I samband med industrialismens framväxt inrättades institutioner i större skala. Den ökade mängden omhändertagna på institution vid 1800‐talets slut kan förklaras med fler medicinskt diagnostiserade, en ökad utstötning, lägre tolerans för avvikande beteende, läkarintresse för ett nytt revir, låg utskrivningsfrekvens och hospitaliseringseffekter. Antalet vårdplatser inom den psykiatriska vården minskade under 1900‐talets sista hälft. År 1992 tillsatte regeringen den så kallade psykiatriutredningen som slog fast att personer med kronisk psykiatrisk sjukdom utgjorde en grupp i samhället som karaktäriserades av allvarligt handikappade personer som berövats sina medborgerliga rättigheter och som hade få resurser till sitt förfogande. Psykiatrireformens intentioner genomsyras av bland annat begreppen normalisering och autonomi. De psykiskt funktionshindrades levnadsvillkor skall normaliseras för att öka deras möjligheter att leva som andra, vilket betyder att de ska delta i besluten om sin egen vård och behandling. Avhandlingen har sin grund i ett hermeneutiskt perspektiv, det vill säga att människor aldrig kan förstå något helt fördomsfritt eller förutsättningslöst. Förförståelse kan förstås som en form av föraning/förkänsla och första idé om det sökta fenomenet, vilket leder förståelsen i en viss riktning. Perspektivets innebörd är att ingen förståelse kan växa fram förutsättningslöst, dvs. växa fram utan någon på förhand given inställning från forskarens sida. Studiens övergripande syfte är att belysa vårdares attityd till personer med psykiska symtom. Avhandlingen består av fyra delarbeten med såväl kvantitativ som kvalitativ design. Data har insamlats med hjälp av frågeformulär, skattningsskalor samt narrativa intervjuer. Resultatet i delstudie I visar att fyra typologier som upptäckts i en tidigare kvalitativ intervjustudie existerade (god, ond, tokig och osynlig). Delstudie II visar att vårdarnas syn på inneliggande deprimerade patienter i hög grad bestäms av diagnosen. Syftet med delstudie III var att klargöra om patientens och vårdarens bild av patientens historia, nutid och framtid överensstämde med varandra. Resultatet visar på en tydlig skillnad mellan parterna. I delstudie IV var syftet att belysa före detta patienters upplevelser av att vara inlagda på en psykiatrisk avdelning. Studien visar att de tidigare patienternas upplevelser mestadels var negativa och att de kan tolkas som om det under sin sjukhusvistelse varit utsatta för ett subtilt förtryck. För att förstå vårdarnas syn på den drabbade personen kommer resultatet i studien att tolkas utifrån en teoretisk referensram inspirerad av den franske filosofen Michael Foucaults och den ryske filosofen Mikhail Bakhtins texter. Tolkningen visar att vårdarna har en tendens att undvika “annanhet” (otherness) och därigenom se patienten enbart som en karaktär, en typologi. Härigenom kommer patienten att placeras i ett ”ingenmansland”, i en kontext där han/hon inte tillhör vårdargemenskapen samtidigt som kontakten med den gamla privata gemenskapen upphör. Genom att se patienten som ett enskilt fall undviker vårdarna att se det lidande som finns i ”rummet” och därigenom blir det ”rum” som skapas till en ”isvärld” som inte är livsbejakande och därför ohälsosam för patienten. Att förändra vårdarnas attityder är en långvarig samhällelig process som kräver inte bara resurser i form av utbildning och handledning utan kanske främst utrymme för kontinuerlig diskussion och debatt. Grunden för förändringen finns redan idag i psykiatrireformens ideala normaliseringsbegrepp. Kravet är dock att politiker och tjänstemän inom vård och omsorg börjar leva upp till lagens intentioner. Detta kräver dock att synen på en person med psykisk sjukdom psykiskt handikapp måste ändras på samma sätt som till exempel synen på homosexuella ändrats från att de varit marginaliserade och levt i ett utanförskap, till att bli sedda som fullvärdiga samhällsmedborgare. För att bryta det strukturella maktmönstret behövs en total samhällelig attitydförändring. Endast en politisk förändring är inte tillräcklig.

Syftet med studien var att undersöka hur samarbetet för individer med samsjuklighet ser ut mellan kommun och landsting samt hur möjligheterna ser ut till samordnad vård och behandling. Frågeställningarna var att ta reda på hur samarbetet ser ut mellan kommun och landsting gällande individer med samsjuklighet samt vilka tillvägagångssätt som finns för att förbättra samordnad vård och behandling mellan kommun och landsting. Studien genomfördes med kvalitativa semistrukturerade intervjuer. Den teoretiska utgångspunkten var Fridolfs (2004) fyra motiv till ett bra samarbete. Utifrån det hermeneutiska synsättet tolkades intervjuerna inför resultatet med hjälp av innehållsanalys. Resultatet visar att det finns ett samarbete mellan kommun och landsting men för förbättring behövs det mer erfarenhet och kunskap om varandras arbetsuppgifter. Slutsatsen av resultatet är att mer forskning fordras om hur och på vilket sätt samarbete mellan kommun och landsting kan förbättras. Kan en gemensam huvudman vara ett alternativ?

The intertwined relationship between physical and psychological problems is a topic of much interest in the rehabilitation of severely injured patients, e.g. after a burn. The present study aims at gaining further knowledge concerning the impact of psychological factors and psychiatric morbidity on short and long-term adaptation after burn injury. Outcome was assessed for three main areas: pruritus, return to work and psychiatric health. Three separate samples of previous or current adult patients treated at the Uppsala Burn Unit during different time periods: 1980-1995 (n=248), 1996-2000 (n=86), and 2000-2005 (n=73), were assessed. Chronic burn-related pruritus is more common than previously reported and psychological factors such as anxiety-related personality traits and coping are significantly associated with its presence. Only a small group of former patients with work-related accidents were not working an average of nine years after injury. The unemployed reported more pain and worse perceived health, particularly in psychosocial domains. Returning to work was explained by both injury severity and personality characteristics. Those who were not working had lower health-related quality of life and poorer traumarelated physical and psychological health, and more pain. Preburn psychiatric morbidity is high in a lifetime perspective. Two thirds of the sample had at least one disorder according to the Structured Clinical Interview for DSM-IV Axis I disorders. Affective disorders were especially highly represented. A logistic regression showed that having a history of preburn disorders was associated with a higher risk of both PTSD and depression one year after the injury. In this material it was actually uncommon for a patient without a preburn psychiatric history to develop postburn psychiatric symptomatology. The results have strengthened the overall model for adaptation after burn injury by showing that psychological factors and psychiatric history are important moderators of the adaptation process after the injury.

Background Depression is a very common disorder that causes great suffering for the patient. Recognizing depressed patients in primary care (PC) settings is a challenge and only about half are identified as depressed by their general practitioner (GP). Among patients receiving antidepressants (AD) about 70 % are improved, but only about 35 % reach remission. Hence, there is a need to identify depressed patients and to develop optimal treatment strategies in PC. Self-rating scales can be helpful in assisting the recognition. Patients’ beliefs about the cause of depression and their attitudes towards treatment options have been found to influence their help-seeking behavior, coping strategies, treatment preferences and adherence. To increase depressed patients’ knowledge about their disorder and to help them reach and stay in remission, the “Contactus program” was launched in Sweden, containing patient education and group counseling, as supplement to the usual care in PC. Aims To explore patients’ beliefs about causes and improvement factors for depression, and evaluate if the Contactus program could help to improve treatment outcome. Also, to investigate the psychometrics of two commonly used self-rating scales for depression, HADS and PHQ-9. Methods Treatment outcome among patients participating in the Contactus program (N=205) was compared to a control group (N=114) treated as usual. The outcome was measured by HADS, GAF-self and by questionnaires. Both groups also answered an open-ended question about the cause of their depression at baseline and another question about improvement factors at follow-up after six weeks. To compare HADS and PHQ-9, patients (N=737) visiting their physician because of depression filled in both scales. The scales cut-offs were compared with Cohen’s Kappa, internal consistency was calculated and factor analysis was performed.  Results Depressed patients participating in the Contactus program had a response rate of 55 % compared to 29 % in the control group (p=0.006). Also, remission was reached among 42 % in the Contactus group and 21 % among the controls (p=0.02). The patient’s subjective evaluation of the outcome after six weeks showed that 72% of the Contactus patients considered themselves improved vs. 47% among controls (p=0.01). The most common described reason for depression was current stress, most often work related, and own personality traits. Very few mentioned biological factors. For improvement, the most commonly mentioned aspects were participation in the Contactus program and AD. When comparing HADS to PHQ-9 their agreement at recommended cut-offs, HADS-D≥11 and PHQ-9≥10, was low (k=0.35). The highest Kappa value (0.56) and also equal prevalence of depression were found at HADS-D≥8 and PHQ≥12. Both scales had a high internal consistency (α=0.9). Conclusions The results of this thesis indicate that patient education and group counseling are valuable supplements to usual treatment of depression in PC. It is also clear that patients and professionals often have different opinions about the causes of depression, at least concerning biological factors. The patients were generally positive to professional help. The patients’ own beliefs about their illness must be considered when developing new types of interventions and when trying to reach an understanding in the patient-doctor encounter. Finally, there are many self-rating scales for depression. Here two scales were compared and both showed good psychometric properties in terms of internal consistency and factor structure. However their optimal cut-offs were questioned. In conclusion, self-rating scales are useful in identifying depressed patients in PC and might also be apt for measuring treatment outcome. Offering the patient education about their disorder and possibility to share experiences seems to increase response and remission rates, substantially. More studies are needed to explore the effects of educational programs, group interventions, and how patients’ own believes interact with the choice of treatment, adherence and outcome.

The aim of this thesis was to critically examine the current use of the Camberwell Assessment of Need (CAN) in outcome assessment for service evaluation. A further aim was to propose a metric for assessing the adequacy of community mental health services in meeting ongoing needs over longer stretches of time. We made four prospective follow-up studies of CAN assessments of patients with severe mental illness in community-based mental health care. A factor analysis (n=741) gave support for a three-factor model, comprising only 60% of the CAN items. Need assessments (n= 92) in 1997 and 2003 were compared at both the summed total and the underlying item levels of the CAN. The mean total scores did not change, yet there were significant changes in the underlying items. Changes in mean number of needs between 1997 and 1999 were measured (n=262) with both total scores, summed over all CAN items, and with sub-total scores, summed over two sets of items reflecting the social services and the psychiatric services respectively. As indicated by the sub-total scores, all significant changes occurred within the psychiatric services, a result not possible to discern from the total scores. The Met Needs Index (MNI), defined by us as the aggregate measure of beneficial outcome, indicated that needs in general were met during 71% of the intervals between the annuals assessments from 1997 through 2004. However, the variation among particular items was large. In conclusion, the summary scores typically used as outcome measures are likely to conceal meaningful variation at the item level. Nevertheless, sub-total scores, being more transparent, might be more useful in outcome assessment. The MNI is a continuous, normally distributed metric, estimable over any number of consecutive assessments, which seems suitable for assessing the achieved benefit of services for patients with long-term ongoing needs.

A major burn is one of the most severe traumas a person can experience, and recovery can be a protracted process. The principal aim was to increase the knowledge base regarding factors related to return to work and health-related quality of life (HRQoL) after burns. Patients treated at the Uppsala Burn Center between 2000 and 2007 were included on a consecutive basis. Assessments were made at hospitalization, and thereafter and included a home visit 2 to 7 years after injury. The psychometric properties of the generic HRQoL instrument EQ-5D were investigated. The results support the use of EQ-5D as an adjunct to burn-specific assessments of HRQoL. Most former patients exhibited a good HRQoL at 2 to 7 years postburn. Not working at the time of injury and having PTSD at 12 months, as well as having low scores on the EQ VAS at 12 months, were related to a worse EQ VAS score at 2 to 7 years after injury. The majority of former patients had returned to work 2 to 7 years postburn. Time to return to work was predicted by length of hospital stay and a personality disorder diagnosis. Predictors for not returning to work were length of stay and having any anxiety or substance use disorder prior to injury. Those who were not back at work reported lower generic and burn-specific health, and exhibited more psychiatric morbidity at follow-up than those who were working. The latter group exhibited HRQoL that was comparable to that of the general population. Participants emphasized their own psychological resources and capabilities as facilitators in the process of returning to active work. The findings suggest that an early and systematic approach for assessing recognized risk factors enhances the possibility of discovering patients at risk of developing problems during postburn adaptation.

Psykisk ohälsa ökar i samhället, 20 % av Sveriges befolkning riskerar att någon gång i livet drabbas av depression. 600 personer varje år drabbas av kronisk njursvikt vilket innebär att dialysbehandling kan bli aktuellt. Att leva med en livslång sjukdom, som det innebär när man behandlas med dialys, och samtidigt drabbas av psykisk ohälsa innebär ett stort lidande för den enskilda individen. Genom att sjuksköterskan bemöter patienterna med empati och medmänsklighet så skapar denne goda förutsättningar för att relationen ska präglas av tillit och ärlighet. Syftet med denna litteraturstudie var att belysa hur sjuksköterskan kan identifiera och förebygga depression hos människor som behandlas med dialys. Resultatet visar att depression är vanligt förekommande bland dialyspatienter. Depression hos dessa människor kan leda till sömnproblem, nutritionsproblem, känsla av förlust och social isolering. Identifiering av depression kan ske genom användning av bedömningsformulär, detta kan även användas som en åtgärd för att förebygga depression. Mer kvalitativ forskning inom ämnet hade varit ett bra sätt för att öka förståelsen för denna patientgrupps situation. Genom att öka kunskapen ökar också förståelsen för depression och vad det innebär att leva med en livslång sjukdom och denna komplexa situation. / Mental illness is increasing in society, 20% of Sweden's population is at risk to suffer some from depression at some point in their lives. 600 people each year suffer from chronic kidney failure, which can lead to the need for dialysis treatment. To live with a lifelong disease and suffer from mental illness at the same time exposes the individual for a great suffering. By responding to the patients with empathy and compassion the nurse creates good conditions for the relationship, to be able to be characterized by trust and honesty. The purpose of this literature study was to elucidate how the nurse can identify and prevent depression for people treated with dialysis. The results show that depression is common among dialysis patients. For these people, depression can lead to sleeping problems, nutritional problems, feelings of loss, and social isolation. Identification of depression can be done through the use of evaluation forms; this can also be used as a measure to prevent depression. More qualitative research on the subject would be a good method to increase the understanding of the situation these patients are in. Raising awareness also increases the understanding of depression and what it means to live with a lifelong disease, and the complex situation it means.

In this paper the authors are focusing on people that work in psychiatric acute care. How do they identify the individual that is in most need of acute care? How do they judge in this kind of cases?    The foundation in this study is in the qualitative method. The material to this study has been collected by doing qualitative interviews with six people in different professions and positions in psychiatric acute care.    The material that we collected from these six qualitative interviews has been analysed with help from Sherif’s and Hovland’s (1961) Social judgement theory. The theory describes people’s judgement based on certain criterions and how it affects them.     It has been noticed that the individuals who asses first acute care are usually the ones that has a suicidal behavior. The resources are decreasing while the need for psychiatric acute care is increasing. The personell have to make decisions about which individual that are in most need of acute care. Their judgments are very important for the indiviuals in need of immediate care. This judgement can be depending on which individual who is doing the judgemet. This paper has given us comprehension for the immortance of good individual properties for doing judgements, and that they are made in several positions.

Depression och psykisk ohälsa är idag ett stort hälsoproblem. Trots att motionens positiva hälsoeffekter är välkända är det få inom sjukvården som använder fysisk aktivitet som  kompletterande behandling vid depressionstillstånd. Syftet med denna kvalitativa studie var att identifiera och beskriva personalens erfarenhet och syn på fysisk aktivitet som en del av den psykiatriska omvårdnaden vid depressionstillstånd. Studien var en kvalitativ studie med strukturerande fokusgrupp intervjuer som analyserades med hjälp av innehållsanalys där ett huvudtema; Att ha kunskap och idéer men att inte få till det, två teman och sju subteman utgjorde resultatet. Resultatet från studien visade att vårdpersonalen upplevde att det var bättre förr då det var en mer strukturerad tillvaro med motion och planerade aktiviteter på varje avdelning som patienterna skulle delta i. Resultatet visade både på hinder och möjligheter när det gällde fysisk aktivitet som omvårdnadsåtgärd. Slutsatsen var att personalen hade stora kunskaper kring omvårdnadsåtgärder vid depression men det fanns ett stort behov av förbättrade rutiner för fysisk aktivitet vid depression för linneliggande patienter. / Depression and mental illness is now a major health problem. Although the physical health benefits are well known, there are few in health care that uses physical activity as complementary treatment of depression state. The purpose of this qualitative study was to identity and describe staff's experience and views on physical activity as part of psychiatric care for depression condition. The study was a qualitative study of structuring focus group interviews who were analyzed using content analysis in which a major theme; To have knowledge and ideas but not getting to it, two themes and seven subthemes, was the result. The results of the study showed that nursing staff felt that it was better before when it was a more structured life with exercise and planned activities of each department that the patients would participate in. The results showed both obstacles and opportunities in terms of physical activity as health care measure. The conclusion is that the staff has knowledge of care measures for depression but it is a great need for improved physical activity on depression for patients in psychiatric clinic.

Syftet med studien var att få ny och fördjupad kunskap om faktorer som upplevts vara till hjälp respektive hinder för föräldrar i kontakten med barn- och ungdomspsykiatrin. Kvalitativa djupintervjuer gjordes med åtta föräldrar till ungdomar som fått bipolär- eller psykosdiagnos. Analysen av materialet skedde genom meningskategorisering enligt principerna för hermeneutisk tolkning. Fyra teman identifierades: upplevelse av vårdpersonalens intentioner, upplevelse av vårdpersonalens kompetens, upplevelse av vårdens organisation samt upplevelse av behandlingsinterventioner. Resultatet visar att det upplevs som en avlastning (hjälp) för föräldrarna om de känner tillit till vårdpersonalens intentioner och tilltro till den professionella kompetensen, samt om de upplever att vårdens organisation och de vårdinsatser som erbjuds har en sådan flexibilitet att de kan möta familjens individuella behov. Upplevelser av motsatsen kan i stället utgöra en merbelastning (hinder) för föräldrarna vilket riskerar att försvåra samarbetet med vårdpersonalen. De kliniska implikationerna av resultaten diskuteras avslutningsvis.