Björn Axel Johansson

Overrepresentation of unaccompanied refugee minors in inpatient psychiatric care

BackgroundUnaccompanied refugee minors (URMs) have high levels of psychiatric symptoms, and concerns for their access to mental health services have been raised. From the mid-2000s, an increasing number of asylum-seeking URMs, mainly adolescent boys from Afghanistan, have been referred to the Child & Adolescent Psychiatry emergency unit in Malmö, Sweden. The aim of the study was to compare inpatient psychiatric care between URMs and non-URMs.FindingsAll admissions in 2011 at the emergency unit were identified and divided into URMs (n = 56) and non-URMs (n = 205). On the basis of unique patients’ first treatment occasion, a group level analysis was performed on gender, age, treatment duration, additional treatment occasions/patient, involuntary care, involuntary care by gender, and ICD-10 principal diagnosis. To retrieve further sample characteristics, a questionnaire was administered to the physicians responsible for admitting patients in 2011.More URMs than non-URMs exhibited self-harm or suicidal behaviour in conjunction with referral. 86% of URMs were admitted with symptoms relating to stress in the asylum process. In the catchment area, 3.40% of the URM population received inpatient care and 0.67% inpatient involuntary care, compared to 0.26% and 0.02% respectively of the non-URM population, both comparisons p < 0.001. There were more boys in the URM group (95%) compared to the non-URM group (29%). A difference in use of involuntary care disappeared after adjusting for gender. No differences were found in diagnoses except for neurotic disorders (F40-48), which were more common in the URM group.ConclusionFrom an epidemiological perspective, URMs were overrepresented in inpatient psychiatric care.

Efficacy of maintenance treatment with methadone for opioid dependence: A meta-analytical study

The two aims of this study were to analyse the impact of methadone on outcome, and to confirm the results from previous meta-analyses by using a different methodology. The literature on randomized controlled trials (RCT) of methadone as maintenance treatment for opioid dependence was systematically reviewed. Eight studies involving 1511 patients were included. Both dichotomous and continuous variables were transformed into the standardized effect size (d). Homogeneity was analysed. A random effect model was used in all calculations. The combined analyses for retention, abuse and criminality were all significant: d=0.90, d=0.61, and d=0.35, respectively. A test of heterogeneity was significant for all three outcomes: P<0.01 for all comparisons. The type of study design was a significant moderator in five of nine comparisons: for retention in all three comparisons, concerning abuse in gradual detoxification vs. untreated controls and concerning criminality in placebo vs. untreated controls. In these sub-groups, three of six studies were homogeneous. In one study, methadone maintenance treatment reduced abuse of illegal opioids in prisoners. We conclude that methadone maintenance treatment in opioid dependence shows positive effects on retention, opioid abuse and criminality compared with non-active controlled conditions. Type of study design could explain some of the heterogeneity found. A different meta-analytical approach made it possible to confirm effects of methadone on retention and opioid abuse from previous studies and document effect on criminality.

Evaluation of Interactive Voice Response (IVR) and postal survey in follow-up of children and adolescents discharged from psychiatric outpatient treatment: a randomized controlled trial.

Systematic evaluation of child and adolescent psychiatric outpatient treatment is important but time-consuming. The aim of this paper was to study whether Interactive Voice Response (IVR) is a more effective method than a questionnaire sent by post when following up outpatient treatment in child and adolescent psychiatry. Eighty patients were recruited from a child and adolescent psychiatric outpatient unit in Sweden. One parent of each of the patients was randomized to complete the BCFPI follow-up form, using either IVR (n = 40) or postal survey (n = 40) one month after discharge. The response rate for complete answers was 65% in the IVR group and 38% in the postal survey group (p = 0.014). There was less need for reminders in the IVR group (p = 0.000). IVR is a promising and cost-effective method for evaluating evidence-based treatment in child and adolescent psychiatric care.

Interactive voice response - an automated follow-up technique for adolescents discharged from acute psychiatric inpatient care: a randomised controlled trial

Follow-up methods must be easy for young people to handle. We examine Interactive Voice Response (IVR) as a method for collecting self-reported data. Sixty inpatients were recruited from a child and adolescent psychiatric emergency unit in Malmö, Sweden and called every second (N = 30) or every fourth (N = 30) day from discharge until first visit in outpatient care. A pre-recorded voice asked them to evaluate their current mood using their mobile phones. Average response rate was 91%, and 71% had a 100% response rate. Gender, age and length of inpatient treatment did not affect response rate, nor did randomisation. Boys estimated their current mood on average as 3.52 units higher than girls, CI = (2.65, 4.48). Automated IVR is a feasible method of collecting follow-up data among adolescents discharged from a psychiatric emergency unit.

Drug-induced acute psychosis in an adolescent first-time user of 4-HO-MET

4-HO-MET (4-hydroxy-N-methyl-ethyltryptamine), also known as metocin, is a synthetic hallucinogenic psychedelic drug. It resembles psilocin, the hallucinogenic component found in ‘‘magic mushrooms’’ [1]. In many countries including Sweden [2], 4-HO-MET has not yet been classified as an illicit substance, and can be ordered on the internet as a so-called ‘‘legal high’’. We describe a case where an adolescent presenting with apathy and mutism was later diagnosed with a drug-induced acute psychosis after inhalation of 4-HO-MET. ‘‘B’’, a 17-year-old boy living with his parents, was admitted to the acute medical department after being found by police, wandering along a motorway in his underwear. He expressed to the policemen that ‘‘I will not talk to anyone’’ and then remained mute and apathetic. ‘‘B’’ had been well psychiatrically and somatically until this acute presentation. He had been abusing cannabis for 5 months, contributing to unpermitted time off school, but did not fulfil criteria for a dependence syndrome and maintained acceptable school grades and good social functioning. He used alcohol infrequently, and reported using cocaine once only, 2 days before admission. Cocaine and cannabis are well-established psychosis precipitants, but while prior drug use may have increased the patient’s vulnerability to psychosis, there was no suggestion that ‘‘B’’ had not been himself 1 day prior to admission, suggesting a very sudden onset of severe psychiatric illness. Apart from a grandfather with depression during middle age, there was no family history of psychiatric or neurological disease. ‘‘B’’ had no previous contact with psychiatric services. On admission, blood tests and a CT head scan were conducted, showing no significant abnormalities. A bedside urinary toxicology screen was positive for THC and cocaine, but no further analysis was done. ‘‘B’’ received supportive care. On the evening of admission, after being apathetic all day, he suddenly took his own discharge. He was soon found outside the hospital, having jumped 3–4 m from a roof. A full-body trauma CT showed a fractured right radius and a small right-sided pneumothorax, but no intracranial pathology. A neurological examination, including an EEG, showed no abnormalities. ‘‘B’’ was detained under the Swedish mental health act due to severe agitation and presumed acute suicidality and was moved to the psychiatric intensive care unit. He soon again became apathetic. Due to ongoing need for medical supportive treatment, ‘‘B’’ was discharged back to an acute medical care unit. After 2 days with supportive care, his medical condition stabilised. At this stage a further psychiatric assessment was made. The patient was mute and withdrawn during the J. Täljemark (&) Department of Child and Adolescent Psychiatry, Clinical Sciences, Faculty of Medicine, Lund University, Sofiavägen 2D, 222 41 Lund, Sweden e-mail: jakob.taljemark@med.lu.se

Atypical course in severe catatonic schizophrenia in a cannabis-dependent male adolescent: a case report

IntroductionAdolescents with psychoses usually have full recovery from their first psychotic episode, but the first relapse often arises within 2 years of the first episode. Cannabis-related psychoses are difficult to distinguish from schizophrenic psychoses. Here, we describe a particularly severe clinical case, with a first psychotic episode occurring after heavy cannabis smoking, an atypically long symptom-free duration, and a subsequent non-substance-related episode.Case presentationA 17-year-old male adolescent of Middle-East origin presented with delusions and hallucinations after extensive cannabis smoking. His first psychotic episode, with paranoid delusions and hallucinations, progressed into severe catatonic symptoms. His symptoms were treated with electroconvulsive therapy and risperidone and he was transferred to a residential substance abuse treatment center. He remained drug-free and non-psychotic for 3.5 years. Given the temporal association with extensive cannabis use, and his full remission of symptoms lasting several years, a cannabis-induced psychosis—though atypically extended—could be suspected. However, after 3.5 years without psychiatric care, and in a drug-free state, our patient again presented with positive psychotic symptoms, possibly induced by a period of severe psychosocial stress.ConclusionWe here discuss whether a primary schizophrenic episode possibly induced by cannabis can increase the risk of subsequent non-drug-related schizophrenic episodes.

Effects of gradual benzodiazepine taper during a fixed 10-day schedule: A pilot study

The aim of this pilot study was to investigate clinical symptoms during a 10-day benzodiazepine (BZD) taper procedure. Twenty-one BZD-dependent patients attended a fixed 10-day inpatient tapering program. The patients developed mild to moderate withdrawal symptoms. Concomitant codeine dependence and initially high BZD serum levels were associated with a worse prognosis.

Development of a smartphone application for inpatient assessment and post discharge follow-up in child and adolescent psychiatry: a research protocol (Preprint)

Background New methods are needed for collecting data of in- and outpatients and for improving outpatient compliance after discharge. Mobile technologies, such as smartphone apps, have shown promising results, (eg, helping unwell people by offering support and resources). Screening for the condition, including comorbidities, is a vital part of psychiatric care. Comorbid conditions, especially in emergency evaluation, are often missed, leading to inaccurate diagnosis and treatment. One way of improving diagnostic accuracy is to use a structured diagnostic process. Digitalized screening and follow-up have the advantage of making administration and scoring easier and less time consuming, thereby increasing response rate. To address these problems, we decided to create a smartphone app called The Blue App. The Blue App was developed through 6 steps, described in the manuscript. Objective The aim of this paper is to describe (1) the development of The Blue App and (2) 2 planned research studies to evaluate the app. Methods Two studies will be performed. Study 1 has a descriptive design, mapping comorbidities before and after the introduction of The Blue App. Study 2 has a randomized controlled design, measuring compliance with outpatient treatments as well as depressive symptoms, rated as changes in Montgomery-Åsberg Depression Scale scores during a 1-year follow-up. Results We have described app development. Data collection for Study 1 started in autumn 2017. Study 2 will start in autumn 2018. We expect to have enrolled the 150 patients in Study 2 by December 2019. Final results will be published in a scientific journal. Conclusions A technically advanced and easy-to-use Web-based mobile phone app corresponding to the unit’s needs was developed, and 2 studies are planned to evaluate its usefulness. International Registered Report Identifier (IRRID) RR1-10.2196/10121