Patienter med somatisk och psykiatrisk samsjuklighet är en sårbar och vårdmässigt komplex grupp som löper större risk, jämfört med normalpopulationen, att avlida i förtid till följd av sjukdomar som kunde ha förebyggts. Bristande socioekonomiska resurser tycks vara en förklaring men forskning visar också på sämre bemötande av patientgruppen samt att fler diagnostiska misstag görs vid samsjuklighet. Syftet med denna studie var att undersöka hur läkare inom somatiken upplever svårigheter i diagnostik och behandling gällande samsjukliga patienter. Semistrukturerade intervjuer genomfördes med tio läkare verksamma inom somatisk vård. Induktiv tematisk analys visade att läkarnas upplevelser kunde delas in i fyra teman; Osäkerhet, Relationen, Kapacitet och Integration. Resultaten visar att läkare upplever svårigheter kopplat till individen, patient-läkar-relationen och vården i stort. Kärnkategorin Otillräcklighet är beskrivande för samt genomsyrar samtliga teman och handlar om en otillräcklighet i hela vården, hos såväl patient som vårdpersonal och organisation. Dessa fynd bekräftar dels tidigare forskning och tillför fördjupade perspektiv i en svensk kontext. Behov finns av vidare kvantitativ forskning inom ämnet för ett mer generaliserbart resultat. / Patients with somatic and psychiatric comorbidity constitute a vulnerable and care-wise complex group at higher risk, compared to the general population, of premature death due to preventable diseases. A lack of socio-economic resources seems to be one explanation, but research also shows that these patients are subjected to worse interpersonal treatment and that more diagnostic mistakes are made in relation to comorbid patients. The purpose of this study was to investigate how physicians in the somatic care experience difficulties in diagnosis and treatment of comorbid patients. Semi-structured interviews were conducted with ten physicians in the somatic care. Inductive thematic analysis showed that the experiences could be categorized into four themes; Uncertainty, The relationship, Capacity and Integration. The results show that physicians experience difficulties relating to the individual, the patient-physician-relationship, and the care system as a whole. The core category Insufficiency is descriptive of all themes and refers to an insufficiency regarding the patient herself as well as the staff and the organization. The findings confirm previous research and adds an in-depth perspective in a Swedish context. There is a need for future quantitative research on this topic in order to generate more generalizable results.

Benämningen dubbeldiagnos är ett vitt begrepp men i denna kontext syftar det på personer som har en psykiatrisk diagnos i kombination med ett dokumenterat och diagnostiserat alkohol- och/eller narkotikamissbruk. Personer med dubbeldiagnos är en utsatt grupp i samhället med betydligt högre dödlighet än övriga befolkningen. Trots detta verkar det finnas svårigheter i samverkan kring behandling, främst eftersom vården är utlagd på två huvudmän. Syftet med denna studie är därför att undersöka hur samverkan kring behandlingsinsatserna fungerar mellan kommun och region för personer med dubbeldiagnos i en mellanstor kommun. Undersökningen har genomförts med semistrukturerade intervjuer som analyserats med hjälp av konventionell innehållsanalys. Data har insamlats från åtta respondenter, fyra från vardera huvudman.    Resultatet visar att region och öppenvård inte har ett gemensamt synsätt när det gäller vilken behandling som är bäst för personer med dubbeldiagnos. Båda instanser ser behov av samtidig behandling för bägge tillstånden men regionen ser medicinsk behandling som det primära medan kommunen anser att allians och långsiktig behandling är det viktigaste. Resultatet visar också att det saknas riktlinjer och en gemensam strategi för att lösa de befintliga samverkansproblemen. De hinder för samverkan som respondenterna belyste handlade främst om strukturella faktorer som resursbrist och byråkrati.    Det är svårt att komma tillrätta med de glapp som uppstår mellan regionens slutenvård och kommunens öppenvård och i detta glapp finns en hög återfallsrisk. Respondenternas rekommendation för att minska det tidigare nämnda glappet mellan huvudmännen är ett slags mellanhus. Detta skulle ge kommunen förutsättningar att stå redo med insatser när klienten är medicinskt färdigbehandlad från regionens sida. Personer med dubbeldiagnos skulle på så sätt ges möjlighet att få vård och fortsatt stöd i de perioder då risken för återfall är som störst. Slutsatsen är att det finns brister i samverkan mellan kommun och region. En metod för att bättra samverkan är interprofessionella team som arbetar tillsammans mot gemensamma mål. På så sätt tas den bästa kunskapen tillvara från såväl socialtjänst som region. Inte minst visar dubbeldiagnosteamet på att detta är en framgångsrik väg för god samverkan.

Abstract Att ge adekvat stöd och behandling till sexuellt våldsutsatta kvinnor med psykisk ohälsa och substansmissbruk är komplext, Trots att problematiken uppmärksammats sedan mitten av 1990-talet står det klart att bristerna kvarstår. Sedan 2003 är rekommendationen att psykisk ohälsa och substansberoende ska behandlas samtidigt.   Syftet med uppsatsen är att belysa hur professionella inom psykiatrins och socialtjänstens öppenvård upplever möjligheten att erbjuda adekvat vård till våldsutsatta kvinnor med psykisk ohälsa och substansmissbruk samt möjligheten till samverkan med andra aktörer.  Ansatsen i studien är kvalitativ, det vill säga bygger på semistrukturerade intervjuer och tematisk analys. Informanter rekryterades via ett bekvämlighetsurval och sju intervjuer med professionella inom socialtjänsten och psykiatrin genomfördes. Intervjuerna genomfördes utifrån en vinjett av en fiktiv ung kvinna och med hjälp av en semistrukturerad intervjuguide. Intervjuerna transkriberades och analyserades med hjälp av tematisk innehållsanalys. Resultatet bekräftar tidigare forskning hos de sju informanterna i studien i det att de inte har möjlighet att erbjuda adekvat vård och behandling till sexuellt våldsutsatta kvinnor med psykisk ohälsa och ett substansmissbruk. Därtill är det en organisatorisk utmaning att navigera i en komplex verksamhetsdomän där olika aktörer verkar i stuprör med skilda förklaringsmodeller till hur målgruppen ska bemötas. / Abstract Providing support and treatment to women who have been sexually abused and also have comorbidity of substance abuse and mental disorder is complicated. Despite the fact that the problem has raised attention since the mid 1990's, it is evident that the shortcomings remain. The recommendation from 2003 is that both mental disorders and substance abuse be treated in parallel. The aim of the essay is to illuminate to which extent professionals in psychiatry and the social services experience the possibilities they have to offer adequate care to sexually abused women, while aso having the possibility of co-operation with other agencies.The approach of the study is qualitative, built on semi-structured interviews and thematic analysis. The informants were recruited by means of a comfort sample; seven interviews were conducted with professionals within the social welfare and psychiatric services. Interviews were held concerning a fictional construction about a young woman, using a semi-structured interview-guide. The interviews were transcribed and analysed with the help of thematic content analysis. The information gleaned from the interviews confirms earlier research such that there is a consensus among the interviewees in the study, that they do not have the possibility of offering adequate care to women who have been sexually abused and who have comorbidity of pychiatric disorder and substance abuse. Additionally, to navigate simultaneously in a complex domain of professional services, where representatives for different areas of function work in a cascade of different models-of-explanation on how to approach the patient group,  is a serious organisational challenge.

This paper describes the distribution of dependence criteria and diagnoses in a sample of 14- to 24-year-olds from Munich, Germany (n = 3,021; 71% response rate), evaluates differences between nondependent and dependent smokers and examines associations of smoking with other substances, affective and anxiety disorders. Assessment was made using the M-CIDI. The lifetime prevalence of DSM-IV nicotine dependence in the total sample is 19%, rising to 52% among regular smokers. No gender differences were seen in the progression from regular smoking to nicotine dependence, although men were more likely than women to initiate regular use. Analysis of daily cigarette use identified a significant dose-response relationship with the number of endorsed DSM-IV dependence criteria with unsuccessful cut-backs being the most prevalent criterion. As compared to nondependent smokers, dependent smokers were more likely to associate negative health effects with smoking and to have a desire to change and attempt a change in their pattern of use. Regular use of nicotine was found to be significantly associated with other substance and nonsubstance disorders, although dependent regular use was more strongly associated with these disorders than nondependent regular use. These results indicate that daily smoking is a behavior which is resistant to change despite an expressed desire and repeated cut-back attempts. Although initiation of regular smoking among nonsmokers does not occur frequently after the early twenties, the risk for dependent smoking among regular users persists into adulthood and is associated with a range of mental disorders.

Social phobia is increasingly recognized as a prevalent and socially impairing mental disorder. However, little data is available regarding the general and disease-specific impairments and disabilities associated with social phobia. Furthermore, most studies have not controlled for the confounding effects of comorbid conditions. This study investigates: (a) the generic quality of life; (b) work productivity; and, (c) various other disorder-specific social impairments in current cases with pure (n = 65), comorbid (n = 51) and subthreshold (n = 34) DSM-IV social phobia as compared to controls with no social phobia (subjects with a history of herpes infections). Social phobia cases reported a mean illness duration of 22.9 years with onset in childhood or adolescence. Current quality of life, as assessed by the SF-36, was significantly reduced in all social phobia groups, particularly in the scales measuring vitality, general health, mental health, role limitations due to emotional health, and social functioning. Comorbid cases revealed more severe reductions than pure and subthreshold social phobics. Findings from the Liebowitz self-rated disability scale indicated that: (a) social phobia affects most areas of life, but in particular education, career, and romantic relationship; (b) the presence of past and current comorbid conditions increases the frequency and severity of disease-specific impairments; and, (c) subthreshold social phobia revealed slightly lower overall impairments than comorbid social phobics. Past-week work productivity of social phobics was significantly diminished as indicated by: (a) a three-fold higher rate of unemployed cases; (b) elevated rates of work hours missed due to social phobia problems; and (c) a reduced work performance. Overall, these findings underline that social phobia in our sample of adults, whether comorbid, subthreshold, or pure was a persisting and impairing condition, resulting in considerable subjective suffering and negative impact on work performance and social relationships. The current disabilities and impairments were usually less pronounced than in the past, presumably due to adaptive behaviors in life style of the respondents. Data also confirmed that social phobia is poorly recognized and rarely treated by the mental health system.

Anxiety and depressive disorders are common mental disorders in general population, imposing tremendous burden on both affected persons and society. Moreover, comorbidity between anxiety and depressive conditions is high, leading to substantial disability and functional impairment. Findings consistently suggest that anxiety disorders are primary to depression in the majority of comorbid cases. Yet, the question of whether anxiety disorders are risk factors for depression, and potentially even causal risk factors for the first onset of depression, remains unresolved. Recent results have shown that anxiety disorders increase the risk for subsequent depression, and also affect the course of depression, resulting in a poorer prognosis. Further, some results suggest a dose–response-relationship in revealing that a higher number of anxiety disorders and more severe impairment associated with anxiety disorders additionally increase the risk for subsequent depression. The goal of this paper is to review recent literature, summarize implications of previous findings, and suggest directions for future research regarding preventive and intervention strategies.

Syftet med denna studie är att undersöka vilka uppfattningar som lärare, speciallärare och specialpedagoger har kring vilka stödåtgärder som prioriteras för elever med samtidig dyslexi och ADHD, komorbiditet. För att få tillgång till dessa lärarkategoriers uppfattningar genomfördes elva semi-strukturerade intervjuer. Resultatet som framkom var för det första att det inte fanns någon kunskap om begreppet komorbiditet och vad det innebär, och för det andra att alla informanter kunde erinra en elev som troligtvis haft denna kombination utan att skolan vetat om det. Det framkom även att ADHD är det som prioriteras när stödåtgärder sätts in, eftersom det är svårt att bedriva undervisning om eleven har stora koncentrationssvårigheter och/eller är utåtagerande. Stödåtgärder för dyslexi sätts oftast inte in förrän eleven kommit upp på mellanstadiet och blivit utredd för sin ADHD samt fått medicin som lugnat beteendet. Relation lyfts fram som mycket viktigt för att arbetet med eleven ska bli framgångsrikt. Kunskapen om vilka stödåtgärder som fungerar bäst varierar från stor kring ADHD, relativt stor kring dyslexi, till att vara i stort sett obefintlig kring den komorbida formen ADHD - dyslexi.

The purpose of this study was to examine staff's experiences of comorbidity between persons with disabilities and substance abuse disorder as well as collaboration between the concerned occupational activities. We used a qualitative method and interviewed six informants from four different municipalities. With organisational theory and stamping theory, we analysed the result and comparing with the earlier research contributed to the reflections in the discussion. The result showed that comorbidity is not unusual and that it can be difficult for staff to handle at times. Furthermore, it emerged that the collaboration situation is an important part of the work of the occupational activities. Other types of collaboration models may be needed for the target group, since collaboration must not become a forum for professionals to distribute the work, unless it focuses on the individual's needs and wishes. / Syftet med studien var att undersöka personalens, boendepersonal och chefer på mellannivå, erfarenheter av samsjuklighet mellan funktionsnedsättningar och substanssyndrom hos brukare/boende samt samverkan mellan berörda verksamheter. Vi använde oss av kvalitativ metod och intervjuade sex personer från fyra olika kommuner för att besvara studiens syfte. Med organisationsteori och stämplingsteori analyserade vi resultatet och jämförande med den tidigare forskningen bidrog till reflektionerna i diskussionen. Resultatet av studien visade att det inte är ovanligt med samsjuklighet i verksamheterna och i perioder kan det vara svårt för verksamheterna att hantera det. Vidare framkom det att samverkan utgör en viktig del av verksamheternas arbete men att det kan behövas andra typer av samverkansmodeller för målgruppen då samverkan inte får bli ett forum för professionella att fördela arbetet utan fokus på den enskildes behov och önskemål.

The purpose of this qualitative study is to examine barriers and facilitators to collaboration within compulsory care for substance abusers according to LVM. Furthermore, the aim is to examine how these factors affect the care provided to clients with comorbidity of substance abuse and mental health disorders. The empirical data are based on experiences of professionals who work at the social services, at LVM-institutions and at operations that accept clients according to 27 § LVM. The result is divided into three periods, which are before the institution, during the institution and after the institution. The barriers and facilitators are divided into three theoretical themes in each period. These themes are regulations, organisation and point of view. Different forms of vertical and horizontal integration are used to supplement the analysis and examine what significance each form of integration has on the care provided to clients with comorbidity. The result shows that the barriers and facilitators are relatively similar in each period of the LVM-care. Overall, it seems that it is set up for the collaboration to fail at some point because of the unpredictable barriers, which is why it is important that a high degree of both vertical and horizontal integration exist, since one of them is not enough to bring overall satisfactory care for the clients with comorbidity. A closeness to each other and an organisation that is more coordinated can lead to a high degree of integration on both levels.

Background: Tertiary hospitals have multiple specialist outpatient clinics attended by patients suffering from various comorbid diseases. This results in individuals attending more than one clinic per month, since dedicated clinic days are seldom on the same day. As patients attend discrete clinics, they have separate encounters with various prescribers, increasing the potential for irrational drug use. In addition, multiple clinic visits have a negative socio-economic impact on health care users from poorer communities where financial resources are limited due to transport expenses and days of work missed. The aim of this study was to determine the prescribing pattern of drugs to chronic disease outpatients, and find possible solutions to provide a system that would reduce overprescribing of chronic medication at Steve Biko Academic Hospital (SBAH) in one measure namely drug duplication. Methods: A retrospective descriptive cross-sectional study with the use of convenience sampling was employed to determine the medication prescribing practises to comorbid chronic disease patients attending multiple specialist clinics at SBAH from February 1, 2018-May 31, 2018. Participants were selected according to their appearance in the hospital records, with sample saturation reached when each participant had visited all the different clinics. Chronic disease outpatients attending the SBAH clinics had reviews every three months. The reviews were controlled by issuing patients with medication for a three-month period, where after a follow up visit was mandatory in order to ensure prescription and medication renewal. Therefore, each patient visited all the clinics rendering a service relating to a specific chronic condition within a four-month period that determined the study period chosen. Hospital records of patients attending the most frequently visited clinics as reported by the SBAH Pharmacy and Therapeutics committee (PTC) were evaluated. These clinics included outpatient departments of diabetes, haematology, internal medicine, neurology, oncology and psychiatry. Each drug prescription observed was evaluated using guidelines of World Health Organization (WHO) titled, “How to investigate drug use in health facilities: selected drug use indicators.” Prescribing indicators relevant to this study were used from the WHO guidelines. Results: One hundred and six patients were multiple clinic-attendees during the study period. Of the 106 patients retained, 103 (97.17%) patients attended two clinics and three (2.83%) patients attended three clinics. Regarding the WHO prescribing indicators, the average number of visits to SBAH by the comorbid chronic disease outpatients observed was 3.03 visits during the four-month study period. Prescription analysis included 80 (75.47%) patients out of 106 patients attending multiple clinics at the same time. The average number of drugs prescribed per encounter was 4.97. The results also showed that 45.45% of the 187 prescriptions observed contained five or more drugs. Most frequently prescribed drugs were tramadol 51 (5.49%), followed by simvastatin 48 (5.17%) and enalapril 45 (4.84%). Drug duplication occurred in 68 individual cases in the 80 patients observed. In total, drug duplication affected 39 patients (48.75%) [95% CI = 37.80%: 59.70%]. The most duplicated drug classes were analgesics 18 (26.47%), followed by anti-depressants 14 (20.59%) cases recorded. Conclusion: The results from this study support findings from similar studies at different institutions. The study confirmed multiple clinic visits are prevalent in the medical disciplines, often prescribing drugs from the same class. Clinical implications from these frequent and separate encounters may result in irrational prescribing, adverse drug events, drug-drug interactions and polypharmacy. The establishment of polypharmacy to comorbid chronic disease patients indicates the high risk of drug-drug interactions and adverse drug events. A prospective study would have provided more data for analysis to determine the level of polypharmacy and drug duplication. Thus, supplementation of this study with further studies could provide conclusions on whether the patients suffered from problematic or had appropriate polypharmacy. Physicians treating multiple clinicattendees should be equipped to monitor rationality of prescribing encounters. Installation of an advanced electronic Hospital Information System (HIS) could aid in improving drug prescribing in tertiary hospitals. Use of electronic prescribing tools as shown in previous studies is a requirement to improve tertiary hospitals in developing countries such as SBAH. The incidence of drug duplication at SBAH builds on existing evidence of unnecessary healthcare costs because of medication errors. / Dissertation (MSc)--University of Pretoria, 2020. / Pharmacology / MSc (Pharmacology) / Unrestricted