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Sand P, Dervisoski E, Kollia S, Strand J, Di Leone F. Psychiatrists' Perspectives on Prescription Decisions for Patients With Personality Disorders. J Pers Disord 2024; 38:225-240. [PMID: 38857158 DOI: 10.1521/pedi.2024.38.3.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
There is currently insufficient evidence for the use of a specific pharmacological treatment for personality disorders (PD). The research literature lacks a systematic exploration of clinicians' experiences of pharmacological treatment of PD. The aim of the qualitative study was to examine how psychiatrists make decisions about pharmacological treatment for patients with PD. The interviews were analyzed using inductive thematic analysis. The results showed that ambiguous guidelines had the effect that the psychiatrists often relied on their own experience, or that of their colleagues. As a basis for decisions concerning drug treatment, an interpersonal component was also identified. Some of the psychiatrists in the current study argued that medications may be part of the alliance-building with the patient and that medications were a way of tying the patient to the clinic. Our findings show that it is important to work on how the clinical guidelines should be implemented in practice.
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Affiliation(s)
- Peter Sand
- Department of Psychology at Gothenburg University, Gothenburg, Sweden
- Department of Psychiatry for Affective Disorders at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Evelina Dervisoski
- Department of Psychiatry for Affective Disorders at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sofia Kollia
- Department of Psychiatry for Affective Disorders at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jennifer Strand
- Department of Psychology at Gothenburg University, Gothenburg, Sweden
| | - Flavio Di Leone
- Department of Psychiatry for Affective Disorders at Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
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Lathe J, Silverwood RJ, Hughes AD, Patalay P. Examining how well economic evaluations capture the value of mental health. Lancet Psychiatry 2024; 11:221-230. [PMID: 38281493 DOI: 10.1016/s2215-0366(23)00436-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/30/2024]
Abstract
Health economics evidence informs health-care decision making, but the field has historically paid insufficient attention to mental health. Economic evaluations in health should define an appropriate scope for benefits and costs and how to value them. This Health Policy provides an overview of these processes and considers to what extent they capture the value of mental health. We suggest that although current practices are both transparent and justifiable, they have distinct limitations from the perspective of mental health. Most social value judgements, such as the exclusion of interindividual outcomes and intersectoral costs, diminish the value of improving mental health, and this reduction in value might be disproportionate compared with other types of health. Economic analyses might have disadvantaged interventions that improve mental health compared with physical health, but research is required to test the size of such differential effects and any subsequent effect on decision-making systems such as health technology assessment systems. Collaboration between health economics and the mental health sciences is crucial for achieving mental-physical health parity in evaluative frameworks and, ultimately, improving population mental health.
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Affiliation(s)
- James Lathe
- MRC Unit for Lifelong Health and Ageing, Department of Population Science and Experimental Medicine, Faculty of Population Health Sciences, University College London, London, UK.
| | - Richard J Silverwood
- Centre for Longitudinal Studies, Social Research Institute, Institute of Education, Faculty of Education and Society, University College London, London, UK
| | - Alun D Hughes
- MRC Unit for Lifelong Health and Ageing, Department of Population Science and Experimental Medicine, Faculty of Population Health Sciences, University College London, London, UK
| | - Praveetha Patalay
- MRC Unit for Lifelong Health and Ageing, Department of Population Science and Experimental Medicine, Faculty of Population Health Sciences, University College London, London, UK; Centre for Longitudinal Studies, Social Research Institute, Institute of Education, Faculty of Education and Society, University College London, London, UK
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Sveen CA, Pedersen G, Ulvestad DA, Zahl KE, Wilberg T, Kvarstein EH. Societal costs of personality disorders among treatment-seeking patients in Norway: the relative contribution of specific DSM-5 categories. Eur Arch Psychiatry Clin Neurosci 2024; 274:139-149. [PMID: 37598131 PMCID: PMC10786999 DOI: 10.1007/s00406-023-01655-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/17/2023] [Indexed: 08/21/2023]
Abstract
Personality disorders (PDs) are associated with high levels of societal costs, regardless of whether a single PD or a broad range of PDs have been studied. However, research on the relative contribution of specific PD-types on societal costs is limited. The aim of this study was to explore the possible contributions of the individual DSM-5 categories of PDs on the level of societal costs and its components (health service costs and productivity loss), while controlling for the impact of comorbid mental health and substance use disorders on these outcomes. Participants (n = 798) were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD-treatment units within specialist mental health services. The patients were referred to treatment in the time-period 2017-2020. Costs were assessed using a structured interview covering the 6-month period prior to assessment. Diagnoses were determined by semi-structured diagnostic interviews (SCID-5-PD and M.I.N.I.). Statistics included multiple regression analyses. The main result was that no specific PD had a unique contribution to the high level of societal costs generally found among treatment-seeking patients with PDs. Borderline PD (BPD) was the only PD with significantly higher health service costs than the other PDs, while BPD, avoidant PD, and unspecified PD were independently associated with enhanced productivity loss. The differential cost-effects of specific PDs on the cost components were small. Several comorbid mental health and substance use disorders were significant contributors to costs, irrespective of PD status. The results underscore the importance of developing and implementing effective treatments for a broader range of PDs, to reduce the high levels of societal costs associated with all PDs.
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Affiliation(s)
- C A Sveen
- Department of Child and Adolescent Psychiatry, Division of Mental Health and Addiction, Vestre Viken Hospital, Drammen, Norway.
| | - G Pedersen
- Network for Personality Disorder, Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Norwegian Centre for Mental Disorders Research (NORMENT), Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - D A Ulvestad
- Outpatient Clinic for Specialized Treatment of Personality Disorders, Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - K E Zahl
- Group Therapy Section, Follo District Psychiatric Centre, Akershus University Hospital, Ski, Norway
| | - T Wilberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Section for Treatment Research, Department for Research and Innovation, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - E H Kvarstein
- Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Nawata K. Evaluation of physical and mental health conditions related to employees' absenteeism. Front Public Health 2024; 11:1326334. [PMID: 38274521 PMCID: PMC10808730 DOI: 10.3389/fpubh.2023.1326334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/12/2023] [Indexed: 01/27/2024] Open
Abstract
Background Employees' health conditions are issues for not only employees themselves but also companies and society to keep medical costs low and productivity high. Data and methods In this analysis, 15,574 observations from 2,319 employees at four operational sites of a large corporation were used. The dataset contained physical and mental health conditions obtained from annual mandatory medical checkups, the Brief Job Stress Questionnaire (BJSQ), and work record information. Health and other factors related to long-term absenteeism (over three days in a quarter) were analyzed. Data were collected between February 2021 and January 2022, and we converted into quarterly observations. A logit (logistic regression) model was used in the analysis. Results Age and gender were identified as important basic characteristics. The estimates for these variables were positive and negative and significant at the 1% level. Among the variables obtained from the medical checkups, the estimates for diastolic blood pressure, HbA1c, anamnesis, heart disease history, smoking, increased weight, and frequency of alcohol consumption were positive and significant at the 1% level, further those for taking antihypertensive medications and kidney disease history were positive and significant at the 5% level. In contrast, the estimates for systolic blood pressure and amount of alcohol consumption were negative and significant at the 1% level. The estimate for taking antihyperglycemic medications and health guidelines were negative and significant at the 5% level. Among the variables obtained from the BJSQ, the estimates for amount of work felt, fatigue and support from family and friends were positive and significant at the 1%, and the estimate for irritation was positive and significant at the 5% level. The estimates for controlling job and physical complaints were negative and significant at the 1% level, and those for usage of employee's ability to work and suitability of the work were negative and significant at the 5% level. As all four operational sites were located in the northeastern region of Japan (cold and snowy in winter), the seasonal effects were significant at the 1% level. The effect of year was also significant and significant differences were observed among the sites at the 1% level. Conclusion Some physical and mental health conditions were strongly associated with long-term absenteeism. By improving these conditions, corporations could reduce the number of employee absence days. As absenteeism was costly for corporations due to replacement employees and their training costs to maintain operations, employers must be concerned about rising healthcare (direct and indirect) costs and implement investments to improve employees' health conditions. Limitations This study's results were based on only one corporation and the dataset was observatory. The employees were primarily operators working inside the building and most of them are healthy. Therefore, the sample selection biases might exist, and the results cannot be generalized to other types of jobs, working conditions, or companies. As medical checkups and the BJSQ are mandatory for most companies in Japan, the framework of this study can be applied to other companies. Although we used the BJSQ results, better mental measures might exist. Similar analyses for different corporations are necessary.
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Affiliation(s)
- Kazumitsu Nawata
- Hitotsubashi Institute for Advanced Study (HIAS), Hitotsubashi University, Kunitachi, Japan
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Sveen CA, Pedersen G, Hummelen B, Kvarstein EH. Personality disorders: the impact of severity on societal costs. Eur Arch Psychiatry Clin Neurosci 2023:10.1007/s00406-023-01715-6. [PMID: 37991536 DOI: 10.1007/s00406-023-01715-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/29/2023] [Indexed: 11/23/2023]
Abstract
Personality disorders (PDs) are associated with high levels of societal costs. However, previous research has found limited or no evidence of unique contributions of individual PD categories on the overall level of societal costs. Recent research supports the validity of PD as a dimensional construct, and PD severity may be a better predictor of societal costs than specific PD categories. The aim of this study was to explore if PD severity could predict the level of societal costs among treatment-seeking patients with PDs, while controlling for the impact of comorbid mental health and substance use disorders. Four different severity indicators were explored: the number of PDs, the total number of PD criteria, the number of BPD criteria, and the Level of Personality Functioning Scale (LPFS) from the alternative model in DSM-5. Participants (n = 798/794) were retrieved from the quality register of the Norwegian Network for Personality Disorders for the period 2017-2020. Societal costs were assessed using a structured interview covering the six-month period prior to assessment. Diagnoses and diagnostic criteria were determined using a semi-structured diagnostic interview (SCID-5-PD and M.I.N.I), and the LPFS was assessed by the LPFS-Brief Form 2.0 (LPFS-BF 2.0) questionnaire. Statistics included multiple regression analyses. None of the severity indicators were significant predictors of overall societal costs among treatment-seeking patients, and effect sizes were small.
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Affiliation(s)
- Carl-Aksel Sveen
- Vestre Viken Hospital Trust, Drammen, Viken, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Geir Pedersen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Network for Personality Disorder, Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Benjamin Hummelen
- Department of Research and Innovation, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Elfrida Hartveit Kvarstein
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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Langjord T, Pedersen G, Bovim T, Christensen TB, Eikenæs IUM, Hove O, Kildahl AN, Mork E, Norheim AB, Ramleth RK, Ringen PA, Romm KL, Siqveland J, Schønning T, Stänicke L, Torgersen T, Pettersen M, Tveit T, Urnes Ø, Walby F, Kvarstein EH. Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project. Front Psychiatry 2023; 14:1258025. [PMID: 37920539 PMCID: PMC10619742 DOI: 10.3389/fpsyt.2023.1258025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/19/2023] [Indexed: 11/04/2023] Open
Abstract
Background Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited. Objectives To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors. Method A cross sectional study (period 2019-2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report. Results The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life - greater impairment than the outpatient comparison sample. Conclusion The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.
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Affiliation(s)
- Tuva Langjord
- Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Faculty of Social Sciences, Department of Psychology, University of Oslo, Oslo, Norway
| | - Geir Pedersen
- Network for Personality Disorders, Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Tone Bovim
- Regional Centre – Violence, Trauma and Suicide Prevention, Oslo, Norway
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Ingeborg Ulltveit-Moe Eikenæs
- National Advisory Unit Personality Psychiatry, Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Oddbjørn Hove
- Department of Research and Innovation, Helse Fonna Health Trust, Haugesund, Norway
| | - Arvid Nikolai Kildahl
- Norwegian Centre of Competence for Intellectual Disabilities and Mental Health, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Nevsom Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias, Oslo University Hospital, Oslo, Norway
| | - Erlend Mork
- Early Intervention in Psychosis Advisory Unit for Southeast Norway, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | | | - Ruth Kari Ramleth
- Department for Child and Adolescent Psychiatry, Oslo University Hospital, Oslo, Norway
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Petter Andreas Ringen
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristin Lie Romm
- Early Intervention in Psychosis Advisory Unit for Southeast Norway, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johan Siqveland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department for Research, Division of Mental Health and Addiction, Akershus University Hospital, Oslo, Norway
| | | | - Line Stänicke
- Faculty of Social Sciences, Department of Psychology, University of Oslo, Oslo, Norway
- Child and Adolescent Psychiatry, Nic Waal Institute, Lovisenberg Hospital, Oslo, Norway
| | - Terje Torgersen
- Department of Mental Health Care, St. Olavs Hospital, Trondheim, Norway
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Mona Pettersen
- Department of Health and Care Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Tone Tveit
- Division of Mental Health and Addiction, Bergen University Hospital, Bergen, Norway
| | - Øyvind Urnes
- National Advisory Unit Personality Psychiatry, Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Fredrik Walby
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Elfrida Hartveit Kvarstein
- Section for Personality Psychiatry and Specialized Treatments, Department for National and Regional Functions, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Kvarstein EH, Frøyhaug M, Pettersen MS, Carlsen S, Ekberg A, Fjermestad-Noll J, Ulvestad DA, Gikling EL, Hjermann E, Lindberget K, Omvik S, Eikenæs IUM, Hummelen B, Morken KTE, Wilberg T, Pedersen GAF. Improvement of personality functioning among people treated within personality disorder mental health services. A longitudinal, observational study. Front Psychiatry 2023; 14:1163347. [PMID: 37229394 PMCID: PMC10203961 DOI: 10.3389/fpsyt.2023.1163347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
Objective Evidence-based personality disorder (PD) treatments are dominated by interventions targeting Borderline PD, although clinical populations characteristically include different PD features and severity. Personality functioning is a new concept intended to capture common features across PDs. This study aimed to investigate longitudinal improvement of personality functioning in a clinical sample assigned to PD treatment. Method An observational, large, longitudinal study of patients in PD treatments on specialist mental health service levels (N = 1,051). DSM-5 PDs were systematically assessed on referral. Personality functioning was repeatedly assessed (LPFS-BF-2.0), supplemented by symptom distress (anxiety: PHQ-GAD-7, depression: PHQ-9), and social/occupational activity (WSAS, work/study activity). Statistics were linear mixed models. Results Thirty per cent had personality difficulties below PD threshold. Among PDs, 31% had Borderline (BPD), 39% Avoidant (AvPD), 15% not otherwise specified, 15% other PDs, and 24% > one PD. More severe initial LPFS-BF was associated with younger age, presence of PD and increasing number of total PD criteria. Across PD conditions, LPFS-BF, PHQ-9 and GAD-7 improved significantly (overall effect size 0.9). Mean duration of PD treatment was 15 (SD 9) months. Drop-out rates were low (12%). LPFS-BF improvement-rates were higher for BPD. Younger age was moderately associated with slower PHQ-9 improvement. Work/study activity was initially poor, poorer levels associated with AvPD and younger age, and improvement was non-significant across PD conditions. AvPD was associated with slower WSAS improvement-rates. Conclusion Personality functioning improved across PD conditions. The results highlight BPD improvements. The study points to challenges concerning AvPD treatment, poor occupational activity and age-related differences.
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Affiliation(s)
- Elfrida H. Kvarstein
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mathias Frøyhaug
- Groruddalen District Psychiatric Center, Akershus University Hospital, Akershus, Norway
| | | | - Sara Carlsen
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway
| | - Andreas Ekberg
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
- Department for Adult Psychiatry, Diakonhjemmet Hospital, Oslo, Norway
| | - Jane Fjermestad-Noll
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
| | - Dag A. Ulvestad
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
| | | | - Eirik Hjermann
- Kronstad District Psychiatric Center, Haukeland University Hospital, Bergen, Norway
| | - Kenneth Lindberget
- Strømme District Psychiatric Center, Sørlandet Hospital, Kristiansand, Norway
| | - Siri Omvik
- Kronstad District Psychiatric Center, Haukeland University Hospital, Bergen, Norway
| | - Ingeborg U-M. Eikenæs
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
| | - Benjamin Hummelen
- Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Katharina T. E. Morken
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Theresa Wilberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Geir A. F. Pedersen
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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