<p>According to the health care law and the national care guarantee, all individuals with mental illness have the right to good health care that is knowledge based as well as to rehabilitation where and when they need it. They also should be able to choose and have control over who is performing the care, including the design of these efforts. The purpose of this study is to investigate patients' experiences of general psychiatric emergency care and the cooperation between outpatient care, inpatient care and the municipality. This study is a descriptive cross-sectional study, conducted with a quantitative and qualitative method. The study is performed in collaboration with Akademiska Sjukhuset and is part of a larger quality improvement project. The participants in the study are patients who got in contact with the general psychiatric emergency care during a 6 weeks period. Data collection method consists of a questionnaire that was distributed to patients at discharge from different units. The questionnaire was designed by the project's principals, in collaboration with department managers, operations manager and the authors. The results show that the psychiatric care can be improved in all the areas this study has highlighted, where; encounter, information, participation and staff availability are included. The improvements, which need to be done, are not only between patients and health professionals, but also improvements between and within different professions in the mental health services.</p> / <p>Enligt hälso- och sjukvårdslagen och den nationella vårdgarantin ska alla individer med psykisk sjukdom ha rätt till en god vård som är kunskapsbaserad samt till rehabilitering där och när de behöver den. De ska även ha möjlighet att välja och ha inflytande över vem som utför vården samt utformningen av dessa insatser. Syftet med detta arbete är att undersöka patienters upplevelser av allmänpsykiatrisk vård samt av samarbetet mellan öppenvård, slutenvård och kommun. Denna studie är en deskriptiv tvärsnittsstudie, utförd med kvantitativ och kvalitativ metod. Studien utförs i samarbete med Akademiska Sjukhuset och är en del av ett större kvalitetsförbättrings-projekt. Deltagarna var de patienter som kom i kontakt med den allmänpsykiatrisk akutvården under en sex-veckorsperiod. Datainsamlingsmetoden bestod av en enkät som delades ut till patienterna vid hemgång från olika enheter. Enkäten utformades av projektets huvudansvariga i samarbete med avdelningschefer, verksamhetschef samt författarna. Resultatet visar att den psykiatriska vården kan förbättras i alla de områden som denna studie har belyst där; bemötande, information, delaktighet och personalens tillgänglighet ingår. Det inte bara förbättringar mellan patienter och vårdpersonalen som behöver göras, utan även förbättringar mellan och inom olika yrkeskategorier i den psykiatriska vården.</p>

In recent years, a number of reforms have been made regarding the provision of care to people experiencing psychiatric disabilities. The aim of these reforms was to enable these people to participate in society and to ”live as others”. This political ambition, as well as research on recovery, stands to a certain extent in contrast to the message conveyed in the media, where the mentally ill/disabled to a great extent are represented as dangerous and incurable. The aim of the thesis is to analyse if, and how a group of people experiencing psychiatric disabilities create a sense of being like others, and to relate the analysis to the historical emergence of the contemporary conception of mental illness/psychiatric disability. This thesis employs the method of interviews. I highlight the informants encounter with the historically based stereotype that defines the persons as unreasonable, irrational and incapable of taking care of themselves. When the informants face the stereotype, they act to reduce the negative consequences. The informants’ actions can be interpreted in terms of approaches and in this perspective the informants appear as strong actors, who, contrary to the stereotype, are capable of take care of themselves. Three approaches are described: expertise, adaptation, and distancing. In situations where the stereotype is not present, the informants can create a feeling of being like anyone else. Their stories show that the feeling of being like others is individual. The development taking place in the field is “path-dependent”, meaning that the initial activity, the differentiation of persons with mental illness and the subsequent events is a development following a pattern which could explain the failure of the good political intentions. It has progressed from closed institutions to an institutionalized care service.

Inom rättspsykiatrin vårdas många patienter med samsjuklighet missbruk/beroende. Patientgruppen är heterogen med komplexa och specifika vårdbehov. Vårdare är de som tillbringar mest tid med dessa patienter. Studiens syfte var att beskriva vårdares erfarenheter av att vårda patienter som lider av allvarlig psykisk störning med samsjuklighet missbruk/beroende, inom rättspsykiatrisk vård. Tio sjuksköterskor och tio skötare som arbetade på en rättspsykiatrisk regionvårdsklinik intervjuades och materialet bearbetades med kvalitativ innehållsanalys. Intervjuer gjordes med stöd av en semistrukturerad intervjuguide. Ur analysen framkom 14 subkategorier som bildade fyra kategorier; samverkan, skapa funktionellt vardagsliv, finnas kvar över tid och kunskap/kompetens. Resultatet visade att vårdares samverkan med patienter och övriga yrkeskategorier gav vårdprocessen en helhetssyn. Goda vårdrelationer kunde hjälpa patienter att bryta förnekelse av missbruksproblem. Individanpassade aktiviteter och praktisk färdighetsträning var betydelsefullt i patienters rehabilitering. Vårdprocessen kunde inte forceras och motivationsarbetet var centralt. Klinisk erfarenhet, livserfarenhet, teoretisk kunskap kombinerat med en trygg och stabil personlighet, var den kompetens som enligt vårdare behövdes för att vårda dessa patienter. Inom kunskapsområdet missbruk/beroende upplevde vårdare behov av teoretisk komplettering. / Many psychiatric patients with comorbidity of addiction /dependence are treating in forensic mental health. The patient group is heterogenic with complex and specific health needs. Nursing care staffs are those who spent the most time with these patients. The aim of this study was to describe caregivers' experiences of caring for patients suffering from severe mental disorder with comorbidity of addiction /dependence, in psychiatric care. Ten registered nurses and ten licensed mental nurses who worked at a forensic psychiatric clinic were interviewed, and the material was processed with content analysis. Interviews were conducted with support of a semi-structured interview guide. From the analysis revealed 14 subcategories to form four categories: collaboration, create functional everyday life, persist over time and knowledge / skills. The results showed that nursing care staff´s interaction with patients and other health care professionals gave a holistic approach. Good health care relationships could help patients to break the denial of substance abuse problems. Individualized activities and practical skill training was important in patients' rehabilitation. Nursing process could not be rushed and motivational work was crucial. Clinical experience, life experience, theoretical knowledge combined with a secure and stable personality, were the skills as nursing care staff´s needed to care for these patients. In the area of knowledge abuse/dependence experienced nurses need theoretical completion.

According to the health care law and the national care guarantee, all individuals with mental illness have the right to good health care that is knowledge based as well as to rehabilitation where and when they need it. They also should be able to choose and have control over who is performing the care, including the design of these efforts. The purpose of this study is to investigate patients' experiences of general psychiatric emergency care and the cooperation between outpatient care, inpatient care and the municipality. This study is a descriptive cross-sectional study, conducted with a quantitative and qualitative method. The study is performed in collaboration with Akademiska Sjukhuset and is part of a larger quality improvement project. The participants in the study are patients who got in contact with the general psychiatric emergency care during a 6 weeks period. Data collection method consists of a questionnaire that was distributed to patients at discharge from different units. The questionnaire was designed by the project's principals, in collaboration with department managers, operations manager and the authors. The results show that the psychiatric care can be improved in all the areas this study has highlighted, where; encounter, information, participation and staff availability are included. The improvements, which need to be done, are not only between patients and health professionals, but also improvements between and within different professions in the mental health services. / Enligt hälso- och sjukvårdslagen och den nationella vårdgarantin ska alla individer med psykisk sjukdom ha rätt till en god vård som är kunskapsbaserad samt till rehabilitering där och när de behöver den. De ska även ha möjlighet att välja och ha inflytande över vem som utför vården samt utformningen av dessa insatser. Syftet med detta arbete är att undersöka patienters upplevelser av allmänpsykiatrisk vård samt av samarbetet mellan öppenvård, slutenvård och kommun. Denna studie är en deskriptiv tvärsnittsstudie, utförd med kvantitativ och kvalitativ metod. Studien utförs i samarbete med Akademiska Sjukhuset och är en del av ett större kvalitetsförbättrings-projekt. Deltagarna var de patienter som kom i kontakt med den allmänpsykiatrisk akutvården under en sex-veckorsperiod. Datainsamlingsmetoden bestod av en enkät som delades ut till patienterna vid hemgång från olika enheter. Enkäten utformades av projektets huvudansvariga i samarbete med avdelningschefer, verksamhetschef samt författarna. Resultatet visar att den psykiatriska vården kan förbättras i alla de områden som denna studie har belyst där; bemötande, information, delaktighet och personalens tillgänglighet ingår. Det inte bara förbättringar mellan patienter och vårdpersonalen som behöver göras, utan även förbättringar mellan och inom olika yrkeskategorier i den psykiatriska vården.

Emotional suffering in old age is largely caused by various psychiatric conditions, of which depression is the most common. Depression is associated with a decline in both well-being and daily functioning and reduces both morale and social capacity among the very old, which may produce high health and social costs for society. The overall aim of the thesis was to study the prevalence of depression among the very old, to identify factors associated with depression and to evaluate the prognosis of depression among the very old. In total, 363 people were evaluated for depression, 242 from an urban municipality in the year 2000 and 121 from five rural municipalities in 2002. In 2005, those still alive in the urban municipality were asked to participate again, and were therefore re-evaluated. The prevalence of depression was 27% in the urban municipality, 34% in the rural municipalities and 29% in the total sample. Of those depressed, about 67% were receiving antidepressive treatment, and of those, approximately 50% had responded to treatment. In the rural municipality, the depressed were less often treated with Selective Serotonin Re-uptake Inhibitor medications, receiving instead Tri-Cyclic Antidepressants. In the rural municipalities, only 38% of the depressed had responded to treatment. A higher proportion of women were diagnosed as depressed, 33% vs. 19%, p=0.006, although the response rate was the same for men and women. Depression was twice as common among those with dementia, 44% vs. 23%. There were discrepancies concerning associated factors between the depressed participants with dementia and those without. Experiencing the death of a child during the preceding ten years was associated with depression and independently associated with depression among men and participants with dementia. In all the studies, the depressed were less often able to go outside independently and to visit others. They also received fewer visits from others and often experienced loneliness. The great majority of those who were depressed in 2000 died during the subsequent five years, only 13 out of 65, 22%, were still alive in 2005, compared to 41% of those who were not depressed, p=0.003. Of 13 who survived, only two had recovered. Twenty-four out of 70 non-depressed people, 34%, had developed depression during the five years (2000-2005), and the total prevalence in year 2005 was 42% (35 out of 83 participants). Ten out of the 24 who had developed depression were prescribed antidepressants. Of those ten, four were regarded as responders. In the group with persistent depression, nine out of eleven were receiving antidepressants and 67% were responders. In conclusion, a large proportion of the very old suffer from under-diagnosed and undertreated depression. The response rate to treatment seems to be low, and the quality of treatment and follow-up also seems to be poor. The mortality rate among the depressed was high. The spectrum of factors associated with depression in people with dementia is different from that associated with depression among non-demented. Depression among the very old clearly emerges as a common and serious public health problem, with probably the most serious impact on quality of life. More efforts have to be made to improve the quality of assessments, treatment and research regarding depression among the very old.

Background: The challenges of research in economically stunted countries’ settings remains a profound concern and is linked to socioeconomic development of these countries. More research is needed regarding psychiatric morbidity in rural areas of the developing and poverty stricken countries. The present studies were undertaken within the framework of a broader ongoing community-based project on the course and outcome of major psychiatric disorders in the rural Butajira district located in Ethiopia. This thesis treats the course and outcome of bipolar I disorder in the district. Objectives: Through appraising mental health and population based research in a rural Ethiopian district, to evaluate the utility of modern research instruments, and to obtain baseline information relating to bipolar I disorder in the poverty stricken rural Butajira district of Ethiopia. The specific objectives were: 1. Evaluating and comparing two different screening methods of case detection and identification for schizophrenia and bipolar I disorder in the adult population of Butajira district. 2. Assesing the prevalence and clinical characteristics of of bipolar I disorder in Butajira at the community level. 3. Evaluating short-term outcome at follow-up of bipolar I disorder in the Butajira district. 4. Determining Neurological Soft Signs in community-identified cases of bipolar I disorder in Butajira district in comparison with healthy controls. 5. Assessing the burden of care among caregivers of those affected by bipolar I disorder identified in the Butajira Study. Methods: The district’s entire adult population aged 15-49 was identified through a double-sampling design. In the first stage of screening, door-to-door interviews were conducted by lay trained high school completed individuals who knew the culture of the people. Females interviewed females whereas males interviewed males. Additionally, the key-informants method was used to identify cases that would be missed by the CIDI or otherwise. The final confirmatory diagnostic interview was conducted by clinicians using the SCAN on door-to-door basis as well. The probable cases that fulfilled the lifetime DSM-IV diagnosis of bipolar I disorder were assigned for assessment by other baseline research instruments such as Neurological Evaluation vii Scale (NES), Young Mania Rating Scale, Hamilton Rating Scale for Depression, LCSS, PANS and SANS, BISS, BII, FIS and so on. Cases so identified with bipolar I disorder were subject to a follow-up for upto 2.5 years on the average (range 1 to 4 years). Two of the main clinical outcomes assessed were relapse to a mood episode, and remission from a mood episode. Outcomes were assessed annually by the instruments, and were further assessed monthly by trained psychiatric nurses. We also did a cross-sectional study of caregivers of bipolar I disorder cases, and assessed objective burden on the caregivers as considered from social, family strain, occupational and financial domains. Results: Information provided by the key informants was better at detecting schizophrenia or chronic psychiatric disease, whereas the CIDI was better at detecting affective disorders. Of the around 100 000 adults living in Butajira, 83.3% were found by the project’s census, of which 82% (68,378 subjects) were successfully screened by the CIDI, yielding 2,161 CIDI positive. These, together with 719 cases identified by the key informants, were invited for the SCAN interview, of which 74.7% agreed. This yielded 315 SCAN positive cases for bipolar I disorder, and complete information could be collected on 295 of these. Lifetime prevalence was estimated as 0.6% for males and 0.3% for females. The mean age of onset of the manic phase was 22.0 years and that of the depressive phase was 23.4 years. For 22.7% of the cases the illness started with a depressive episode and for the remaining 77.3% it started with a manic episode. Over half of the cases (55.9%) had never sought help from modern health care sector, and only 13.2% had ever been admitted to psychiatric hospital. At follow-up, 65.9% had exprerienced a relapse and 31.1% had persistent illness, while only 5% of the patients were in remission for most of the follow-up time. The bipolar I cases, as compared with healthy controls, performed worse on several items of NES, thus having more neurological dysfunction compared to controls. Caregives were largely (80.3%) first-degree relatives and spouses. Overall, 84% of the caregivers reported difficulties in at least one of the domains of family burden. Of these, 58.7% reported a severe degree of difficulties. Caregivers reported a high level of difficulties in intrafamilial relationships and social restrictions, disruption in earning a livelihood, and financial difficulties. Conclusions: The prevalence of bipolar I disorder is comparable to the prevalences reported from other countries, and our findings support the cross-cultural validity of the concept of bipolar I disorder. Majority of the cases are not treated in contrast to that in the developed countries. The burden of care for the caregivers is substantial in the population studied.

In developed countries, suicidal behaviour is recognised as a significant public health problem among young people, but there are few studies from developing countries on this subject. The present thesis aims at estimating the extent of the problem and at exploring factors related to suicidal behaviour among young people in a developing country, Nicaragua, using a combined quantitative and qualitative approach. Three studies were conducted between 1999 and 2006. In the first study, all hospital admitted suicide attempt cases in the area of León were assessed over a three year period. Secondly, a qualitative study using individual in-depth interviews was conducted with eight girls aged between 12 and 19 admitted to hospital after attempting suicide. Thirdly, a study using the Attitudes Towards Suicides (ATTS) questionnaire was conducted in a community based sample of 278 young people aged 15-24 years to assess own suicidal behaviours, attitudes towards suicide as well as exposure to suicidal behaviour among significant others. The hospital surveillance showed that suicide attempt rates were highest among females in the age group 15-19 years with a female rate three times that of males (302.9 versus 98.9 per 100,000 inhabits per year). Drug intoxication and pesticides were the most commonly used methods for the attempts. A consistent seasonal variation with peaks in May-June and September-October was found in each of the three years, possibly related to exam periods in schools. Findings in the qualitative approach led to a tentative model for pathways to suicidal behaviour based on four main categories: Structuring conditions, triggering events, emotions and action taken. Dysfunctional families, lack of confidential and trustworthy contacts and interpersonal conflicts followed by emotions of shame and anger were some important components in the model. The community studies showed that suicidal expressions (life-weariness, death wishes, suicidal ideation, suicide plans and suicide attempts) were common among young people where more than 44.8% of males and 47.4% of females reported some kind of suicidal expression. Gender differences were small. Exposure to suicidal behaviour among others was associated with higher levels of self-reported suicidal behaviour. The attitude study showed that boys had less pro-preventive attitudes than girls, possibly indicating their higher risk for completed suicide. Exposure to suicidal behaviour and own suicidal behaviour showed an association with specific patterns of attitudes. The findings should be taken into consideration when planning for prevention of suicidal behaviour among young people in a developing country like Nicaragua.

Background: There are about 23.7 million internally displaced persons worldwide today, still living in the low-income countries. Ethiopia has for the past four decades been ravaged by war and famine. A lengthy civil war resulted in Eritrea, formerly a part of Ethiopia, becoming an independent state in 1991. This war led to displacement of one million people, and currently there are about 55000 internally displaced Ethiopians in Addis Ababa, most of them living in temporary shelters. A minority resettled in a small town Debre Zeit south east of Addis Ababa, dispersed in the community. Objectives: To study the consequences of trauma and extreme stress among these displaced persons. Methods: A random sample of 1200 displaced persons was selected from the Kaliti and Kore shelters of Addis Ababa, aged between 18 and 60 years. They were interviewed by internationally validated instruments which were translated into the Ethiopian official language Amharic. Information thus obtained covered sociodemographics, childhood trauma, traumatic life events, and mental distress as assessed by the SCL-90-R, the four domains of quality of life assessed by WHOQOL-BREF, coping strategies, perceived social support, and basic living conditions. A sample of 120 subjects from the displaced persons living in Debre Zeit was similarly evaluated. A study comparing prevalence rates and risk factors for PTSD in four postconflict, low-income countries (Algeria, Cambodia, Ethiopia, Gaza) was also undertaken. Results: Men, compared to women, reported significantly higher experience of trauma, higher perceived social support, and higher task-oriented coping. Women reported higher emotion-oriented coping. In both genders, emotion-oriented coping was correlated with higher trauma events, and task-oriented coping was correlated with higher perceived social support. Mental distress increased and quality of life decreased with age. Mental distress mediated the effects of most trauma in reducing quality of life, and some trauma reduced quality of life directly. Living conditions were also significantly related to quality of life. Coping strategies and perceived social support influenced mental distress and quality of life directly as well as indirectly by moderation, in part gender specific. Placement in the community setting of Debre Zeit gave a better quality of life compared to placement in the shelters of Addis Ababa. This difference was accounted for by the difference in living conditions, particularly protection from animals (rodents) and insects (mosquitoes), for three domains of quality of life. For domain 3 (social relationships), however, several further factors accounted for the difference, like marital status, ethnic belonging and coping strategy. The comparative study of 4 postconflict countries contributes to the theory that trauma may be the direct cause of the onset of PTSD but that a multiplicity of other adverse events determine the development of this disorder. Conclusions: Using the same assessment methods, a wide range of rates of symptoms of PTSD were found among 4 low-income populations who have experienced war, conflict, or mass violence. In the Ethiopian context we also found gender differences in the trauma background, coping strategies and perceived social support. Mental distress mediated much of the effects of trauma on quality of life. Coping strategies and perceived social support were significant moderators in this process.

Anorexia Nervosa är en komplex sjukdom som kräver en individualiserad vård. Då patienter med anorexi ofta kännetecknas av att vara ambivalenta angående att tillfriskna, behövs ett gott samarbete och en god relation med sjuksköterskorna. Syftet med studien är att undersöka vad god omvårdnad innebär för patienten och sjuksköterskan vid vård och behandling av Anorexia Nervosa. Arbetet är utformat till en litteraturstudie grundad på tio vetenskapliga artiklar. I resultatet, som är tvådelat, framkommer sju teman vilka är självständighet, socialt stöd, isolering, en utmaning, relationen, omtanke och respekt samt tillit. I resultatet framkom det att patienter prioriterade ett gott stöd från sjuksköterskorna genom att finnas tillhands, visa omtänksamhet samt vara icke-dömande. Sjuksköterskorna ansåg att vägen till god omvårdnad var; empati, tillit, acceptans samt ömsesidig respekt. Slutsatsen blev att en god relation mellan patienten och sjuksköterskan var av stor betydelse för att nå framgång i behandlingen av Anorexia Nervosa. Förhoppningen med denna studie är att sjuksköterskor ska kunna få en inblick och ta lärdom av det presenterade materialet, för att på så sätt förbättra omvårdnaden av flickor med diagnosen Anorexia Nervosa. / Anorexia Nervosa is a complex disease that requires an individual treatment. Patients with Anorexia are known to be ambivalent when it comes to making a recovery and therefore need strong teamwork and a good relationship with the nurse. The aim of this study is to examine what good care means for the patient and the nurse when it comes to treating Anorexia Nervosa. The essay is a literature review based on ten scientific articles. In the result, which is divided in two parts, seven themes arise and these are: independence, social support, isolation, a challenge, the relationship, caring and respect and trust. In the result it was revealed that the patients prioritize support from the nurses, showing that they care and don’t judge the patients. The nurses describe compassion, trust, acceptance and mutual respect as important parts in the given care. The conclusion is that a good relationship between the nurse and patient means a great deal to achieve success when treating Anorexia Nervosa. Hopefully this study gives nurses an ability to learn from the presented material, and be able to improve the care of girls suffering from Anorexia Nervosa.

Forensic psyhiatric care protects the society by giving patients care to diminish risks of serious crimes. In their work the nurses use different care methods to help and support the patient in managing his or her life situation. To clarify how a group of nurses describe the nursing process in forensic psychiatric care. A qualitative study based on interviews. Six nurses were interviewed about their work in four different forensic psychiatric care units. The nursing process in is divided into four categories: evaluation, planning, implementation and assessment. The results are based on the way the interviewed nurses described the essential roles of nurse-patient relationship and structured routines in nursing process. The study also shows some specific difficulties in nursing work, for example the mental dysfunctions of patients, the level of competence among staff and the patients need for social interaction and existence beyond their specific needs.