Eija Stengård

Gender and short-term outcome in schizophrenia

227 first-contact schizophrenic patients (DSM-III) were followed-up for 2 years. The psychiatric teams responsible for the treatment of the patients conducted a detailed, standardized interview with the patients at entry and during the follow-up. Men showed a poorer premorbid heterosexual development and they also tended to be more withdrawn than women. Following the onset of the illness, men still failed to establish satisfactory heterosexual relationships, they suffered more often from negative symptoms, and they displayed poorer working capacity and functional ability than women. At the beginning of the follow-up men had a more pessimistic view of the development of their life situation over the next 2 years, a prediction which turned out to be correct. The predictions made by the psychiatric teams were very similar. In their plans for treatment the psychiatric teams recommended primarily psychotherapeutic methods for female patients--and women actually went to psychotherapy more often than men--whereas it was felt that the rehabilitation of men should concentrate on working capacity and basic social skills. The poorer psychosocial outcome of men seems to be due to their poor premorbid development--specifically heterosexual development--and negative symptoms. Together, these factors form a particularly harmful combination from the point of view of the social role of men in our society. The treatment system seems to be unable to adequately respond to the specific needs of men suffering from schizophrenia.

Violent victimization in schizophrenia

We investigated the 3-year prevalence, and the sociodemographic and clinical correlates of violent victimization in a large and unselected nationwide sample of deinstitutionalized patients with schizophrenia. The sample comprised 670 schizophrenic patients aged 15–64 years, who had been discharged from psychiatric hospitals in Finland in 1994. Comprehensive data were collected from psychiatric case records on the patients’ sociodemographic factors and psychiatric history, as well as the patients’ overall level of functioning. The patients were interviewed 3 years after discharge by each district’s psychiatric professionals using a structured interview schedule specifically designed for the purposes of the present study project. The prevalence of self-reported violent victimization during the 3-year follow-up was 5.6%. In the multivariate analysis, a poor financial situation, alcohol abuse and being a perpetrator of a violent or some other crime were associated with violent victimization. The prevalence of violent victimization among schizophrenic patients in Finland was markedly lower than that reported on patients in the United States or Great Britain, but correlates were similar. Patients with a poor financial situation and a history of alcohol misuse, as well as of violent behaviour, seem to have an increased risk for violent victimization, and constitute a vulnerable subgroup in this respect. This subgroup of deinstitutionalized patients with schizophrenia may need additional care and protection from the danger posed to them from other members of the society.

Mortality in chronic schizophrenia during decreasing number of psychiatric beds in Finland

Mortality, especially mortality due to suicides, is higher among patients suffering from schizophrenia than among the general population. Little is known about the factors predicting the mortality of schizophrenia patients. It has also been suggested that mortality among psychiatric patients increases as the number of beds in mental hospitals decreases. These questions were studied in 4338 schizophrenia patients discharged in 1982, 1986, 1990 and 1994 from mental hospitals in Finland. During this period, the number of beds in mental hospitals in Finland decreased from 3.8 to 1.3 per 1000 inhabitants. During the three-year follow-up, 226 patients or 5.2% died. There were no statistically significant differences in mortality between the cohorts. The total mortality was higher in males than in females. Age, physical illness and number of hospital days predicted increased mortality due to natural causes. Mortality due to unnatural causes (suicides and accidents) was predicted by number of prescribed psychosedatives, number of hospitalisations and short duration of illness. Mortality due to unnatural causes was higher in the first year after index discharge from hospital. The reduction in number of beds in mental hospitals does not seem to be associated with increased mortality in chronic schizophrenia. The high mortality of schizophrenia patients indicates the need for careful medical examinations and treatment of physical illnesses, as well as counselling for a healthy lifestyle. Need for psychosedative medication at discharge from hospital and multiple previous hospitalisations may indicate an increased suicide risk and thus requires special attention. In outpatient treatment, it is important to remember that the risk of unnatural death increases during the first years after discharge from hospital.

Young men exempted from compulsory military or civil service in Finland — A group of men in need of psychosocial support?:

Aims: The aim of this study was to find out whether young men exempted from compulsory military or civil service constitute a group of young men in need of psychosocial support from the social and health services. Methods: The study involved a total of 356 men exempted from military or civil service and 440 young men conscripted into service. The research data were collected using questionnaires and register data. Results: Men exempted from military or civil service differed from conscripts in terms of psychosocial well-being. Compared with conscripts, they had already been in a more disadvantaged position with regard to their childhood living conditions. As young adults, they had met with a greater number of mental and social problems than conscripts: alcohol-related problems, unemployment, financial problems, homelessness, lack of social support and psychological distress. Young men exempted from service typically suffered from an accumulation of problems. Diverse problems were common particularly among men who had interrupted their service. There was a moderate correlation between current and childhood adversities. Conclusions: Men exempted from military or civil service comprise a group with a wide range of psychosocial problems and are a target group for supportive interventions. Special attention should be paid to the prevention of problems and promotion of well-being of men who interrupt their service. The accumulation of problems poses a challenge for the development of such interventions.

Negative symptoms and neuroleptics in catatonic schizophrenia

The association between neuroleptic treatment and the negative symptom dimension (ND) was evaluated in 1528 schizophrenia patients. In patients receiving more than 820 mg chlorpromazine (CPZ), those with catatonic-type disorder had significantly (p<0.05) higher ND scores than those in any of the other diagnostic subtypes. Even in patients receiving 450 mg CPZ or more, catatonic patients had significantly (p=0.046) higher ND scores than other patients. Patients with catatonic schizophrenia are highly vulnerable to negative symptoms related to neuroleptic drugs, probably because of a defect in their dopaminergic neuronal pathways.

Schizophrenic Patients in Different Treatment Settings During the Era of Deinstitutionalization: Three-Year Follow-Up of Three Discharge Cohorts in Finland

Objective: We investigated differences in psychosocial and clinical characteristics, as well as the use of services, of schizophrenic patients in different treatment settings three years after their discharge from a psychiatric hospital. Furthermore, we examined secular changes in these phenomena during the era of rapid deinstitutionalization in Finland. Method: Three nationally representative samples comprised 3257 schizophrenic patients who had been discharged in 1986, 1990 and 1994. The patients were interviewed three years after discharge by each districts psychiatric professionals using a structured interview schedule specifically designed for the purposes of the present study. Psychosocial functioning was assessed on the Global Assessment Scale and on a modified version of the Medical Research Council Practices Profile. Results: In the 1990s, more patients with a poor clinical and psychosocial state were transferred from hospital to alternative outpatient facilities, such as sheltered workshops or supported residences. In successive cohorts, the proportion of patients who had dropped out of treatment decreased and the psychiatric and somatic state of the drop-outs improved. Conclusion: In general, the psychiatric treatment system has worked well for most deinstitutionalized patients. In the future, however, it is important that the quality of care and adequate resources in the alternative outpatient facilities are ensured.

Psychosocial factors associated with suicidal ideation among young men exempted from compulsory military or civil service.

Aims: The aim of this study was to identify factors associated with suicidal ideation among young men exempted from compulsory military or civil service in Finland. Methods: The study involved a total of 356 men exempted from military or civil service. The research data were collected using questionnaires and register data. Results: One third of the young men exempted from compulsory military or civil service reported serious suicidal ideation. Of the men with serious suicidal ideation, one third had attempted suicide. Various childhood adversities and current stressful life events and problems were associated with suicidal ideation. Multivariate logistic regression analysis showed that the following factors were independently associated with suicidal ideation: maternal alcohol-related problems, changes in the family, discord with the boss over the past 12 months, and lack of social support. Accumulation of problems predicted suicidal ideation. Conclusions: Men exempted from compulsory military or civil service comprise an important target group in the prevention of suicide. In order to prevent suicidal behaviour among young men at risk, it is important to address the significance of social support and relationships, and likewise to be aware of early risk indicators such as maternal alcohol-related problems.

A systematic concept analysis of mental health promotion

Abstract This study explored and clarified the nature and characteristics of the concept of mental health promotion. The study also investigated how these characteristics appear in current policies and strategies. A total of 30 scientific articles and policy documents were identified and analysed using Rodgers’s systematic evolutionary concept analysis method. The analysis provided valuable information on the attributes, related concepts, antecedents, consequences and references of mental health promotion, indicating that the concept is a distinct concept comprising a unique set of attributes and characteristics. A concept mapping of mental health promotion was subsequently developed. The analysis and the concept mapping provide health professionals, policy-makers and researchers with a framework, upon which well-grounded mental health promotion practice and evaluation research can be based.

Mental health promotion competencies in the health sector in Finland: a qualitative study of the views of professionals:

Aims: In this study, we aimed to investigate what competencies are needed for mental health promotion in health sector practice in Finland. Methods: A qualitative study was carried out to seek the views of mental health professionals regarding mental health promotion-related competencies. The data were collected via two focus groups and a questionnaire survey of professionals working in the health sector in Finland. The focus groups consisted of a total of 13 professionals. Further, 20 questionnaires were received from the questionnaire survey. The data were analysed using the qualitative data analysis software ATLAS.ti Scientific Software Development GmbH, Berlin. A content analysis was carried out. Results: In total, 23 competencies were identified and clustered under the categories of theoretical knowledge, practical skills, and personal attitudes and values. In order to promote mental health, it is necessary to have a knowledge of the principles and concepts of mental health promotion, including methods and tools for effective practices. Furthermore, a variety of skills-based competencies such as communication and collaboration skills were described. Personal attitudes and values included a holistic approach and respect for human rights, among others. Conclusions : The study provides new information on what competencies are needed to plan, implement and evaluate mental health promotion in health sector practice, with the aim of contributing to a more effective workforce. The competencies provide aid in planning training programmes and qualifications, as well as job descriptions and roles in health sector workplaces related to mental health promotion.

Social role behaviour of patients with long-term schizophrenia in the community during sharp decline in number of psychiatric beds

Objective: Social role behaviour (SRB) was studied among patients with long-term schizophrenia living in the community when the number of psychiatric beds was decreasing. Methods: A representative national sample of 2502 schizophrenia patients discharged from mental hospitals in 1986, 1990 and 1994 in Finland were interviewed three years after discharge. During the study period, the number of psychiatric beds decreased from 3.3 to 1.2 beds per 1000 people. Social role behaviour (SRB) was evaluated at follow-up and predicted with data at discharge. Results: More than four-fifths of patients had considerable problems in at least one area of SRB. In the majority of SRB areas, men had more problems than women. Later discharge years associated with poor SRB at follow-up, although the effects of other (confounding) factors were taken into account. Being married and having good psychosocial functioning and ability to work, as well as having paranoid schizophrenia, associated with fewer problems in SRB at follow-up. Conclusions: SRB of long-term schizophrenia patients in the community is extensively damaged. Decrease in psychiatric beds is associated with increase in SRB of long-term schizophrenia patients. Men have more SRB problems than women. The situation at discharge strongly predicts patients SRB also in the community.