Transdiagnostic Associations between Anger Hostility and Chemokine Interferon-gamma Inducible Protein 10

Objective

Many psychiatric disorders are linked to low grade systemic inflammation as measured by systemic cytokine levels. Exploration of cytokines and immune activity and their role in psychiatric symptoms may inform pathobiology and treatment opportunities. The aim of this study is to explore if there are associations between cytokines and psychiatric symptom clusters. Comparison between patients regularly using and those not using psychotropic medication is also conducted.

Methods

This was a cross sectional naturalistic study with 132 participants from a general open inpatient psychiatric ward at the Nordland Hospital Trust, Norway. Serum levels of 28 different cytokines were assessed. Psychiatric symptoms the last week were assessed by a self-rating scale (Symptom check list, SCL-90-R) and grouped in defined clusters. Multiple linear regression model was used for statistical analyses of associations between levels of cytokines and symptoms, adjusting for possible confounding factors.

Results

We found a positive association (p = 0.009) between the chemokine interferon-gamma inducible protein 10 (CXCL 10; IP-10) and the anger hostility cluster. No associations were found between the other symptom clusters and cytokines. IP-10 and the anger hostility cluster were positively associated (p = 0.002) in the subgroup of patients using psychotropic medication, not in the subgroup not using psychotropic medication.

Conclusion

Our analyses revealed a significant positive association between the symptom cluster anger hostility in SCL-90-R and the chemokine IP-10 in the subgroup of patients using psychotropic medications.

Cytokines in hepatitis C-infected patients with or without opioid maintenance therapy

OBJECTIVE

Both chronic hepatitis C virus (HCV) infection and opioids cause altered blood levels of cytokines. Previous studies have investigated levels of selected groups of cytokines in patients on opioid maintenance treatment. Little is known about the levels of multiple cytokines in patients with chronic HCV infection on opioid maintenance treatment. Our aim was to investigate the cytokine profile in patients with active HCV infection with and without opioid maintenance treatment.

METHODS

We conducted a cross-sectional study in an out-patients population included upon referral for antiviral hepatitis C infection treatment. The level of 27 cytokines was measured in serum using multiplex technology. Patients were interviewed using a modified version of the European addiction severity index. Data pertaining to weight, height, current medication, smoking habits, allergies, previous medical history and ongoing withdrawal symptoms were collected. Non-parametric testing was used to investigate differences in levels of cytokines between the two groups. A 3-model hierarchical regression analysis was used to analyse associations between cytokines and confounding variables.

RESULTS

Out of 120 included patients, 53 were on opioid maintenance treatment. Median duration of opioid treatment was 68.4 months. There were no demographical differences between the two groups other than age. IL-1β was lower and eotaxin-1 higher in the group on opioid maintenance treatment than in the non-opioid group. No other inter-group differences in the remaining cytokine levels were found.

CONCLUSION

In HCV infection patients, the impact of chronic opioid administration on peripheral circulating cytokine level is minimal.

Association between brain-derived neurotropic factor (BDNF), high-sensitivity C-reactive protein (hs-CRP) and psychiatric symptoms in medicated and unmedicated patients

BACKGROUND

There is evidence that brain-derived neurotropic factor (BDNF) plays a protective role in the brain. Peripheral levels of BDNF correlate with its concentration in the brain. Previous studies have revealed lower serum BDNF levels in patients with mental illnesses. In most studies serum BDNF correlates negatively with psychiatric disorders and disease severity. Most studies in this field are on psychiatric diagnosis and personality traits. The aim of our study is to explore associations between general psychiatric symptoms, independent of diagnostic groups, and serum BDNF as well as the inflammatory biomarker high-sensitive CRP (hs-CRP). Comparison between the group regularly using psychotropic medication and those not using psychotropic medication is conducted.

METHODS

The study is a cross sectional study with 132 participants from a general open inpatient psychiatric ward at the Nordland Hospital Trust, Bodoe, Norway. Participants were assessed on serum levels of BDNF and hs-CRP. Psychiatric symptoms were assessed by a self-rating scale (Symptom check list, SCL-90- R). Multiple linear regression model was used for statistical analyses of associations between levels of BDNF, hs-CRP and symptoms.

RESULTS

We found a positive association (p < 0.05), for most SCL-90 symptom clusters with BDNF in the psychotropic medication-free group. No associations were found in the group of patients using psychotropic medication, except one, the paranoid ideation cluster (p 0.022). No associations were found between hs-CRP and symptom clusters.

CONCLUSION

We found no relation between symptom clusters and the inflammatory biomarker hs-CRP. Serum BDNF levels were positively associated with intensity of psychiatric symptoms in the group of patients not using psychotropic medication. Our findings are in conflict with several previous studies reporting increased hs-CRP as well as decreased rather than increased BDNF in mental suffering. Patients on psychotropic medication may not require the same upregulation because the medication is modulating the underlying biological pathology.

Concurrent validity of the Health of the Nation Outcome Scales compared with a patient-derived measure, the Symptom Checklist-90-Revised in out-patient clinics

The psychometric properties of the Health of the Nation Outcome Scales (HoNOS) have been questioned. The present study examined the concurrent validity of the HoNOS against a patient-derived measure (the Symptom Checklist-90-R (SCL-90-R)) in out-patients. This relationship has previously only been investigated in in-patients. The study considered newly admitted patients, and only those with a complete data set were analyzed (N=118). Internal consistency (Cronbach's alpha) and effect sizes were calculated on pre- and post-treatment data. Concurrent validity was assessed using correlation (Spearman's rho) as well as agreement (kappa) on reliable and clinically significant change (RCSC). The internal consistencies associated with the SCL-90-R were satisfactory, a property shared only by the HoNOS sum score. The pre- to post-treatment changes in both instruments corresponded to medium to large effect sizes and were comparable in size. However, the correlations between the two were low, as was their agreement. This suggests that the HoNOS and the SCL-90-R measure somewhat different phenomena. The findings shed doubt on whether the patient-derived measures should be regarded as the "gold standard". The instruments seem to complement each other.

Acknowledging illness and treatment needs in first-time admitted psychiatric patients

PURPOSE

Help-seeking and service utilization depends on the patients' interpretation of their illness and treatment needs. Worry, denial of illness, need for treatment and need for hospitalization in first-time admitted patients was studied.

SUBJECTS

New patients in two mental hospitals were consecutively recruited. Three hundred and thirty-four satisfied the inclusion criteria and 251 gave informed consent. One hundred and ninety-six had complete datasets (56% of those eligible).

METHODS

Demography was recorded with the Minimal Basic Dataset by Ruud et al. (1993). Experiences of hospitalisation were measured with the Patient's Experience of Hospitalisation Questionnaire by Carskey et al. (1992). MINI was used for diagnosing and SCL-90-R by Derogatis (1997) for subjective symptoms. Standard multiple regressions were performed with the PEH subscales (Denial, Worry, Need for treatment and Need for hospitalisation) as dependents and demography, diagnosis and SCL-90-R subscales as explanatory variables.

RESULTS

(a) Psychoticism and the diagnosis of schizophrenia were associated with little worrying, denial of illness, of treatment needs and of need for hospitalisation. (b) Anxiety and affective disorders were related to worries, acknowledgement of illness, need for treatment and for hospitalisation.

CONCLUSIONS

In contrast to patients with mainly anxiety and affective disorders, psychotic patient tended to deny illness-related worries, that they had an illness and that they needed treatment and hospitalisation. An affective disorder together with suicidal thoughts (not attempts) was a strong drive towards hospital admission.

The Barents project in psychiatry: a systematic comparative mental health services study between Northern Norway and Archangelsk County

BACKGROUND

There is virtually no readily accessible systematically recorded evidence on how the organization of mental health services in Europe's largest country, Russia, may differ from other national systems. This study systematically compares the mental health services in Archangelsk County and Northern Norway using instruments developed for trans-cultural use.

METHODS

The European Service Mapping Schedule (ESMS) and The International Classification of Mental Health Care (ICMHC) were used to describe: (i) resources, organisation and utilisation of the services; (ii) their decentralisation and differentiation; (iii) some interventions delivered by the mental health service units (n = 132) in both regions.

RESULTS

The Norwegian services are more decentralised and differentiated, while the Russian services are largely hospital-based. The GPs are of considerable importance to the Norwegian services, functioning as gatekeepers-both centrally and peripherally. In contrast, the GP model is still poorly established in Archangelsk County. There are more units for long term stay in the Russian services than in Norway. General health care and taking over daily living activities are more organised in Archangelsk County, while psychopharmacological treatment and psychosocial interventions are more developed in Norway.

CONCLUSION

The study has revealed several differences in resources, organisation and utilisation of the mental health services between the two compared areas. The very large variations indicate that underlying local patterns of service delivering must be further investigated and taken into account in the planning of the services development.

A comparative study of diagnostic practice in psychiatry in Northern Norway and Northwest Russia

BACKGROUND

The co-operation between psychiatrists in Norway and Russia is increasing. The object of this study was to find out whether there were differences in diagnostic practice of psychiatrists in both countries, to look at the nature of the differences and to examine whether these differences affected diagnostic quality.

METHOD

Thirty medical doctors working at psychiatric hospitals in both countries diagnosed 12 clinical case vignettes selected from a wide spectre of psychiatric disorders.

RESULTS

The Russian clinicians used a larger range of diagnoses than the Norwegians. The Russians tended to diagnose schizophrenia and schizophrenia-like disorders in cases that presented psychotic syndromes, and somatoform disorders in cases that presented agoraphobia. The Norwegians tended to evaluate affective aspects in preference to psychotic symptoms in the case of schizoaffective disorder and overestimate the degree of depression. In general, the Russians had lower total score of correct answers than the Norwegians.

CONCLUSION

In spite of the limitations due to minor differences in the data collection phase in the two countries, the study clearly demonstrates differences in diagnostic practice between the countries.

Predictors for readmission risk of new patients: the Nordic Comparative Study on Sectorized Psychiatry

OBJECTIVE

Predictors for readmission risk were investigated in this study, which forms part of the Nordic Comparative Study on Sectorized Psychiatry.

METHOD

Included were a total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted to in-patient stay during a period of 1 year to seven psychiatric hospitals in four Nordic countries.

RESULTS

Multivariate survival analyses showed that younger age predicted increased readmission risk. Stratifying on gender, diagnostic group and sector revealed a general pattern concerning age which was the only consistent main effect. Living alone and unemployed increased readmission risk in the non-psychosis group, while receipt of aftercare decreased readmission risk in the psychosis group. A curvilinear relationship was found between availability of psychiatric resources and readmission risk: an intermediate amount of resources was associated with increased risk.

CONCLUSION

Our findings support a hypothesis that readmission risk is multifactorially determined and that interactions have to be considered.

The Nordic Comparative Study on Sectorized Psychiatry--length of in-patient stay

OBJECTIVE

Length of stay (LOS) of 'first' in-patient episodes was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry.

METHOD

A total of 837 consecutive 'new' patients (not in contact with the psychiatric services for at least 18 months) admitted as in-patients during a period of 1 year to seven psychiatric hospitals in four Nordic countries were included.

RESULTS

Survival analyses showed considerable differences in LOS between the hospitals, and the factors analysed in this study could not explain this variance. Older age, being female, having no children at home, psychosis, planned admission and out-patient contacts were all associated with increased LOS.

CONCLUSION

Stratifying on gender, diagnostic group and hospital revealed a general pattern of associations except for age.

The Nordic comparative study on sectorized psychiatry: rates of compulsory care and use of compulsory admissions during a 1-year follow-up

BACKGROUND

As part of a Nordic comparative study on contact rates of new patients and use of services in seven catchment areas, rates of compulsory care and use of compulsory admissions were explored and analyzed. The total cohort comprised 2834 patients.

RESULTS

A total of 219 patients, 7.7%, were subject to compulsory care during the follow-up. The proportion of compulsorily admitted patients of all admitted patients ranged from 6% to 58% in the seven psychiatric services, and the rate of compulsory care per 1,000 inhabitants, from 0.14 to 0.99. The diagnostic subgroup most commonly committed to inpatient care was functional psychosis, comprising around 50% of all compulsory admissions. The strongest predictor of being compulsorily admitted was the specific psychiatric service the patient was in contact with, followed by having a psychosis diagnosis. High consumption of care was also associated with compulsory care, while social variables played only a minor role in predicting compulsory care.

CONCLUSIONS

There was a great variation in rates of compulsory care. No consistent rural-urban pattern in rates of commitment was found. It is discussed whether a formal referral procedure to the psychiatric service is associated with higher rates of compulsory care.

The Nordic comparative study on sectorised psychiatry: repeated emergency admissions to inpatient care during a 1-year follow-up

The emergency admissions to hospital care in six psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorised psychiatry. One year treated incidence cohorts were used, with the total cohort comprising 2,454 patients. Of the 803 patients who were admitted to inpatient care during a 1-year follow-up, 82% had at least one emergency admission and 23% repeated emergency admissions. The definition for the repeated emergency admissions was at least two admissions during the follow-up. The mean length of stay in emergency inpatient care per treatment episode for this patient subgroup was 28 days. Their emergency inpatient episodes constituted 30% of all inpatient days during the follow-up. However, the variations between the services and diagnostic subgroups were large. The results of a logistic regression analysis indicated that the following variables predicted repeated emergency admissions: inpatient care at index contact, emergency outpatient contacts or no planned hospital admissions during the follow-up, psychiatric service, age under 45 years, and a diagnosis of psychosis, personality disorder or dependency. The repeated emergency admissions were related to the existence of a special service unit for abusers but not to the rates of outpatient staff or acute beds in the services, to geographical distances, referral practice or existence of emergency services.

The Nordic Comparative Study on Sectorized Psychiatry: continuity of care related to characteristics of the psychiatric services and the patients

The problem addressed in this paper is how continuity of care is related to characteristics of psychiatric services, previous events in a patient's pattern of care and patient characteristics. The present paper is a part of a Nordic Comparative Study on Sectorized Psychiatry in seven catchment areas in four Nordic countries. One-year-treated-incidence cohorts were used. Each patient was followed for 1 year after the first contact with the psychiatric service. Continuity of care was measured by the time from discharge from hospital to the first subsequent day-patient or outpatient contact. Notable findings were large differences in the continuity of care in the seven services, high proportions of discharges without any aftercare contacts and long time lags between discharges and aftercare contacts in most of the catchment areas. A Cox regression analysis revealed that aftercare following hospitalisation seems to be more probable if the outpatient services are located geographically close to the patients, if the hospitalisation lasted between 2 and 4 weeks, if there was a community care contact shortly before the hospital admission and if the patient is not retired and not divorced. Staff resources were not related to continuity of care.

The Nordic Comparative Study on Sectorized Psychiatry: patients who use only psychiatric in-patient care in comprehensive community-based services--a 1-year follow-up study

In the present paper a sample of patients using psychiatric in-patient care only is characterized and analysed with regard to characteristics of the psychiatric services. This paper forms part of the Nordic Comparative Study on Sectorized Psychiatry, designed to investigate contact rates and use of psychiatric care by new patients in 7 catchment areas in 4 Nordic countries during a 1-year follow-up. One-year treated incidence cohorts were used. The logistic regression analysis revealed that the variable 'psychiatric service' was one of the statistically significant determinants of using only in-patient care during the follow-up. The diagnostic groups with the highest probability of using only in-patient care were dependencies and functional psychoses. The following factors were associated with a high risk of using only in-patient care: older age, being referred by another psychiatrist, having received previous psychiatric in-patient care, male sex, being retired, and not living with one's parents or a partner. Patients who used only in-patient care had fewer admissions and days in in-patient care than others during the 1-year follow-up period. Lack of 24-hour emergency services in out-patient care correlated positively with the use of only in-patient care.

The Nordic Comparative Study on Sectorized Psychiatry: contact rates and use of services for patients with a functional psychosis

As part of a Nordic comparative study on contact rates of new patients and use of services in seven catchment areas, contact rates and use of services for patients with a functional psychosis during a 1-year follow-up period were investigated. The highest contact rates were found in two large city catchment areas in Stockholm and Copenhagen. Compared to other patients in the cohorts, patients with a functional psychosis were more often found to be unemployed and living alone. They also showed more extensive service use in terms of both voluntary and compulsory admissions, and in the use of day-care facilities. In addition, they were more often multiple users of in-patient care (> or =3 admissions during the follow-up period). Large differences in service use among patients with a functional psychosis were discovered between the catchment areas, with the most extensive use of voluntary in-patient care and day-care facilities in Frederiksberg. Patients most frequently had compulsory admissions in Bodö and least frequently had them in Frederiksberg. Out-patient services were most frequently used in Stockholm. Correlations between levels of resources and use of services for patients with a functional psychosis were in general low, except for the rates of short-term beds, which showed a strong and significant correlation with the number of days in voluntary in-patient care (r=0.89).

Factors associated with referral to psychiatric care by general practitioners compared with self-referrals

BACKGROUND

The gatekeeper function of the general practitioner (GP) in the pathway to specialized psychiatric services was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. The question addressed in this paper is whether different sociodemographic and clinical factors as well as factors related to service utilization are associated with referral from the GP compared with self-referrals (including referrals from relatives).

METHODS

The study comprised a total of 1413 consecutive patients, admitted during 1 year to five psychiatric centres in four Nordic countries. The centres included in this study were those that accepted non-medical referrals. Only new patients (not in contact with the service for at least 18 months) were included.

RESULTS

Increasing age was the only sociodemographic factor significantly associated with referral by the GP. The clinical factors (psychosis, being totally new to psychiatry and being in need of in-patient treatment) and some treatment characteristics (planned out-patient treatment and involuntary in-patient treatment), were all significantly associated with referral by the GP. Some indication was found that self-referred patients have shorter episodes of care.

CONCLUSIONS

The findings were remarkably stable across the different centres indicating a general pattern. This study extends previous work on the role of GPs in the pathway to specialized psychiatric services and indicates that the GP has an important gatekeeper function for the most disabled patients.

The Nordic Comparative Study on Sectorized Psychiatry. Part V. Contact rates, contact patterns and care level at index contact

As part of a Nordic comparative study on sectorized psychiatry in seven Nordic catchment areas, a prospective investigation of contact rates of new patients and pathways to the psychiatric services was performed. The results showed that there was more than a twofold difference between the services in the total contact rates. Regarding diagnostic groups, contact rates for neurosis were predominant in three of the services, while adjustment disorders, dependencies and personality disorders were predominant in other the services. The contact rate of functional psychosis, as well as the ratio of psychotic patients to the total contact rate were highest in two catchment areas serving inner parts of big cities. The most common way of getting into contact with the services was by self-referral, 39.4% of total referrals, followed by primary care referrals, although there were large differences between the services. Psychotic patients made contact with the services to a significantly less extent by self-referral. The majority of patients were treated in outpatient care at entry to the services, with a large variation between the services. It was also found that inpatient care at index contact was predicted by clinical characteristics-a diagnosis of psychosis and a history of former inpatient care-as well as by social characteristics-male, widowed or divorced, sick pension/old age pension.

The Nordic comparative study on sectorized psychiatry. Utilization of psychiatric hospital care related to amount and allocation of resources to psychiatric services

As a part of a Nordic comparative study on sectorized psychiatry, utilization of inpatient care was related to resources and dynamic qualities of psychiatric services in seven catchment areas in four Nordic countries. One-year treated incidence cohorts were used. Each patient was followed for 1 year after first contact with the psychiatric service. Data were collected concerning number of beds and staff, number of long-term patients and turnover rate of patients in inpatient care. Findings gave some support to the earlier reports that the utilization of inpatient care is determined by the supply of available beds. Highly staffed community services did not themselves reduce the use of inpatient services, but availability of day care services seemed to reduce utilization of inpatient care among psychotic patients.

The Nordic Comparative Study on Sectorized Psychiatry. III. Accessibility of psychiatric services, degree of urbanization and treated incidence

As part of a Nordic Comparative Study on Sectorized Psychiatry, accessibility of psychiatric services and degree of urbanization in seven catchment areas were related to treated incidence. One-year treated incidence cohorts were used. Accessibility was assessed according to referral practice, existence of a round the clock emergency service and geographical location of the services. Accessibility was surprisingly weakly associated with treated incidence. Easy access to the psychiatric services was not related to a high treated incidence of less severe psychiatric problems at the expense of patients suffering from severe illness. Geographical distance to the services did not predict the demand for services. A positive correlation was found between the degree of urbanization and treated incidence of psychoses but not of other diagnostic groups.

The Nordic comparative study on sectorized psychiatry. Part IV. The influence of patient social characteristics on treated incidence

As part of a Nordic comparative study on sectorized psychiatry, sociodemographic characteristics (gender, age and marital status) were studied in relation to treated incidence in eight diagnostic subgroups. One-year incidence cohorts in seven sectorized psychiatric services were used. Women with a neurosis diagnosis had a significantly higher relative probability of contact with all services. Men with a dependence diagnosis had a significantly higher relative probability of contact with four of the seven services. Older people had a significantly higher relative risk for affective psychosis in six of the seven centres, and younger individuals had a significantly higher relative risk for personality disorders in six of the seven centres. Unmarried people showed a higher relative risk for functional psychosis and personality disorders in five of the seven services.

The Nordic comparative study on sectorized psychiatry. II. Resources of the psychiatric services and treated incidence

As a part of a Nordic comparative study on sectorized psychiatry, treated incidence was related to the resources and dynamic qualities of psychiatric services in 7 catchment areas. One-year treated incidence cohorts were used. Data was collected concerning number of beds and staff, number of long-term patients and turnover rate of patients in the services and availability of specialized services. A positive correlation was found between rates of outpatient staff and treated incidence. No statistically significant correlation was found between the dynamic qualities of the services and treated incidence. Treated incidence of dependence was the highest in a center that had a special service unit for abusers. Special services for young and old people were not clearly reflected in treated incidence in respective patient groups.

The Nordic comparative study on sectorized psychiatry. I. Treated point prevalence and characteristics of the psychiatric services

Comparative studies relating characteristics of psychiatric services to rates of treated prevalence are scarce. As part of a Nordic comparative study on sectorized psychiatry, a point-prevalence study was performed in 5 sectorized psychiatric services with comprehensive service facilities for a defined population under responsibility. The rates of treated prevalence on a census day were related to a number of characteristics of the respective services and to accessibility of care. The results showed a great variation in one-day point prevalence in the 5 services, with almost fourfold differences. There were also marked differences in the diagnostic distribution of the cohorts. A positive correlation was found between number of beds and point prevalence, measured both as total point prevalence and impatient prevalence. The rates of beds and psychiatrists were most strongly related to the prevalence of patients with organic disorders and functional psychoses. A closed referral system was associated with a lower level of treated prevalence.