminal record for sex crime after CAP treatment was increased 11-fold, but the risk for later non-sex-related violent crimes was not increased compared to the rest of the male adolescent CAP population. Conclusions and implications for practice: In this first longitudinal study of criminal convictions for sex offending after a period of inpatient psychiatric treatment as an adolescent such convictions were rare, but the difference in post discharge risk of further convictions for sexual offending and non-sexual violent offending raises questions about whether more attention and specific treatment for aberrant sexual behaviours is needed for male adolescents with severe mental disorders.publishedVersionPeer reviewe

Educational attainment of adolescents treated in psychiatric inpatient care : a register study over 3 decades

Mental disorders may for various reasons impair educational attainment, and with far-reaching consequences given the impact of education on subsequent employment, social life, life choices and even health and mortality. This register-based study addresses trends in educational attainment among Finnish adolescents aged 13–17 with mental disorders severe enough to necessitate inpatient treatment between 1980 and 2010. Our subjects (N = 14,435), followed up until the end of 2014, were at greater risk of discontinuing education beyond compulsory comprehensive school or of lower educational attainment than their age-peers in general population. Only 50.0% had completed any post-comprehensive education compared to 84.9% in same-aged general population. Those at highest risk were males and those with organic, intellectual disabilities and developmental, externalizing disorders or schizophrenia group diagnoses. Despite improvements in adolescent psychiatric care, school welfare services and pedagogical support, risks have remained high. Greater effort in psychiatric treatment, school welfare and pedagogy are needed to combat this severe inequality.publishedVersionPeer reviewe

Nuoren hoitosuunnitelmaan tehtävä kirjaus etähoidon osuudesta

Nuorisopsykiatrisessa erikoissairaanhoidossa etähoito täydentää hyvin palveluvalikkoa. On tärkeää, että nuorta kuullaan hoitosuunnitelmaa tehtäessä

Cross-impact analysis of Finnish electricity system with increased renewables: Long-run energy policy challenges in balancing supply and consumption

AbstractClimate change and global economic pressures are strong drivers for energy economies to transition towards climate-neutrality, low-carbon economy and better energy and resource efficiencies. The response to these pressures, namely the increased use of renewable energy, creates a set of new challenges related to supply-demand balance for energy policy and electricity system planning. This study analyses the emergent problems resulting from the renewable energy response. These complex aspects of change in the electricity system are analysed with a cross-impact model based on an expert-driven modeling process, consisting of workshops, panel evaluations and individual expert work. The model is then analysed using a novel computational cross-impact technique, EXIT. The objective of the study is to map the important direct drivers of change in the period 2017–2030 in electricity consumption and production in Finland, construct a cross-impact model from this basis, and discover the emergent and systemic dynamics of the modeled system by analysis of this model.</div