Anne Høye

Randomised Trials in Surgery: The Burden of Evidence

A randomised controlled trial (RCT) is considered the hierarchical peak of evidence-based medicine and a general demand for any result to be evaluated by RCTs has evolved. Yet, many advances in operative surgery do not result from RCTs and many controversies remain without an RCT being conducted. A randomised comparison of laparoscopic versus open liver resection has recently been called for. Using such a trial and others as examples, we examine the limitations of randomised design in skill-dependant interventions. Surgical procedures are skill-dependant, constantly developing, irreversible and traumatising. Additionally, placebo control is usually unethical and adequate blinding difficult or impossible to accomplish. Under these circumstances, surgeon and patient participation will be problematic and the resulting data will tend to have low external validity. While some of these obstacles can be modified, others will remain. Nonrandomised, prospective cohort comparison has other weaknesses, but may add complementary data with good external validity. An alternative hierarchy of evidence is warranted in this field.

Increasing mortality in schizophrenia: Are women at particular risk? A follow-up of 1111 patients admitted during 1980–2006 in Northern Norway

A study of mortality for all patients with schizophrenia admitted to the University Hospital of North Norway during 1980-2006 was performed, with a special focus on gender differences and changes in mortality during a period of transition from hospital-based to community-based care. A total of 1111 patients with schizophrenia were included, and the cohort was linked to the Causes of Death Register of Norway. Males and females had 3.5 and 2.6 times, respectively, higher mortality than the general population. The standardized mortality ratios were higher during the last nine years than the first nine years, and for women admitted after 1992, we found evidence for an increasing difference in mortality compared to the general female population as well as an increase in absolute mortality. In the subgroup of patients who had always been admitted voluntarily, women tended to have higher mortality, and a particularly high standardized mortality rate (SMR) was found in this group of female schizophrenic patients. Our results confirmed a persisting mortality gap between patients with schizophrenia and the general population over a period of 27 years, with a tendency of increasing standardized mortality ratios over time. The SMR for total mortality of women with schizophrenia is rising and becoming just as high as for men, both for unnatural and natural causes of death.

The effect of gender in diagnosing early schizophrenia

BackgroundStudies of diagnostic practice confirm that there is a diagnostic delay in diagnosing women with schizophrenia compared to diagnosing men. The aim of the present study was to investigate the diagnostic practice of Norwegian and Russian psychiatrists when it comes to early psychosis, emphasising gender differences. We wanted to study the association between patient gender as such and diagnostic decision-making among psychiatrists.Materials and methodsPsychiatrists in Norway and the Archangels region in Russia were invited to participate in a study of diagnostic practice, and received a written case description of a patient with early psychosis symptoms that could be interpreted as schizophrenia. They were, however, not informed that 50% of them received a female case description and 50% a male case description. Apart from the patient being described as “he” or “she” the stories were identical. Effects of patient gender, clinician gender, age and main area of interest were estimated using logistic regression analysis.ResultsA total of 467 psychiatrists answered the questionnaire. We found that schizophrenia diagnosis was given significantly more often to the male case than to the female case. Our finding remained significant after adjustment for country, clinician gender, age and main area of interest, and is unlikely to be explained by known biases.ConclusionPatient gender in itself affects clinicians’ diagnostic practice regarding schizophrenia, as schizophrenia diagnosis is given significantly more often to a male case description than to a female one, the descriptions being otherwise identical.

Sex differences in mortality of admitted patients with personality disorders in North Norway - a prospective register study

BackgroundIt is well established that patients with serious mental disorders have higher mortality than the general population, yet there are few studies on mortality of both natural and unnatural causes in patients with personality disorders. The aim of this study was to investigate the mortality of in-patients with personality disorder diagnosis in a 27-year follow-up cohort in North Norway, with a special focus on gender differences.MethodBased on a hospital case register covering 1980 to 2006, 284 female and 289 male patients were included. The cohort was linked to the Norwegian Cause of Death Registry for information concerning mortality. The mortality rates were adjusted for age by applying a Poisson regression model. The relative mortality in men compared to women was tested with Cox regression with attained age as the time variable. The number of deaths to be expected among the patients if the mortality rates of the general population in Norway had prevailed was estimated and excess mortality, expressed by the standardized mortality ratio (SMR), calculated.ResultsWhen compared to the mortality in the general population, men and women with personality disorder diagnoses had 4.3 (95% CI: 3.2 - 5.9) and 2.9 (95% CI: 1.9 - 4.5) times, respectively, increased total mortality. Patients with personality disorder diagnoses have particularly high mortality for unnatural deaths; 9.7 (95% confidence interval (CI): 6.3 - 15.1) times higher for men and 17.8 (95% CI: 10.1 - 30.3) for women, respectively, and even higher for suicides – 15 (95% CI: 9–27) for men and 38 (95% CI: 20–70) for women. The mortality due to natural causes was not statistically significantly increased in women, whereas men had 2.8 (95% CI: 1.8 - 4.4) times higher mortality of natural deaths than the general population.ConclusionCompared to the general population, patients with a personality disorder have high mortality, particularly mortality from unnatural causes. The number of deaths caused by suicides is especially high for women. Men also have higher mortality of natural causes than the general population.

Gender differences in the use of psychiatric outpatient specialist services in Tromsø, Norway are dependent on age: a population-based cross-sectional survey.

BackgroundOverall, men are less likely than women to seek health care services for mental health problems, but differences between genders in higher age groups are equivocal. The aim of the current study was to investigate the association between gender and the use of psychiatric outpatient specialist services in Norway, both in a general population and in a subpopulation with self-reported anxiety and/or depression.MethodsUsing questionnaires from 12,982 participants (30–87 years) in the cross-sectional sixth Tromsø Study (2007-8) we estimated proportions reporting anxiety/depression, and proportions using psychiatric outpatient specialist services in a year. By logistic regressions we studied the association between gender and the use of psychiatric outpatient specialist services. Analyses were adjusted for age, marital status, income, education, self-reported degree of anxiety/depression, and GP visits last year. Analyses were also performed for genders separately.ResultsAnxiety/depression was reported by 21.5 % of women and 12.3 % of men in the general population. Visits to psychiatric outpatient services during one year were reported by 4.6 % of women and 3.3 % of men. The general population’s probability of a visit was significantly lower among men compared to women in ages 30–49 years (odds ratio [OR] 0.58, confidence interval [CI] 0.39–0.84, p-value [p] = 0.004), whereas men used services slightly more than women in ages 50 years and over (OR 1.36, CI 1.00–1.83, p = 0.047). Among those with anxiety/depression 13.5 % of women and 10.5 % of men visited psychiatric outpatient services in a year. We found no statistically significant gender differences in the use of services in this subgroup. Other factors associated with services use in women with anxiety/depression were higher education, more severe anxiety/depression, and GP visits the last year, whereas in men only a more severe anxiety/depression was associated with psychiatric outpatient visits. Overall, the use of services decreased with higher age.ConclusionsMost people with self-reported anxiety/depression did not visit specialist outpatient clinics. This applies in particular to men aged 30–49 years, older individuals, and individuals with lower education. Gender differences in the use of services in the general population were dependent on age, whereas in the subgroup with anxiety/depression gender differences were not confirmed.

Sex differences in mortality among patients admitted with affective disorders in North Norway: a 33-year prospective register study

Previous studies from North Norway showed significantly increased mortality in patients with schizophrenia and personality disorder. The aim of the present study was to investigate total and cause‐specific mortality in inpatients with affective disorder in a 33‐year follow‐up cohort, with a specific focus on sex differences.

First-admission schizophrenic patients northern Norway, 1980-95: Sex differences in diagnostic in practice

Several studies of first-contact incidence studies of schizophrenia suggest a significant excess of males. We wanted to investigate the clinical diagnostic process in a cohort of first-episode schizophrenic patients to search for possible implications for epidemiologic research. All first-ever admitted schizophrenic patients in the two northernmost counties in Norway (Troms and Finnmark, covering 250,000 inhabitants) with three or more admissions during the period 1980? 95 (60 females and 91 males with a total of 1326 admissions) were included in the study. Norway shifted diagnostic system from ICD-8 to ICD-9 in 1987. The impact of this shift on the diagnostic process was also studied. Our study shows that females had a significantly longer period than did males from first admission until the first diagnosis of schizophrenia (2.6 years and 3.4 admissions versus 1.6 years and 2.3 admissions). Thirtythree per cent of the females received the diagnosis at first admission, and 47% of the males. Females received the diagnosis of personality disorder significantly more often than males before the first diagnosis of schizophrenia. The schizophrenia diagnosis remained unchanged in 79% of the cases; stability was even higher (90 %) for those diagnosed at first admission. Our conclusion is that diagnostic practice in the course of schizophrenia showed a significant sex difference, both in diagnostic distribution and in latency period before first schizophrenia diagnosis. The total latency period decreased after the introduction of new guidelines in 1987, but the sex difference in latency period persisted.Several studies of first-contact incidence studies of schizophrenia suggest a significant excess of males. We wanted to investigate the clinical diagnostic process in a cohort of first-episode schizophrenic patients to search for possible implications for epidemiologic research. All first-ever admitted schizophrenic patients in the two northernmost counties in Norway (Troms and Finnmark, covering 250,000 inhabitants) with three or more admissions during the period 1980? 95 (60 females and 91 males with a total of 1326 admissions) were included in the study. Norway shifted diagnostic system from ICD-8 to ICD-9 in 1987. The impact of this shift on the diagnostic process was also studied. Our study shows that females had a significantly longer period than did males from first admission until the first diagnosis of schizophrenia (2.6 years and 3.4 admissions versus 1.6 years and 2.3 admissions). Thirtythree per cent of the females received the diagnosis at first admission, and 47% of the males. Females receiv...

Time for new thinking on psychiatric diagnoses.

It has been noteworthy that the American psychiatrist Allen Frances, who led the work on DSM-IV, has been sharply critical of DSM-5 (1). He is concerned about a narrowing of the concept of normality, false epidemics driven by the psychopharmaceutical industry, the American Psychiatric Association’s dependence on revenues from DSM-5 and the widespread consequences of the revision for individual patients – in that the spotlight will be diverted away from the seriously ill, with regard to both treatment and economics (2).

Når jusen kommer i veien for kommunikasjonen

Godt fagspråk og presise begreper er viktig og nødvendig for å kunne belyse og ivareta etiske dilemmaer i psykisk helsevern, ettersom språket former måten vi tenker på, men også hva vi prioriterer (1). Teknologisk utvikling, økt brukermedvirkning og rett til innsyn har sannsynligvis hatt flere positive effekter på pasientjournalen, som mindre bruk av fremmedgjørende språk og mer respektfull omtale av pasienten. Krav til juridisk dokumentasjon gir etter alt å dømme økt rettssikkerhet, men dette innebærer ikke nødvendigvis god behandling eller god kommunikasjon. Kan behovet for å ha juridisk ryggdekning faktisk fjerne oppmerksomheten fra pasienten?

Total and cause-specific standardized mortality ratios in patients with schizophrenia and/or substance use disorder

Individuals with schizophrenia or substance use disorder have a substantially increased mortality compared to the general population. Despite a high and probably increasing prevalence of comorbid substance use disorder in people with schizophrenia, the mortality in the comorbid group has been less studied and with contrasting results. We performed a nationwide open cohort study from 2009 to 2015, including all Norwegians aged 20–79 with schizophrenia and/or substance use disorder registered in any specialized health care setting in Norway, a total of 125,744 individuals. There were 12,318 deaths in the cohort, and total, sex-, age- and cause-specific standardized mortality ratios (SMRs) were calculated, comparing the number of deaths in patients with schizophrenia, schizophrenia only, substance use disorder only or a co-occurring diagnosis of schizophrenia and substance use disorder to the number expected if the patients had the age-, sex- and calendar-year specific death rates of the general population. The SMRs were 4.9 (95% CI 4.7–5.1) for all schizophrenia patients, 4.4 (95% CI 4.2–4.6) in patients with schizophrenia without substance use disorder, 6.6 (95% CI 6.5–6.8) in patients with substance use disorder only, and 7.4 (95% CI 7.0–8.2) in patients with both schizophrenia and substance use disorder. The SMRs were elevated in both genders, in all age groups and for all considered causes of death, and most so in the youngest. Approximately 27% of the excess mortality in all patients with schizophrenia was due to the raised mortality in the subgroup with comorbid SUD. The increased mortality in patients with schizophrenia and/or substance use disorder corresponded to more than 10,000 premature deaths, which constituted 84% of all deaths in the cohort. The persistent mortality gap highlights the importance of securing systematic screening and proper access to somatic health care, and a more effective prevention of premature death from external causes in this group.