John E. Berg

Migrant participation in Norwegian health care. A qualitative study using key informants.

Abstract Background: Little is known about how migrants adapt to first-world public health systems. In Norway, patients are assigned a registered general practitioner (RGP) to provide basic care and serve as gatekeeper for other medical services. Objectives: To explore determinants of migrant compliance with the RGP scheme and obstacles that migrants may experience. Methods: Individuals in leadership positions within migrant organizations for the 13 largest migrant populations in Norway in 2008 participated in this qualitative study. Semi-structured interviews, with migrants serving as key informants, were used to elucidate possible challenges migrant patients face in navigating the local primary health-care system. Conversations were structured using an interview guide covering the range of challenges that migrant patients meet in the health-care system. Results: According to informants, integration into the RGP scheme and adequacy of patient-physician communication varies according to duration of stay in Norway, the patients country of origin, the reason for migration, health literacy, intention to establish permanent residence in Norway, language proficiency, and comprehension of information received about the health system. Informants noted as obstacles: doctor-patient interaction patterns, conflicting ideas about the role of the doctor, and language and cultural differences. In addressing noted obstacles, one strategy would be to combine direct intervention by migrant associations with indirect intervention via the public-health system. Conclusion: Our results will augment the interpretation of forthcoming quantitative data on migrant integration into the public-health system and shed light on particular obstacles.

The level of non-Western immigrants' use of acute psychiatric care compared with ethnic Norwegians over an 8-year period.

Immigrants are assumed by many to have more mental health problems than the population in the countries they have emigrated to, and clinicians have the impression that an increasing number of non-Western immigrants are referred to acute psychiatric care. Patients referred over an 8-year period to an acute care facility, responsible for a catchment area of close to 100,000 inhabitants in Oslo, Norway, were scrutinized to study the latter assumption. In total 792 men and 701 women (47.0%) were referred. There were 168 men and 59 women among the non-Western immigrants, i.e. 26.0% of the non-Western immigrants were women, whereas 50.2% or 611 out of 1217 ethnic Norwegians were women. Non-Western immigrants were referred twice as often in 2007, n=40, as in 2000, n=19. Non-Western immigrants as a percentage of the other referred patients increased from 15.2% to 16.0% in 2006, which was lower than the representation in the general population. Mean age was lower for non-Western immigrants, 34.6 (standard deviation, s=14.7) than for ethnic Norwegians 39.5 (s=11.6). Mean length of stay was lower for ethnic Norwegians. If the prevalence of mental disorders is the same or higher in immigrants than in the original population, this study indicates that they are under-represented among referred patients from the catchment area population. This seems to be the case especially for women.

Electroconvulsive Treatment: More Than Electricity?: An Odyssey of Facilities

Objective: To investigate whether the practice of electroconvulsive treatment (ECT) today is done in a comparable way in different hospitals on several continents. Materials and Methods: During visits to the ECT facilities of 14 hospitals on 3 continents, comparisons were made, and responsible health professionals were interviewed using a semistructured guide. It is emphasized that the present article is not the result of a well-structured research, but of reflections after observing a lack of homogeneity among facilities. Results: A total of more than 18,000 modified ECT sessions were given per year in the 14 hospitals. The opinion of the public and regulatory bodies on ECT strongly influences the possibility of giving ECT to patients. Indications for ECT are wider than the cases of depression in most facilities visited. A psychiatrist gives ECT in all but 1 facility. Anesthesia is given by an anesthesiologist in all but 1 facility. A mouthpiece was not used in 2 (or 3) facilities, although the rationale was the same as in facilities using mouthpieces. No facility gave unmodified ECT. Holding on to the patient during seizures was judged unnecessary in 12 of 14 facilities. Conclusions: In severe mental illness, the practice of using ECT seems to have its merit also in cases with debilitating illnesses other than unipolar and bipolar depression. Giving ECT may be done by qualified or specially certified nurses, but the giving of anesthesia should be the realm of the anesthesiologist. Mouthpieces are judged by some facilities to be a superfluous device. The holding of patients during seizure can be omitted. Some of the facilities visited give ECT to a huge number of patients each year. They differ in the practice of ECT and could be the focus of comparative research. Despite the differences observed, and procedures that could be altered, giving ECT in a modified way effectively relieves suffering in the patients.

Clinical differences between immigrants voluntarily and involuntarily admitted to acute psychiatric units: a 3‐year prospective study

Involuntary psychiatric admissions are widespread among patients with an immigrant background. According to a study in Norway, involuntary admissions are about 75% of admissions among immigrants compared to roughly 50% among ethnic Norwegians. The aim of the present study was to compare clinical and demographic characteristics of immigrant patients with involuntary or voluntary admissions to two acute psychiatric units. A 3-year prospective study of 94 immigrant patients involuntarily and voluntarily admitted to acute psychiatric units was carried out. Sixty-two patients (66.0%) were voluntarily and 30 (31.9%) involuntarily admitted. Involuntary admissions were significantly higher among men (22, 73.3%) compared to women (8, 26.7%; χ(2) = 4.507, d.f. = 1, P= 0.03). The mean length of stay for voluntary and involuntary patients were 7.8 (SD = 6.6) and 21.6 (SD = 27.3; t=-2.7, d.f. = 88, P= 0.01). Patients diagnosed with schizophrenia and psychotic disorder were more often admitted involuntarily (63.0%; χ(2) = 17.83, P= 0.001). This study confirms that immigrant patients diagnosed with psychotic disorders are more often involuntarily than voluntarily admitted. Comparing the clinical and demographic characteristics of immigrants helps identify the reasons behind involuntary admissions and might improve efforts towards reducing such admissions in the future.

Sense of Coherence in Patients Treated for Depression with ECT

Objective: The purpose of the study was to investigate whether the Antonovsky Sense of Coherence test administered before and after electroconvulsive treatment (ECT) can contribute more information pertinent to outcome than a test of depression. Method: Twenty patients with a severe unipolar or bipolar depression underwent a series of unipolar ECT under standard conditions. As part of the routine of the department, the patients filled in, before and after ECT, the following questionnaires: Beck Depression Inventory (Beck), 20-item version and Antonovsky Sense of Coherence test (SOC), 13-item version. Mean age was 40.3, somewhat less for women. Results: A reduction was obtained from 35 to 17 in total score on Beck, i.e., to mild depression. The SOC value increased to the normal range from a mean of 2.5 to 3.2, indicating a better manageability, comprehensibility and meaningfulness in life. Four patients had an invalidity pension. Ten of the 16 remaining patients attained work after ECT, and scored better than those not starting to work on both tests, SOC >Beck. A low SOC value may indicate increased mortality risk. Conclusions: Patients who are favorably treated with ECT against any depression, but who do not show a considerable improvement in SOC, would need special follow-up on factors not directly related to mental illness to reduce relapse and mortality risk.

Doctor-certified sickness absence in first and second trimesters of pregnancy among native and immigrant women in Norway

Aims: The authors sought to estimate differences in doctor-certified sickness absence during pregnancy among immigrant and native women. Methods: Population-based cohort study of pregnant women attending three Child Health Clinics in Groruddalen, Oslo, and their offspring. Questionnaire data were collected at gestational weeks 10–20 and 28. The participation rate was 74%. A multivariate Poisson regression was used to analyse differences in sickness absence in pregnancy between immigrant and native women. Results: A total of 573 women who were employed prior to their pregnancies were included, 51% were immigrants. After adjusting for age, years of education, marital status, number of children, occupation, part-time/full-time work, health status, severe pregnancy-induced emesis and language proficiency, the immigrant/native differences in number of weeks with sickness absence decreased from 2.0 to 1.2 weeks. Part-time/full-time work, health status, severe pregnancy-induced emesis and language proficiency were significant predictors of sickness absence. Conclusion: Immigrant women had higher sickness absence than native women during pregnancy. The difference in average number of weeks between native and immigrant women was partly explained by poorer health status prior to pregnancy, severe pregnancy-induced emesis and poorer proficiency in the Norwegian language among the immigrant women.

Electroconvulsive treatment of a patient with Parkinson's disease and moderate depression.

Depression is a usual comorbidity in patients with Parkinsons disease. It has been known for more than 50 years that electroconvulsive treatment (ECT) has a positive effect on the muscular symptoms of Parkinsons disease. Many countries do not allow giving ECT for this indication. We have recently treated a resident patient in an acute psychiatric facility referred to the hospital with moderate depressive symptoms and strong suicidal ideation. Before and after a series of ECT he filled out the Beck Depression Inventory and the Antonovsky Sense of Coherence test. The scores before ECT were 20 and 2.69, respectively, and after 12 treatments 14 and 3.38. Both test results indicate improvement regarding level of depression and coping in life. The physiotherapists treating him observed that his rigidity was reduced and his gait improved. Muscular tonus was reduced and increased his tendency of falling as he had less tonus in muscles close to joints. Self help efficiency in daily tasks improved. He got cognitive impairment during and in the weeks after ECT. Electroconvulsive treatment should be offered to more patients with Parkinson disease and depression in order to lessen the burden of both depression and Parkinson symptoms.

Death by suicide long after electroconvulsive therapy. Is the sense of coherence test of Antonovsky a predictor of mortality from depression

Prediction of increased risk of suicide is difficult. We had the opportunity to follow up 20 patients receiving electroconvulsive therapy (ECT) because of severe depression. They filled in the Antonovsky sense of coherence test (SOC) and Beck depression inventory (BDI) before and after a series of ECT treatments. Seventeen surviving patients had a mean observation time of 20.6 months, whereas the three deceased patients had 11.3 months. There was a lower mean age at onset of illness and a longer mean duration of disease in the deceased. Other clinical parameters did not differ. The surviving patients had a significant decrease on the BDI from 35 to 18 (P<0.001) and an increase on the SOC test after ECT from 2.45 to 3.19 (P<0.001), indicating both less depression and better functioning in life. The deceased had a larger change on the BDI from 32 to 13, not attaining significance because of the low number of deceased. The SOC test, however, did not increase to a purported normal level; that is, from 2.43 to 2.87. Although the SOC scale has been shown to predict mortality in substance abusers, the SOC test has not been part of earlier reviews of predictive power. Tentatively, a low pathological score on the SOC test may indicate low sense of coherence in life that might increase the propensity for suicide. These preliminary results need replication in larger studies.

Expectations of the future : immigrant, asylum seeker, or refugee - does it matter?

Background: Refugees and asylum seekers may have other feelings and expectations about the future than immigrants do. The aim of this study was to explore and analyse the expectations for the future among populations of immigrants, asylum seekers and refugees admitted to Norwegian acute psychiatric departments. Method: In a prospective study in the period 2005 to 2008, data were collected from two acute psychiatric departments. Results: There were 48 immigrants, 24 refugees, and 21 asylum seekers. A significantly higher proportion of asylum seekers than refugees had nightmares (p ¼ 0.04), feelings of guilt (p ¼ 0.04) and feelings of hopelessness (p ¼ 0.04). A significantly higher proportion of asylum seekers than immigrants had sleeping problems (p ¼ 0.03), nightmares (p ¼ 0.03), feelings of hopelessness (p ¼ 0.03) and reduced appetite (p ¼ 0.04). Significantly more asylum seekers than refugees maintained that life would change for the better over time (Z ¼ 2.0; p ¼ 0.04). More refugees than asylum seekers indicated problems judging life ten years from now (Z ¼ 2.1; p ¼ 0.04). Conclusion: Being an asylum seeker seems to incur greater distress and higher negative expectations for the future. Preventive strategies should be created to improve refugees’ and asylum seekers’ life in exile. Priority and speed in processing of asylum cases should be given higher priority.

Memory loss after electroconvulsive treatment - May the sudden alleviation of depression-inducing memories explain patient despair?

UNLABELLED Electroconvulsive treatment (ECT) has developed over 70 years to a modern, effective way of lifting depressive moods. Memory loss after electroconvulsive treatment is the only remaining relevant criticism of the treatment modality when considering the overall rate of remission from this treatment compared to all other treatment modalities. A depressive state impedes memory. After treatment memory improves on several qualities of cognition. However, comparing a persons memory ability from the months before depression started to the level after a course of ECT is never done, of obvious reasons. There are great clinical difficulties explaining who would develop memory problems, regardless of stimulation techniques, age or sex of the patient. HYPOTHESES The memory loss seen in some patients undergoing electroconvulsive treatment (ECT) is not explained by the treatment alone. After ECT unpleasant memories are disclosed rapidly and the patient may unconsciously try to defend herself by extending memory repression to other areas of memory. This may be unrelated to treatment modality, number of sessions or severity of depression. Psychological factors may partly explain why some patients unfold memory problems when the depression is rapidly lifted, rather than the treatment modality itself.