Peija Haaramo

Quasi-experimental study on the effectiveness of psychoanalysis, long-term and short-term psychotherapy on psychiatric symptoms, work ability and functional capacity during a 5-year follow-up

BACKGROUND Psychotherapy is apparently an insufficient treatment for some patients with mood or anxiety disorder. In this study the effectiveness of short-term and long-term psychotherapies was compared with that of psychoanalysis. METHODS A total of 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy, short-term psychodynamic and long-term psychodynamic psychotherapies. Additionally, 41 patients suitable for psychoanalysis were included in the study. The patients were followed from the start of the treatment and assessed 9 times during a 5-year follow-up. The primary outcome measures on symptoms were the Beck Depression Inventory, the Hamilton Depression and Anxiety Rating Scales, and the Symptom Check List, anxiety scale. Primary work ability and functional capacity measures were the Work Ability Index, the Work-subscale of the Social Adjustment Scale, and the Perceived Psychological Functioning Scale. RESULTS A reduction in psychiatric symptoms and improvement in work ability and functional capacity was noted in all treatment groups during the 5-year follow-up. The short-term therapies were more effective than psychoanalysis during the first year, whereas the long-term therapy was more effective after 3years of follow-up. Psychoanalysis was most effective at the 5-year follow-up, which also marked the end of the psychoanalysis. CONCLUSIONS Psychotherapy gives faster benefits than psychoanalysis, but in the long run psychoanalysis seems to be more effective. Results from trials, among patients suitable for psychoanalysis and with longer follow-up, are needed before firm conclusions about the relative effectiveness of psychoanalysis and psychotherapy in the treatment of mood and anxiety disorders can be drawn.

Sleep Problems and Disability Retirement: A Register-based Follow-up Study

Among aging employees, sleep problems are prevalent, but they may have serious consequences that are poorly understood. This study examined whether sleep problems are associated with subsequent disability retirement. Baseline questionnaire survey data collected in 2000-2002 among employees of the city of Helsinki, Finland, were linked with register data on disability retirement diagnoses by the end of 2008 (n = 457) for those with written consent for such linkages (74%; N = 5,986). Sleep problems were measured by the Jenkins Sleep Questionnaire. Cox regression analysis was used to calculate hazard ratios and 95% confidence intervals for disability retirement. Gender- and age-adjusted frequent sleep problems predicted disability retirement due to all causes (hazard ratio (HR) = 3.22, 95% confidence interval (CI): 2.26, 4.60), mental disorders (HR = 9.06, 95% CI: 3.27, 25.10), and musculoskeletal disorders (HR = 3.27, 95% CI: 1.91, 5.61). Adjustments for confounders, that is, baseline sociodemographic factors, work arrangements, psychosocial working conditions, and sleep duration, had negligible effects on these associations, whereas baseline physical working conditions and health attenuated the associations. Health behaviors and obesity did not mediate the examined associations. In conclusion, sleep problems are associated with subsequent disability retirement. To prevent early exit from work, sleep problems among aging employees need to be addressed.

Joint associations of sleep duration and insomnia symptoms with subsequent sickness absence: The Helsinki Health Study

Aims: We aimed to examine the joint associations of sleep duration and insomnia symptoms with subsequent sickness absence of various lengths while considering several covariates. Methods: Baseline surveys among 40–60-year-old employees of the City of Helsinki, Finland, (N = 6535) were prospectively linked with employer’s personnel register data comprising short self-certified (1–3 days), medically-certified intermediate (4–14 days) and long (15 days or more) sickness absence spells. Average follow-up time was 4.1 years. Sleep duration, insomnia symptoms, sociodemographics, working conditions, health behaviours and health were self-reported in the surveys. Poisson regression analysis was used. Results: Insomnia symptoms were associated with sickness absence at all levels of sleep duration. Adjusting for gender and age, U-shaped associations regarding sleep hours were found. Thus, those reporting short or long sleep and reporting insomnia symptoms had a higher risk for medically-certified intermediate and long sickness absence as compared to those reporting 7 hours of sleep without insomnia symptoms. Also, those reporting 6, 7, and 8 hours of sleep had a higher risk for such sickness absence, if they reported insomnia. Weak associations were also found for self-certified sickness absence, and for those reporting short and long sleep without insomnia. Adjustments attenuated the associations, but they mainly remained. Conclusions: These results suggest primacy of the effects of insomnia symptoms over sleep duration on sickness absence. Although insomnia dominated the joint association, U-shaped associations suggest that both sleep duration and insomnia symptoms need to be considered to promote work ability.

The joint association of sleep duration and insomnia symptoms with disability retirement--a longitudinal, register-linked study.

OBJECTIVE The aim of this study was to examine the joint association of sleep duration and insomnia symptoms with subsequent disability retirement. METHODS Baseline survey data were collected in 2000-2002 from 40-60-year-old employees of the City of Helsinki, all working at baseline. Baseline data were linked with disability retirement data until the end of 2010, obtained from the Finnish Centre for Pensions registers (N=6042). Sleep duration and self-reported insomnia symptoms (non-restorative sleep and difficulties in initiating and maintaining sleep) were derived from the baseline surveys. All-cause disability retirement (N=561) and the most prevalent diagnostic groups - musculoskeletal diseases (43%) and mental disorders (26%) - were examined. Cox regression analysis was used to yield hazard ratios (HR) with 95% confidence intervals (95% CI). RESULTS A joint association of sleep duration and insomnia symptoms with disability retirement was found, implying a higher risk for those with frequent insomnia symptoms. HR for all-cause disability retirement ranged among those with frequent symptoms from 2.02 (95% CI 1.53-2.68, sleeping 7 hours) to 3.92 (95% CI 2.57-5.97, sleeping ≤ 5 hours). Adjusting for sociodemographic, work, and health-related factors attenuated the associations, which nevertheless remained. The associations were similar for the two diagnostic groups, although stronger for those with mental disorders. CONCLUSION Frequent insomnia symptoms dominate the joint association of sleep duration and insomnia symptoms with subsequent disability retirement. Examining exclusively sleep duration would provide an incomplete understanding of the consequences of poor sleep.

Psychiatric readmissions and their association with physical comorbidity: a systematic literature review

BackgroundComorbidity between mental and physical disorder conditions is the rule rather than the exception. It is estimated that 25% of adult population have mental health condition and 68% of them suffer from comorbid medical condition. Readmission rates in psychiatric patients are high and we still lack understanding potential predictors of recidivism. Physical comorbidity could be one of important risk factors for psychiatric readmission. The aim of the present study was to review the impact of physical comorbidity variables on readmission after discharge from psychiatric or general inpatient care among patients with co-occurring psychiatric and medical conditions.MethodsA comprehensive database search from January 1990 to June 2014 was performed in the following bibliographic databases: Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. An integrative research review was conducted on 23 observational studies.ResultsSix studies documented physical comorbidity variables only at admission/discharge and 17 also at readmission. The main body of studies supported the hypothesis that patients with mental disorders are at increased risk of readmission if they had co-occurring medical condition. The impact of physical comorbidity variables on psychiatric readmission was most frequently studied in in patients with affective and substance use disorders (SUD). Most common physical comorbidity variables with higher probability for psychiatric readmission were associated with certain category of psychiatric diagnoses. Chronic lung conditions, hepatitis C virus infection, hypertension and number of medical diagnoses were associated with increased risk of readmission in SUD; Charlson Comorbidity Index, somatic complaints, physical health problems with serious mental illnesses (schizophrenia, schizoaffective disorder, personality disorders); not specified medical illness, somatic complaints, number of medical diagnoses, hyperthyroidism with affective disorders (depression, bipolar disorder). Co-occurring physical and mental disorders can worsen patient’s course of illness leading to hospital readmission also due to non-psychiatric reasons.ConclusionsThe association between physical comorbidity and psychiatric readmission is still poorly understood phenomenon. Nevertheless, that physical comorbid conditions are more common among readmitted patients than single admission patients, their association with readmission can vary according to the nature of mental disorders, characteristics of study population, applied concept of comorbidity, and study protocol.

The joint contribution of pain and insomnia to sickness absence and disability retirement: A register–linkage study among Norwegian and Finnish employees

Pain and insomnia are both independently associated with work disability. Although pain and insomnia often co‐occur, their joint associations with subsequent sickness absence and disability retirement have not been studied. We aimed to examine these associations in two prospective occupational cohorts while considering key covariates.

Pre-discharge factors predicting readmissions of psychiatric patients: a systematic review of the literature

BackgroundReadmission rate is considered an indicator of the mental health care quality. Previous studies have examined a number of factors that are likely to influence readmission. The main objective of this systematic review is to identify the studied pre-discharge variables and describe their relevance to readmission among psychiatric patients.MethodsStudies on the association between pre-discharge variables and readmission after discharge with a main psychiatric diagnosis were searched in the bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. Relevant publications published between January 1990 and June 2014 were included. For each variable, the number of papers that considered it as a predictor of readmission and that found a significant association was recorded, together with the association direction and whether it was found respectively in bivariate and in multivariate analyses.ResultsOf the 734 articles identified in the search, 58 papers were included in this review, mainly from the USA and concerning patients with severe mental disorders. Analysed variables were classified according to the following categories: patients’ demographic, social and economic characteristics; patients’ clinical characteristics; patients’ clinical history; patients’ attitude and perception; environmental, social and hospital characteristics; and admission and discharge characteristics. The most consistently significant predictor of readmission was previous hospitalisations. Many socio-demographic variables resulted as influencing readmission, but the results were not always homogeneous. Among other patients’ clinical characteristics, diagnosis and measures of functional status were the most often used variables. Among admission characteristics, length of stay was the main factor studied; however, the results were not very consistent. Other relevant aspects resulted associated with readmission, including the presence of social support, but they have been considered only in few papers. Results of quality assessment are also reported in the review. The majority of papers were not representative of the general psychiatric population discharged from an inpatient service. Almost all studies used multivariate analytical methods, i.e., confounders were controlled for, but only around 60% adjusted for previous hospitalisation, the variable most consistently considered associated to readmission in the literature.ConclusionsThe results contribute to increase knowledge on pre-discharge factors that could be considered by researchers as well as by clinicians to predict and prevent readmissions of psychiatric patients. Associations are not always straightforward and interactions between factors have to be considered.

Insomnia symptoms and subsequent cardiovascular medication: a register-linked follow-up study among middle-aged employees.

Sleep disturbances have been associated with an increased risk of cardiovascular disease outcomes. The associations of insomnia with hypertension and dyslipidaemia, the main modifiable cardiovascular risk factors, are less studied. We especially lack understanding on the longitudinal effects of insomnia on dyslipidaemia. We aimed to examine the associations of insomnia symptoms with subsequent prescribed medication for hypertension and dyslipidaemia using objective register‐based follow‐up data. Baseline questionnaire surveys among 40–60‐year‐old employees of the City of Helsinki, Finland, were conducted in 2000–2002 (n = 6477, response rate 67%, 78% women) and linked to a national register on prescribed reimbursed medication 5–7 years prior to and 5 years after baseline. Associations between the frequency of insomnia symptoms (difficulties in initiating and maintaining sleep, non‐restorative sleep) and hypertension and dyslipidaemia medication during the follow‐up were analysed using logistic regression analysis (odds ratios with 95% confidence intervals). Analyses were adjusted for pre‐baseline medication, sociodemographic and work‐related factors, health behaviours, mental health, and diabetes. Frequent insomnia symptoms were reported by 20%. During the 5‐year follow‐up, 32% had hypertension medication and 15% dyslipidaemia medication. Adjusting for age, gender and pre‐baseline medication, frequent insomnia symptoms were associated with hypertension medication (odds ratio 1.57, 95% confidence interval 1.23–2.00) and dyslipidaemia medication (odds ratio 1.59, 95% confidence interval 1.19–2.12). Occasional insomnia symptoms were also associated with cardiovascular medication, though less strongly. Further adjustments had negligible effects. To conclude, insomnia should be taken into account in the prevention and management of cardiovascular disease and related risk factors.

Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature

BackgroundPsychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.MethodsComprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.ResultsOf the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.ConclusionThis review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.

Changes in lifestyle for psychiatric patients three years after the start of short- and long-term psychodynamic psychotherapy and solution-focused therapy.

OBJECTIVES Lifestyle is less favourable among individuals suffering from psychiatric disorders. We studied whether psychotherapy brings along changes in lifestyle and whether these changes differ between short-term and long-term psychodynamic psychotherapy (SPP and LPP) and solution-focused therapy (SFT). METHODS A total of 326 outpatients, 20-46 years of age, with mood or anxiety disorder were randomly assigned to LPP, SPP and SFT. The lifestyle variables considered were alcohol consumption, smoking, body mass index (BMI), leisure time exercise and serum cholesterol. The patients were monitored for three years from the start of treatment. RESULTS During the three-year follow-up, BMI and serum cholesterol rose statistically significantly although no statistically significant trends were shown for alcohol consumption, smoking or exercise. SPP showed a disadvantage of increased alcohol consumption and serum cholesterol level when compared with LPP. SFT showed an advantage of reduced smoking in comparison with SPP. DISCUSSION Small therapy-specific changes in lifestyle may be a result from psychotherapy treatment. These lifestyle changes are apparently more common in short-term therapy. More studies are needed to verify these findings.