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The primary aim of the present study was to investigate the putative excess mortality by suicide in suicide attempters. As a secondary aim, we investigate excess mortality in specific, clinically relevant subgroups: individuals with repeated suicide attempts (RA); individuals who used violent method at the attempt (VA); and those who scored high on the Suicide Intent Scale (HS) at the time of the baseline attempt. Finally, we investigate excess mortality in men and women separately and within 5 years and over 5 years after hospital admission for attempted suicide.Prospective register-based follow-up for 21-32 years. Standardised mortality ratio (SMR) was calculated for suicide using national census data. Clinically relevant subgroups were investigated separately.Medical emergency inpatient unit in the south of Sweden.1039 individuals who were psychiatrically assessed at admission to medical inpatient care for attempted suicide between 1987 and 1998.Suicide.The overall SMR for suicide was 23.50 (95% CI 18.68 to 29.56); significantly higher (p0.001) among women (30.49 (95% CI 22.27 to 41.72)) than men (18.61 (95% CI 13.30 to 26.05)). Mortality was highest within the first 5 years after the index suicide attempt (48.79 (95% CI 35.64 to 66.77)) compared with those who died after 5 years (p0.001) (14.74 (10.53 to 20.63)). The highest independent SMR was found for VA (70.22 (95% CI 38.89 to 126.80)). In a regression model including RA, VA and HS all contributed significantly to excess suicide mortality.An elevated risk of premature death by suicide was found in suicide attempters compared with the general population. Assessment of previous suicide attempts is important, even though the attempt/s may have occurred decades ago. When assessing suicide risk, clinicians should consider repeated attempts and whether the attempts involved high suicidal intent and violent method. Healthcare interventions may benefit from targeting identified subgroups of attempters.

ObjectivesDepression can negatively impact work capacity, but treatment effects on sick leave and employment are unclear. This study evaluates if internet-based cognitive behavioural therapy (ICBT) or physical exercise (PE), with already reported positive effects on clinical outcome and short-term work ability, has better effects on employment, sick leave and long-term work ability compared with treatment as usual (TAU) for depressed primary care patients (German clinical trials: DRKS00008745).MethodsAfter randomisation and exclusion of patients not relevant for work-related analysis, patients were divided into two subgroups: initially unemployed (total n=118) evaluated on employment, and employed (total n=703) evaluated on long-term sick leave. Secondary outcomes were self-rated work ability and average number of sick days per month evaluated for both subgroups. Assessments (self-reports) were made at baseline and follow-up at 3 and 12 months.ResultsFor the initially unemployed subgroup, 52.6% were employed after 1 year (response rate 82%). Both PE (risk ratio (RR)=0.44; 95% CI 0.23 to 0.87) and ICBT (RR=0.37; 95% CI 0.16 to 0.84) showed lower rates compared with TAU after 3 months, but no difference was found after 1 year (PE: RR=0.97; 95% CI 0.69 to 1.57; ICBT: RR=1.23; 95% CI 0.72 to 2.13). For those with initial employment, long-term sick leave (response rate 75%) decreased from 7.8% to 6.5%, but neither PE (RR=1.4; 95% CI 0.52 to 3.74) nor ICBT (RR=0.99; 95% CI 0.39 to 2.46) decreased more than TAU, although a temporary positive effect for PE was found. All groups increased self-rated work ability with no differences found.ConclusionsNo long-term effects were found for the initially unemployed on employment status or for the initially employed on sick leave. New types of interventions need to be explored.

ObjectivesMental health problems and hazardous alcohol consumption often co-exist. Hazardous drinking could have a negative impact on different aspects of health and also negatively influence the effect of mental health treatment. The aims of this study were to examine if alcohol consumption patterns changed after treatment for depression and if the changes differed by treatment arm and patient sex.MethodsThis study of 540 participants was conducted in a large randomised controlled trial (RCT) that aimed to compare the effect of internet-based cognitive behavioural therapy, physical exercise and treatment as usual on 945 participants with mild-to-moderate depression. Treatment lasted for 12 weeks; alcohol consumption (Alcohol Use Disorder Identification Test (AUDIT)) and depression (Montgomery Åsberg Depression Rating Scale (MADRS)) were assessed at baseline and 12-month follow-up. Changes in alcohol consumption were examined in relation to depression severity, treatment arm and patient sex.ResultsThe AUDIT distribution for the entire group remained unchanged after treatment for depression. Hazardous drinkers exhibit decreases in AUDIT scores, although they remained hazardous drinkers according to the cut-off scores. Hazardous drinkers experienced similar improvements in symptoms of depression compared with non-hazardous drinkers, and there was no significant relation between changes in AUDIT score and changes in depression. No differences between treatment arm and patient sex were found.ConclusionThe alcohol consumption did not change, despite treatment effects on depression. Patients with depression should be screened for hazardous drinking habits and offered evidence-based treatment for hazardous alcohol use where this is indicated.Trial registration numberDRKS00008745.

BackgroundEvidence-based treatment of depression continues to grow, but successful treatment and maintenance of treatment response remains limited.AimsTo compare the effectiveness of exercise, internet-based cognitive–behavioural therapy (ICBT) and usual care for depression.MethodA multicentre, three-group parallel, randomised controlled trial was conducted with assessment at 3 months (post-treatment) and 12 months (primary end-point). Outcome assessors were masked to group allocation. Computer-generated allocation was performed externally in blocks of 36 and the ratio of participants per group was 1:1:1. In total, 945 adults with mild to moderate depression aged 18–71 years were recruited from primary healthcare centres located throughout Sweden. Participants were randomly assigned to one of three 12-week interventions: supervised group exercise, clinician-supported ICBT or usual care by a physician. The primary outcome was depression severity assessed by the Montgomery–Åsberg Depression Rating Scale (MADRS).ResultsThe response rate at 12-month follow-up was 84%. Depression severity reduced significantly in all three treatment groups in a quadratic trend over time. Mean differences in MADRS score at 12 months were 12.1 (ICBT), 11.4 (exercise) and 9.7 (usual care). At the primary end-point the group × time interaction was significant for both exercise and ICBT. Effect sizes for both interventions were small to moderate.ConclusionsThe long-term treatment effects reported here suggest that prescribed exercise and clinician-supported ICBT should be considered for the treatment of mild to moderate depression in adults.

BackgroundDepression is common and tends to be recurrent. Alternative treatments are needed that are non-stigmatising, accessible and can be prescribed by general medical practitioners.AimsTo compare the effectiveness of three interventions for depression: physical exercise, internet-based cognitive–behavioural therapy (ICBT) and treatment as usual (TAU). A secondary aim was to assess changes in self-rated work capacity.MethodA total of 946 patients diagnosed with mild to moderate depression were recruited through primary healthcare centres across Sweden and randomly assigned to one of three 12-week interventions (trail registry: KCTR study ID: KT20110063). Patients were reassessed at 3 months (response rate 78%).ResultsPatients in the exercise and ICBT groups reported larger improvements in depressive symptoms compared with TAU. Work capacity improved over time in all three groups (no significant differences).ConclusionsExercise and ICBT were more effective than TAU by a general medical practitioner, and both represent promising non-stigmatising treatment alternatives for patients with mild to moderate depression.

Hazardous alcohol use in psychiatric patients may increase the risk of the development of a substance use disorder and negatively affect the course of the psychiatric disorder.To investigate the prevalence of hazardous alcohol and drug use in a Swedish psychiatric outpatient population with particular focus on hazardous alcohol consumption and assess relationships of hazardous alcohol use to sex, age and psychiatric diagnosis.General psychiatric outpatients, n = 1,679, completed a self-rating Alcohol Use Disorders Identification Test (AUDIT).Hazardous or harmful alcohol habits occurred among 22% of all women and 30% of all men with higher prevalence among younger patients. Nine percent of all women and 22 % of all men reported binge drinking. Binge drinking was more frequent in younger subjects. Women with a personality disorder diagnosis had a higher frequency of at risk drinking. Apart from that, psychiatric diagnosis was unrelated to rate of hazardous drinking.Hazardous alcohol use was common in this psychiatric outpatient population. With regard to possible risks related to drinking in psychiatric patients, alcohol habits should be assessed as a part of good clinical practice.

ObjectivesHazardous drinking could negatively affect health and lead to alcohol use disorders, but it is unclear how hazardous drinking affects treatment outcomes of depression and anxiety and stress-related mental health problems. The aim of this study was to examine whether hazardous drinking, measured by Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), influences the outcomes of repeated assessments of psychological functioning (Outcome Questionnaire-45), stress (Perceived Stress Scale) and sleep (Karolinska Sleep Questionnaire), during and after treatment in patients with mental ill health.MethodsThe study was conducted within REGASSA, a randomised controlled trial aimed at comparing Internet-based cognitive–behaviour therapy and physical exercise with treatment as usual on primary care patients with mental ill health. The study involved 871 participants who completed the AUDIT at baseline and who were assessed repeatedly during and after treatment on psychological functioning, stress and sleep by interactive voice response, a computerised, automated telephone technology.ResultsAt baseline, hazardous drinkers were more depressed and had lower scores on psychological functioning than non-hazardous drinkers, while there were no differences on stress and sleep. During the follow-ups, hazardous drinking negatively influenced perceived stress, that is, hazardous drinkers seemed to have less treatment effect on stress, and the results remained after controlling for depression. There were no differences during the follow-ups regarding psychological functioning and sleep.ConclusionsHazardous drinking negatively influenced perceived stress. The findings of the study emphasise the importance of screening for alcohol habits in mental ill-health patients, since risky drinking may affect the outcomes of treatment.Trial registration numberDRKS00008745; Post-results.

This randomized trial evaluates whether automated telephony could be used to perform daily assessments in paroled offenders ( N = 108) during their first 30 days after leaving prison. All subjects were called daily and answered assessment questions. Based on the content of their daily assessments, subjects in the intervention group received immediate feedback and a recommendation by automated telephony, and their probation officers also received a daily report by email. The outcome variables were analyzed using linear mixed models. The intervention group showed greater improvement than the control group in the summary scores ( M = 9.6, 95% confidence interval [CI] = [0.5, 18.7], p = .038), in mental symptoms ( M = 4.6, CI = [0.2, 9.0], p = .042), in alcohol drinking ( M = 0.8, CI = [0.1, 1.4], p = .031), in drug use ( M = 1.0, CI = [0.5, 1.6], p = .000), and in most stressful daily event ( M = 1.9, CI = [1.1, 2.7], p = .000). In conclusion, automated telephony may be used to follow up and to give interventions, resulting in reduced stress and drug use, in paroled offenders.

Background Depression is a strong risk factor for suicide and suicide attempt. Several studies have examined the pathway to suicide attempt, but few studies have considered aspects important for overcoming being suicidal. The aim of the present study was to examine personal strategies to continue living after a suicide attempt. Methods A qualitative grounded theory approach was used. Thirteen former inpatients diagnosed with severe depression (1956–1969) participated in a follow-up 42–56 years after their last suicide attempt, which occurred between the ages of 21 and 45. They were interviewed on one occasion between June 2013 and January 2014, using semi-structured interviews. Results The pathway to a suicide attempt was defined as ‘being trapped in an overwhelming situation’. Three categories described the recovery process: ‘coming under professional care’, ‘experiencing relief in the personal situation', and ‘making a decision to continue living’. These categories emerged in a core category, labelled ‘taking care of oneself by regaining control’. Overcoming being suicidal occurred regardless of recovering from depression. Conclusion In the very long-term course following a suicide attempt, the process of recovery is multi-dimensional and fluctuating, and includes appropriate treatment, connecting with others, decision making, and overcoming existential issues.

Purpose Substance use disorders and problematic substance use are common problems in adolescence and young adulthood. Brief personalized feedback has been suggested for treatment of alcohol and drug problems and poor mental health. This repeated measurement randomized controlled trial examines the effect of an interactive voice response (IVR) system for assessing stress, depression, anxiety and substance use. Methods The IVR system was used twice weekly over 3 months after treatment initiation, with or without addition of a personalized feedback intervention on stress and mental health symptoms. Both IVR assessment only (control group) and IVR assessment including feedback (intervention group) were provided as an add-on to treatment-as-usual procedures (TAU) in outpatient treatment of substance use problems in adolescents and young adults (N = 73). Results By using a mixed models approach, differences in change scores were analyzed over the three-month assessment period. Compared to the control group, the intervention group demonstrated significantly greater improvement in the Arnetz and Hasson stress score (AHSS, p = 0.019), the total Symptoms Checklist 8 score (SCL-8D, p = 0.037), the SCL-8D anxiety sub-score (p = 0.017), and on a summarized feedback score (p = 0.026), but not on the depression subscale. There were no differences in global substance use scores between the intervention group (feedback on mental health symptoms) and the control group. Conclusion In conclusion, IVR may be useful for follow-up and repeated interventions as an add-on to regular treatment, and personalized feedback could potentially improve mental health in adolescents and young adults with problematic substance use.

Although drinking patterns in women have received increased attention, few studies have focused on middle-aged women. Drinking patterns were investigated in a population sample of 513 Swedish women aged 50-59, and analysed in relation to social situation, and mental and physical health. The chi-square test was used to analyse differences in proportions. Variables showing significant differences were entered into a multivariate or multinomial logistic regression model. Abstainers and occasional drinkers had lower levels of education and more often regular medical control compared with weekly drinkers. Furthermore, abstainers more often had disability pension. Among women drinking alcohol, 56.6% affirmed binge drinking within the last year and 39.4% within the last month. Binge drinkers did not differ in terms of social situation, mental or physical health, compared with other drinkers. Drinking to relieve tension was affirmed by 7.2%. These women had more mental symptoms and less contact with friends compared with other drinkers; furthermore, they were more often binge drinkers. Binge drinking was common and health and social consequences of this drinking pattern in middle-aged women need to be further explored. Women drinking to relieve tension may need intervention for both drinking habits and mental health.

Objective Adolescent substance use is an area of concern because early substance use is associated with a higher risk of adverse outcomes. Parenting style, defined as the general style of parenting, as well as substance-specific parenting practices may influence children9s substance use behaviour. The present study aims to probe the impact of parenting style on adolescent substance use. Method A cohort of 1268 adolescents (48% girls), aged 12–13 years at baseline, from 21 junior high schools was assessed in the first semester of junior high school, and then again in the last semester of the 9th grade, 32 months later. Parenting style, operationalised as a fourfold classification of parenting styles, including established risk factors for adolescent substance use, were measured at baseline. Results Neglectful parenting style was associated with worse substance use outcomes across all substances. After adjusting for other proximal risk factors in multivariate analyses, parenting style was found to be unrelated to substance use outcomes with one exception: authoritative parenting style was associated with less frequent drinking. Association with deviant peers, delinquent behaviour, provision of alcohol by parents, and previous use of other substances were associated with substance use outcomes at follow-up. Conclusions The results of the present study indicate that parenting style may be less important for adolescent substance use outcomes than what has previously been assumed, and that association with deviant peers and delinquent behaviour may be more important for adolescent substance use outcomes than general parenting style.

Aims: The aims of this study are threefold: to investigate formal and informal help with clinical and social needs that patients who attempted suicide received during the year after their attempt; to examine whether help from services was estimated to be adequate; and to look at whether patients who repeated suicide attempt(s) during follow-up differed from those who did not. Methods: The Camberwell Assessment of Need instrument measuring 22 need areas was used in semi-structured interviews with 140 patients at 1 and 12 months after a suicide attempt. Results: Help given from services was rated as high at both 1 and 12 months in health-related areas, but lower in areas related to social needs. Informal help was initially frequent, with some exceptions. The amount of help from services did not decrease in any need area during follow-up, neither in repeaters nor in non-repeaters. There were no changes in informal help in repeaters, while in non-repeaters informal help decreased in some areas. At both 1 and 12 months, repeaters and non-repeaters mostly found help from services to be adequate. However, in the areas of information, intimate relationships, psychotic symptoms and sexual expression about half of the patients in both groups did not consider that they had received the right type of help. Conclusions: The generally high level of formal help in health-related areas during the first year after a suicide attempt and the high rated adequacy of help given is satisfactory. However, in certain areas lack of formal help was evident. Informal caregivers contributed significantly to the help that patients received. The use of the Camberwell Assessment of Need instrument could improve observation on needs areas and whether help is available. Perhaps this kind of evaluation could be used earlier than after 1 year in such a vulnerable group as suicide attempters.

Background Risk factors for suicide and fatal accidental intoxication are extensively studied, while risk factors for intoxications/injuries of undetermined intent are less well known. The latter have shown an overlap with suicides, but also with fatal accidental intoxications. The objective was to analyze potential differences and similarities in the patterns of risk factors for accidental intoxications, injuries/intoxications with undetermined intent, and suicides, respectively. Methods A follow-up register study was conducted, using data from ASI interviews with clients in the criminal justice system in Sweden (n = 6744), followed in the National Causes of Death Register. A set of risk factors from the ASI interview were tested in bivariate analysis with the respective cause of death, yielding significant risk factors further analyzed in three Cox regression models. Results In Cox regression analyses, death from fatal accidental intoxication was associated with male gender (HR 4.09), use of heroin (HR 2.86), and use of cannabis (HR 1.94), and death from intoxication/injury of undetermined intent was associated with use of heroin (HR 3.48), binge drinking of alcohol (HR 2.46) and previous psychiatric hospitalization (HR 2.41), while negatively associated with depression (HR 0.33). Death from suicide was associated with previous suicide attempts (HR 2.78) and use of sedatives (HR 2.17). Conclusions In this population of criminal justice clients with reported substance use problems, fatal injuries/intoxications with undetermined intent – like fatal accidental intoxications – appear to be associated with substance use variables, and cannot readily be assumed to represent the same background factors as suicide.

OBJECTIVES: Mental ill-health has become a large health problem and it is important for caregivers to provide effective treatment alternatives. REGASSA is a randomized controlled study performed in primary care to study the effects of 12 weeks of Internet-based cognitive behaviour therapy (ICBT) and physical exercise (PE) compared with treatment as usual (TAU) in patients with mild-to-moderate mental ill-health. The present study aimed to examine the results of these treatment alternatives on psychological functioning, stress, and sleep disturbances.METHODS: The study comprised 879 patients with mental ill-health taking part in the REGASSA study. Data were collected by Interactive Voice Response (IVR), a computerized, automated telephone technique. The treatments were compared at baseline, twice during treatment, at the end of treatment and at three follow-ups after treatment. Measures used were the Outcome Questionnaire-45, the short versions of the Perceived Stress Scale, and the Karolinska Sleep Questionnaire.RESULTS: Linear mixed models showed that the patients in ICBT and PE had better results than in TAU on psychological functioning and sleep disturbances, p < .001, with weak-to-moderate effect sizes. On stress there were no differences; all groups made improvements. Women had stronger effects than men. More patients recovered on psychological functioning (OQ-45) in ICBT and PE than in TAU.CONCLUSIONS: Internet-based cognitive behaviour therapy and PE proved to be effective treatment alternatives for patients with mild-to-moderate mental ill-health in improving psychological functioning, stress, and sleep disturbances and could be useful alternatives in primary care.PRACTITIONER POINTS: Internet-based cognitive behaviour therapy and physical exercise proved to be effective treatment alternatives for mental ill-health patients in primary care. Automated techniques (Interactive Voice Response) could be useful for following treatment course in large groups of patients in the health care. It is important to use measures that capture different aspects of patients' health problems. The recruitment of participants was based on patients' interest and inclusion criteria which may have affect the generalizability. (Less)

This study aims to analyse mental symptoms, psychotropic drug use and alcohol consumption, in immigrant women born in Finland, the other Nordic countries, Eastern Europe, Western Europe and countries outside Europe, compared with Swedish-born women, and furthermore, to study if age at immigration may have an influence. All women (n=10,766) aged 50-59 years and living in the Lund area of southern Sweden received a postal invitation to a health survey named the Women's Health in Lund Area; 64.2% (n=6917) participated. The participants answered a questionnaire including prevalence of mental symptoms during the past 3 months, regular use of psychotropic drugs, alcohol consumption during an average week, country of birth and age at immigration. Severe mental symptoms were more common among most immigrant groups compared with native Swedes, but the association to country of birth was not significant after adjustment for possible confounders. Regular use of hypnotics was more common among Nordic immigrants only (odds ration, OR = 4.4). East European and non-European immigrants less often were alcohol consumers (OR = 1.6 and OR = 3.8). Heavy drinking was more common among non-Nordic immigrants who immigrated at a younger age than at an older age. Furthermore, it was found that although East European and non-European immigrants had a higher educational level, they were less often gainfully employed compared with native Swedes. In middle-aged women, country of birth as well as age at immigration are important factors to consider in relation to alcohol consumption, but these factors may be of less importance considering mental health.

Aims: In a population of middle-aged women a survey was carried out to ascertain the prevalence of mental symptoms and psychotropic drug use, and further to investigate whether severe mental symptoms are associated with social situation, alcohol consumption, smoking, and physical health. Methods: All women (n=10,766) aged 50—59 years and living in the Lund area were invited to the WHILA study, a health survey including laboratory examinations and a self-administered questionnaire; 6,917 (64.2%) participated. This study is based on the questionnaire only. Results: During the past three months 25.4% (n=1,709) had been troubled by none or 1 mental symptom (labelled ``absent/slight''), 52.8% (n=3,555) by 2—6 mental symptoms (``moderate'') and 21.8% (n=1,471) by 7—10 mental symptoms (``severe''). Among women with severe mental symptoms 15.4% regularly used psychotropic drugs, mainly antidepressants. A multiple logistic regression analysis showed that women with severe mental symptoms had higher odds for living alone (OR 1.7; CI 1.3—2.2) or as single parents (OR 2.1; CI 1.2—3.6), being university-educated (OR 1.5; CI 1.1—2.0), being on long-term sick-leave (OR 8.8; CI 3.0—25.5), using hormone replacement therapy (OR 1.3; CI 1.1—1.6), and having severe physical symptoms (136.8; CI 89.2—209.7) compared with women with absent/slight mental symptoms. Conclusion: Mental symptoms were common among the participating women. The presence of severe mental symptoms was strongly associated with severe physical symptoms. Few women with severe mental symptoms used psychotropic drugs. Middle-aged women with severe mental symptoms need to be identified and provided with appropriate psychopharmacological, hormonal, and/or psychosocial treatment.

Background: The aim of this study was to investigate predictors of Quality of Life in a group of severely mentally ill substance abusers. These patients took part in a multi-centre study aimed at improving co-operation between psychiatric and social services in Sweden during the years 1995 to 1998. Methods: Two hundred and eighty-eight patients, 62.4 % men, were included in the study. The criteria to enter the study were to have a diagnosis of severe mental illness and a diagnosis of substance dependence according to the DSM-III-R criteria. Quality of Life (QoL) was measured by a global assessment, Cantril's ladder (1965). Initially and after 18 months the following measurements were also used: Addiction Severity Index (ASI), Symptom Check List 90 (SCL–90) and The Clinical Rating Scale (CRS) for Alcohol Use (AUS) and Drug Use (DUS). Results: Initially those who were older and those who had an apartment of their own or who lived in sheltered living had a higher QoL than the others. Those belonging to the borderline personality disorder subgroup had a lower QoL than those belonging to other psychiatric diagnostic subgroups. At follow-up QoL had improved significantly. Improvement in QoL was related to improvements in physical health, legal and family problems, psychiatric symptoms and a reduction of alcohol and drug problems (ASI), global functioning (GAF) and psychological problems (SCL–90). A multiple stepwise regression analysis showed that improvement in QoL primarily was predicted by improvements in psychiatric symptoms. Number of months without alcohol and drugs were positively associated with improvement in QoL. As a whole, at follow-up the QoL is still not high. Conclusions: In this group of severely mentally ill substance abusers, improvement in QoL was primarily predicted by improvements in psychiatric symptoms. Further, less alcohol and drug abuse seems to augment the subjective feeling of QoL.

The main aim of the present study was to investigate whether or not temperament dimensions are stable over time. Twenty-six patients (21 women and five men) filled in the Karolinska Scales of Personality (KSP) both at admission after a suicide attempt (index) and at follow-up 5 years later. KSP changes were significantly associated with low severity of psychiatric symptoms and no reported reattempts at follow up. There were significant changes of all five groups of KSP, most prominently in anxiety-related scales. At index, KSP scores did not differ between those who later would repeat a suicide attempt (repeaters) and not, but repeaters more often tended to have a personality disorder and their 24-h urinary cortisol tended to be lower. In this limited sample, repeaters seem to have a protracted high anxiety level as mirrored by high and stable KSP scores over time.

Background Alcohol use has been shown to interfere with treatment for depression, but consumption habits are not routinely screened in primary care. To date, few studies have compared the alcohol consumption habits of patients with depression to the general population. The purpose of this study was to compare alcohol habits in adults diagnosed with depression in primary care to the general adult population in Sweden. Methods Nine hundred fourty six patients diagnosed with mild to moderate depression, without a primary substance use disorder, in primary care settings located across Sweden completed the Alcohol Use Disorders Identification Test (AUDIT). Consumptions habits and alcohol related problems in the depressed sample were compared to those in the general adult population (n = 663). Analyses were stratified by gender and age. Results Ratings of alcohol problems and measures of hazardous drinking and binge drinking were significantly higher among patients seeking treatment for depression in primary care compared to the general population. Male patients scored higher on the AUDIT total and AUDIT-C (consumption) subscale than men in the general population. Compared to younger adults (aged 17–27) older depressed adults (aged 28–50 and 51–71) exhibited higher rates of consumption and problems related to alcohol. Conclusions Compared to the general adult population, consumption and problems related to alcohol use were substantially higher among patients with mild to moderate depression in primary care. Routine screening of alcohol use in primary care is recommended for patients presenting with depression.

SummaryAmbivalence to treatment and repeated suicidal behaviour are well-known problems in suicide attempters. A randomised controlled study was performed to investigate the influence of repeated telephone contacts on treatment attendance, repetition of suicidal behaviour and mental health the year after a suicide attempt.Subjects and methodsOne month after their suicide attempt 216 patients were randomised to either two telephone interventions in addition to treatment as usual, or no such intervention during the subsequent year. The interventions included motivational support to attend and/or to stay in treatment. At 1 month and again after 12 months the following measurements were used: GSI (SCL-90), GAF and SSI.ResultsAt follow-up treatment attendance was high and did not differ between the randomised groups. Among those with an initial treatment contact other than psychiatric, more patients in the intervention group had such contact at follow-up. The randomised groups did not differ in repetition of suicide attempts during follow-up or in improvement in GSI (SCL-90), GAF and SSI. In individuals with no initial treatment the intervention group improved more in certain psychological symptom dimensions (SCL-90).ConclusionsTelephone interventions seem to have an effect on patients who at their suicide attempt had other treatment than psychiatric and in those with no treatment.

Twenty-two female psychiatric outpatients with experiences of childhood sexual abuse took part in a two-year group therapy. All completed therapy. At the end of therapy the women’s psychiatric symptoms were reduced and their social interaction and adjustment were improved. They evaluated relationships to their children, partners and friends to be improved.

Background: In a previous study we interviewed significant others (SOs) directly following a patient's suicide attempt as a part of the psychiatric assessment. SOs added important information to the assessment and they needed professional counselling themselves. In the present study the opinions of SOs were investigated 1 year after a suicide attempt. Methods: Semi-structured interviews of 84 SOs (93% of a consecutive series) were performed by telephone, focusing on the patient's situation, their own involvement in care and treatment as well as their own well-being and need for support. Forty-four percent of the SOs were parents, 27% partners and 29% persons with other relationships. An independent researcher interviewed the patients. Results: According to SOs, 63% of the patients had mental health problems and 80% had other kinds of problems (e.g. relationship problems, financial problems, unemployment and substance abuse) at follow-up. A majority of SOs were worried that the patient was going to hurt themself again. There were differences in the information given by patients and SOs concerning suicide attempts during the follow-up period. Many SOs had questions about the suicidal behaviour, and nearly half of the SOs reported that they had not talked to the patient about the index suicide attempt. Nearly half of the SOs would like to have had professional counselling, preferably shortly after the suicide attempt. Two-thirds of the inpatient SOs and 90% of the outpatient SOs had not been involved in the patient care and treatment, although a majority of them desired such involvement. The well-being of the SOs was generally good, except for a small subgroup. Conclusions: The findings of this study provide further evidence that SOs contribute valuable information about the patient after a suicide attempt. They also point strongly to the fact that SOs themselves need support. Insufficient communication between patient and SOs indicates the need for joint counselling directly after a suicide attempt in order to reduce some of the burden and stress experienced by SOs.

The present review reports on the influence of alcohol drinking and alcohol use disorders on psychiatric disorders and suicidal behaviour. The base of the study was previous reviews of the National Institute on Alcohol Abuse and Alcoholism publication Alcohol and Health in 1993 and by Helgason in 1996. Using a defined search strategy in Medline, another 42 articles from 1994 to 1996 were included in the comorbidity part and 19 in the suicidal part. Epidemiological and clinical studies confirm high comorbidity of substance use disorders and other mental disorders. Alcohol abuse worsens the course of psychiatric disorders. Light to moderate alcohol consumption has no documented positive effect on the course. Levels of risk consumption of alcohol in psychiatric disorders have not been well defined. One-fifth to one-third of increased deaths rate among alcoholics is explained by suicide. In countries with high alcohol consumption, the suicide rate is also high and is increasing with total increased alcohol consumption. Comorbidity is common among suicide victims, and substance use disorders is most frequently combined with depressive disorders. Interpersonal loss within 6 weeks before suicide is more often present among alcoholics than nonalcoholic suicide victims.

Aims: The majority of prospective studies on alcohol use and mortality risk indicate that non-drinkers are at increased risk of death compared to moderate drinkers. This article investigates the association between middle-aged women’s alcohol use and mortality, controlling for socio-demographic and health variables. An association between alcohol use and hospital in-patient care is also analysed. Methods: Baseline data were collected during 1995–2000 in a population-based cohort of 6917 women aged 50–59 years living in southern Sweden, the Women’s Health in Lund Area (WHILA). After 9 years, a register follow-up was performed from the National cause-of-death register and the Swedish hospital discharge register. Cox proportional hazards regression were used to analyse differences in survival. Results: During the observation period, 201 (2.9%) women died. In a crude model, non-drinkers had a significantly increased risk for death. When including socio-demographic predictors in the model, there was a strong indication that non-drinkers were at increased risk for death compared to moderate drinkers. Adding health predictors, not drinking alcohol was no longer a risk factor for death. Further, analyses of in-patient care indicate that non-drinkers had poorer health during their entire adult life. Conclusions: This study underlines the importance of including health status at base-line when prospectively studying the association between alcohol use and mortality, otherwise moderate alcohol consumption may appear more beneficial than is the case.

During the last decades, a positive relation between a good alliance and a successful therapy outcome has been demonstrated across a variety of different therapeutic modalities. The relationship between alliance and drinking outcomes in long-term treatment of alcoholics (12 months or more) has not, as far as we know, been presented. In the present study, alcoholics were randomized to two outpatient treatment programmes; multimodal behavioural therapy (MBT) and psychiatric treatment based on a psychodynamic approach (PT). As part of the study, analyses were performed concerning differences in alliance between the two treatment models (MBT, n = 17; PT, n = 18), and concerning the relationship between alliance and treatment outcome. A Swedish version of the Helping Alliance Questionnaire was used to measure alliance. All therapy sessions were tape-recorded. An independent researcher rated the patient's and therapist's contribution to the alliance at the third session (early alliance). Early patient and therapist alliances were not related to sociodemographic data or initial measures of alcohol severity, psychiatric symptoms, or personality structure in either therapy. Early therapist alliance was better in MBT in comparison with PT. For MBT patients, a significant positive correlation was found between early patient alliance and mood dimensions at 6 months. There were no significant positive correlations between early alliance and drinking outcome during the course of treatment and in the third year after start of treatment. Mood and drinking outcome also showed low correlations. In conclusion, an initial positive alliance seems insufficient to reduce alcohol misuse. The relationship between early alliance and improvement in alcohol misuse needs to be further investigated.

Seventy-five patients were admitted to the ward of the Lund Suicide Research Center following a suicide attempt. After 5 years, the patients were followed up by a personal semistructured interview covering sociodemographic, psychosocial and psychiatric areas. Ten patients (13%) had committed suicide during the follow-up period, the majority within 2 years. They tended to be older at the index attempt admission, and most of them had a mood disorder in comparison with the others. Two patients had died from somatic diseases. Forty-two patients were interviewed, of whom 17 (40%) had reattempted during the follow-up period, most of them within 3 years. Predictors for reattempt were young age, personality disorder, parents having received treatment for psychiatric disorder, and a poor social network. At the index attempt, none of the reattempters had diagnoses of adjustment disorders or anxiety disorders. At follow-up, reattempters had more psychiatric symptoms (SCL-90), and their overall functioning (GAF) was poor compared to those who did not reattempt. All of the reattempters had long-lasting treatment ( > 3 years) as compared to 56% of the others. It is of great clinical importance to focus on treatment strategies for the vulnerable subgroup of self-destructive reattempters.

Aim: The objective of the study was to evaluate the effi cacy of the Outcome Questionnaire 45 (OQ-45) with feedback in a Swedish psychiatric outpatient population using a randomized controlled design. Method: In all 1720 patients made at least one regular visit to the clinics in the period 12 February 2007 to 10 February 2008 and received information about the study. Of these, 374 patients (22%) agreed to participate. After written consent, 188 patients were randomized to the feedback group and 186 patients to the control group. Those constituted the intention-to-treat (ITT) group. Two hundred and sixty-two patients (70%) completed the OQ-45 questionnaire at least twice, and they were included in the per-protocol analysis. Those who improved less than expected and were at risk for treatment failure were called alerted patients. Results: There was a tendency that patients who received feedback improved more than the controls in OQ-45 total score. In the ITT analysis, the P -value was 0.061 and the effect size g 0.21. In the per-protocol analysis the P -value was 0.076 and the effect size g 0.24. In the intervention group, 27% of the patients were alerted because of risk of treatment failure vs. 28% in the control group (reaching level of alertness). The OQ-45 differences between the intervention and control groups did not signifi cantly differ for patients who were alerted/ reaching level of alertness and for non-alerted patients ( g 0.17 and g 0.28, respectively). Conclusions: The feedback group had a tendency to improve more than the control group, possibly indicating that the method is effective, and the result (basically) supports previous fi ndings.  Feedback , Intervention , Outcome Questionnaire 45 (OQ-45) , Psychiatric outpatient population , Psychiatric treatment , Randomized controlled trial.

AIMS: To describe the mortality and causes of death among subjects with alcohol use disorder in comparison with those without alcohol disorder and to study whether mental disorders increase mortality in alcoholics. DESIGN AND SETTING: Data were analysed from the database of the Lundby Study, comprising 3563 subjects followed from 1947 to 1997. METHOD: A community-based sample was investigated in 1947 with follow-ups in 1957, 1972 and 1997. Best-estimate consensus diagnoses of mental disorders, including alcohol use disorder, were assessed. In the total cohort, 427 cases of alcohol use disorders were identified. Differences in mortality between subjects with alcohol use disorders and non-alcoholics were studied using Cox regression models and causes of death were compared between alcoholic subjects and other participants. Risk factors for mortality among the 348 individuals with alcohol use disorders and known age-of-onset were analysed by means of Cox regression analyses. RESULTS: The hazard ratio for mortality was higher for alcoholics compared to other subjects in the cohort. A substantial proportion of the causes of death among the alcoholics was suicide N=27 (6.3%) (26 males, 1 female). In the multivariate models of risk factors in alcohol use disorders, anxiety disorders, psychotic disorders, alcohol induced psychotic disorders and dementia were risk factors for premature death. CONCLUSION: The mortality risk for subjects with alcohol use disorder was increased, females were especially vulnerable. The risk for suicide was high among males with alcohol problems. Anxiety disorders and severity of alcohol use disorder turned out as risk factors for premature death.

Background: In Sweden, a person with substance abuse can be reported to the social services for an investigation about commitment to coercive care. After a change in legislation, municipalities varied greatly in the ratio of commitments/reports compared with the period before the legislation was amended. Aims: The primary aims of this study were first, to investigate whether subjects from municipalities with a high ratio of commitments/reports have a better outcome compared with subjects from municipalities with a low ratio and second, if a high ratio has an impact on mortality. Methods: The study involved two municipalities with high ratio of commitments/reports with 56 cases reported for substance abuse including 31 committed cases (55%). It also included two municipalities with a low ratio, 50 reported cases including six committed cases (12%). Two social service inspectors at the country administrative board assessed the cases in terms of severity of addiction according to legal criteria (kappa(s)=0.66), indicating good inter-rater agreement. A global index based on information about substance abuse, employment and housing was used as outcome measure at the 2-year follow-up. Results: Global outcome did not differ between cases from high- and low-ratio municipalities. Seven subjects had deceased because of causes related to substance abuse. None of the deceased had been committed to coercive care. Conclusions and clinical implications: In conclusion, the different ratios of commitments/reports did not influence global outcome. Commitment may reduce substance-related deaths.

Sixty-nine inpatients who had attempted suicide were studied by means of the Meta-Contrast Technique (MCT), a projective test measuring personality factors, especially defensive strategies. The patients were divided into 3 subgroups, one of which was defined as stereotypy only, which denotes stereotypy (perceptual retardation) without any other coded defenses. At follow-up 7 of 8 completed suicides belonged to this subgroup and they matched various main diagnoses according to DSM-III-R. When the MCT findings of all patients were compared with 99 depressed inpatients from a previous study, the latter group more often had mature defensive strategies. In both investigations most completed suicides were found in the stereotypy only group. Our findings indicate that, regardless of psychiatric diagnosis, stereotypy without other defenses in MCT predicts suicide.

Since 1986 psychiatrists and social workers of the Lund Suicide Research Center have investigated subjects admitted to the medical intensive care unit after a suicide attempt. Fifty-nine of 79 deliberate self-poisoners were interviewed 12 months after a suicide attempt. Twenty-one had previously been interviewed 6 months after the index suicide attempt. We obtained minor information on 8 subjects. Two patients had committed suicide. Sixteen subjects (27%) of those who were interviewed showed repeated suicidal behavior (repeaters) during the 1-year follow-up, and their psychiatric diagnoses at the index attempt were most commonly alcohol abuse and dysthymia (DSM-III, Axis I). Compared with nonrepeaters, repeaters had more often made previous suicide attempts, their index attempt was less serious and they were more often in psychiatric treatment at index. At follow-up, repeaters more often than nonrepeaters expressed the need for professional mental health support. Two-thirds of the patients were in treatment at follow-up. About half had remained in continuous treatment and most in psychiatric care for more than 1 year. Repeated self-poisoning occurred despite ongoing treatment. In view of the fact that numerous suicide attempters obviously remain in treatment for several years, we suggest further development and evaluation of long-term treatment strategies.

Background: The transition to studying at university is associated with increased levels of both stress and hazardous alcohol use. The aim of this study is to investigate the influence of these factors on first-year dropout from university studies. Methods: Two complete cohorts of university freshmen at two homogeneous universities, one in the north and one in the south of Sweden, were asked to participate in an intervention study. Participants responded to a baseline questionnaire including measures of stress and alcohol use. Official university records showing dropout over 12 months were collected. Results: A multivariate analysis established that high stress and admission to the northern university were associated with dropout from university studies, while symptoms of depression and anxiety as well as hazardous drinking were not. Conclusions: There is a need to address the issue of stress associated with the start of university studies. It seems important to offer stress-reducing interventions, specifically aimed at reducing transitional stress, as soon as students start university.

Background: The aim of this study was to evaluate the measurement properties of the Arnetz and Hasson seven-item stress questionnaire in order to select high-risk freshmen for a stress and alcohol intervention research project. Methods: Two complete cohorts of university freshmen at two universities were asked to participate in an intervention study. All subjects responded to seven Visual Analogue Scales (VAS) measuring common areas associated with stress. Measurement properties were evaluated by analysing internal consistency and construct validity. Results: A total of 2,032 (72%) freshmen agreed to participate. In total 14,184 out of 14,224 (99.7%) of the Visual Analogue Scales were answered. The Chronbach's alpha coefficient for the complete scale was 0.787. The Varimax rotation factor analysis, using an eigen value of 1, resulted in one factor that covered all items with factor scores of 0.50 and over. This factor explained 46% of the variance. A logistic regression analysis established that mental symptoms, living outside a serious relationship, and female gender were associated with a high stress level. Conclusions: The Arnetz and Hasson stress questionnaire is easy to use and offers sufficient internal consistency and construct validity.

Seventy-nine patients admitted to the Lund Intensive Care Unit after deliberate self-poisoning were investigated by a psychiatrist and a social worker by means of a semistructured interview. Suicide risk evaluation included statistical risk factors according to the SAD PERSONS Scale, severity of suicidal intent according to the Suicidal Intent Scale, and interviewer reaction according to Motto. Two-thirds of the patients were in treatment or had had counselling with a social worker. More than half of the sample were repeaters. Compared with nonrepeaters, repeaters were less often employed, lacked social support and more often had relational problems. The majority of the repeaters had ongoing treatment, mostly psychiatric treatment. Repeaters more often acted impulsively, and their suicidal intent tended to be less severe than those of nonrepeaters. Interviewers more often reacted with negative or neutral feelings towards repeaters. Our results indicate that those who repeat suicidal behaviour differ from nonrepeaters. Self-poisoners, and especially repeaters, often had ongoing or previous psychiatric treatment. For the repeater group it is important to consider their impulse dyscontrol and their hostile attitude when alternative treatment strategies are devised and evaluated. Language: en

In a 2-year outpatient treatment programme for alcoholics, 90% of the patients used aversive drugs during some part of the treatment period. Long-term use was significantly related to a favourable drinking outcome during 2 years subsequent to treatment compared with short-term use. Long-term and short-term users did not differ in background data. Continued use of aversive drugs after the first 6 months might have been critical for favourable outcome.

Hazardous alcohol use is associated with an increased risk for development of a substance use disorder, leading to negative outcomes in psychiatric patients.In order to investigate whether psychiatric outpatients' hazardous alcohol consumption could be reduced by way of a brief intervention by telephone.Non-psychotic psychiatric outpatients, n = 1,670, completed a self-rating form concerning alcohol habits (AUDIT). Participants with scores indicating risk consumption (n = 344) were randomised to intervention (immediate advice) or control (advice after 6 months).Hazardous alcohol habits occurred among 19% of the women and 24% of the men. In the intervention group, half of the patients reduced their alcohol consumption to non-hazardous levels at 6-month follow-up (ITT analysis). In women, 41.5% in the intervention group had no hazardous consumption at follow-up compared to 24.7% in the control group (P = 0.003), corresponding figure for men was 49.1 and 34.0%.Brief intervention seems to be effective to reduce hazardous alcohol consumption in psychiatric outpatients.

The use of screening instruments has been proposed to facilitate identification of risky substance use and misuse. This study aims to investigate the use of a screening procedure to identify hazardous or harmful use of alcohol, drug-related problems and riskful use of cigarettes in a clinical psychosis setting. The use of alcohol, drugs and cigarettes was examined by three self-reporting instruments: Alcohol Use Disorders Identification Test (AUDIT), Drug Use Disorders Identification Test (DUDIT) and Fagerstrom Test for Nicotine Dependence (FTND). Two hundred and forty-one out of 374 patients (64%) took part in the investigation. Eighteen per cent had a hazardous or harmful alcohol use, 9% drug-related problems and 49% were smokers. Multivariate analyses showed that women, as well as smokers had an increasing risk of having drug-related problems. The use of screening questionnaires increases the awareness that risky use of alcohol, drugs and cigarettes is common among persons with psychosis. Many persons with psychosis used alcohol, drugs and cigarettes in a risky way. It is important to identify these problems to make proper interventions due to the negative medical and social consequences of this use. Such identification may be facilitated by use of screening instruments.

The importance of family and friends for patients with mental health problems has been recognized over the past few years. Significant others (SO) of patients admitted to a psychiatric ward specializing in affective disorders and suicide prevention filled in a self-rating questionnaire concerning their burden as SOs, the Involvement Evaluation Questionnaire (IEQ). The aims of this study were twofold: first, to test whether the questionnaire IEQ was applicable in psychiatric services in Sweden and second, to relate the IEQ results to socio-demographic data and diagnosis of the patients, and also to the situation of the SOs. We found the questionnaire useful. Nearly half of the SOs had difficulties in accepting and handling the patient's psychiatric problems. More than half had been worried that the patient was going to harm him/herself and because of this had kept close watch on the patient. Almost all SOs worried about the patient's general health and future. Most of them felt obliged to intervene in the patient's activities of daily living. More than half worried about the kind of medical and psychological treatment the patient was receiving. Most SOs concluded that they were burdened by their engagement in the patient. Our results were compared with a European study of schizophrenic patients also investigated with the IEQ. The comparison indicated that the perceived burden on SOs of these different kinds of psychiatric patients can be equally burdensome. SOs need information, help and support in their difficult support role. This questionnaire could be useful in finding new routines for increasing the involvement by SOs in the treatment of patients with mental health problems.

The aim was to investigate patients and therapists perception of receiving and giving dialectical behavioral therapy (DBT). Ten deliberate self-harm patients with borderline personality disorder and four DBT-therapists were interviewed. The interviews were analyzed with qualitative content analysis. The patients unanimously regard the DBT-therapy as life saving and something that has given them a bearable life situation. The patients and the therapists are concordant on the effective components of the therapy: the understanding, respect, and confirmation in combination with the cognitive and behavioral skills. The experienced effectiveness of DBT is contrasted by the patient's pronouncedly negative experiences from psychiatric care before entering DBT.

According to Swedish legislation (LVM) compulsory treatment shall be decided on if someone, due to ongoing abuse of alcohol, drugs or volatile solvents, is in need of care to overcome abuse and if a voluntary intervention is not possible. Very little research has been conducted in Sweden on this particular legislation with regard to the clients' experiences of entire process from assessment to aftercare. We interviewed 74 subjects who were being assessed prior to the court's decision on involuntary care (n = 39), or with previous experience of assessment and involuntary care (n = 35). The assessment group more often reported having the opportunity to express their opinions to the social worker during the assessment period (55% vs. 21%, p < .05) and they were more positive towards the final decision (60% vs. 24%, p < .05). In spite of the law, 18% were not contacted by the social services while in coercive treatment. The clients who did meet with a social worker, often described the conferences as more of a perfunctory nature with a lack of focus on the actual situation and aftercare planning. This study points at a need of studying the subjects' experiences of the whole continuum of the coercive process: from the investigation, to treatment and to aftercare. It also points at the need for new instruments to be developed covering all aspects of the coercive process and in particular the period of investigation prior to the decision on involuntary care.

Although it is evident from numerous studies that patients with mood disorders generally have a deficient social functioning and a weak social network, little is known about these aspects of seasonal affective disorder (SAD) patients. We studied the social situation, the social network and the social functioning of SAD (n = 20) patients in comparison with matched suicide attempters (SA) with non-seasonal major depression, and with findings from other major depressive disorder (MDD) studies and community samples. The social situation and the clinical background of both the SAD and the SA groups were almost similar and the social networks were equally disadvantageous and weaker than those observed in some community/healthy populations. Furthermore, the data on global functioning and social adjustment of the SAD group were well comparable to those of other MDD patients and significantly worse than that of a community sample. Thus, the results indicate a considerable social impairment in SAD.

BackgroundTo investigate predictors for repetition of suicide attempts 1–12 months after a suicide attempt.MethodsTwo hundred and sixteen patients who had made a suicide attempt were investigated after 1 month, and 178 were followed up again after 12 months.ResultsDuring 1–12 months after the suicide attempt, 30 patients reattempted suicide (repeaters). During 0–1 month 13 patients had reattempted suicide (early repeaters), and nine of them also repeated between 1 and 12 months. Repeaters had more often made three or more attempts before index attempt, they more often were in treatment at the index attempt and at 1 month they had lower global functioning and higher suicide ideation. In a Cox Regression analysis two predictors for repetition between 1 and 12 months remained significant; early repetition (OR 6.7, 95% CI, 3.0–14.9) and having GAF-scores below 49 (median cut-off) (OR 3.4 (95% CI, 1.5–7.5).ConclusionsOur findings suggest that repetitive behaviour in itself is a strong predictor of future attempts. Strategies focusing on the repetitive behaviour are warranted.

The objective of this cross-sectional study was to analyse the influence of biological, socio-demographic, and psychosocial factors and current perimenopausal status on hypertension in a geographically defined population of 10,766 women aged 50-59 years, of whom 6901 attended the study. Altogether 1887 (27.3%) women had hypertension: 996 with drug treatment and 891 diagnosed at the study. In a logistic multiple regression analysis (controlled for age), drug treatment of hyperlipidaemia, family history of hypertension, waist-to-hip ratio, body mass index (BMI) increaseor = 25% during the past 25 years, S-triglycerides, S-cholesterol, education up to comprehensive school, and to upper secondary school, consumption of 84-167 g of alcohol/week, and ofor = 168 g of alcohol/week, were positively associated with hypertension, while high-density lipoprotein cholesterol and current smoking were negatively associated. A significant interaction was found between current smoking and BMI increase, with a lower risk for hypertension among smokers who had increased their BMIor = 25%. No interaction was found between smoking and alcohol. In conclusion, hypertension was predominantly associated with biological factors, and with heredity for hypertension. Of the socio-demographic factors, only low level of education was associated with hypertension in a comprehensive analysis. Perimenopausal status showed no relation to occurrence of hypertension in the multiple regression analysis. The risk for hypertension increased with moderate and high consumption of alcohol, whereas smoking showed a decreased risk. Among women with weight gain, present smoking remained protective. Although both smoking and hypertension are established risk factors for cardiovascular disease, they seem not to be directly linked, indicating a complexity of mechanisms.

Background: The aims of this study were to investigate initial characteristics and improvement after 18 months in patients with comorbidity of severe mental illness and substance dependence. These patients took part in a multicentre study aimed at improving co-operation between psychiatric health care units and social services. Methods: A total of 358 patients, 66% men, were included. There were four diagnostic subgroups: psychosis 29%, depression 17%, borderline personality disorder 23%, and other diagnoses of equal severity 31%. Initially and at follow-up the following measurements were used: global functioning axis V DSM-III-R (GAF), seven areas of Addiction Severity Index (ASI) and psychological symptoms (SCL-90). The outcome of substance use during the past 6 months was estimated by the Clinical Rating Scale (CRS). Results: Most patients were single (77%) and few (10%) had income from employment. Many (61%) had made suicide attempts, and 52% had somatic diseases before entering this project. After 18 months, 14 patients (3.9%) had died, and 288 patients (84%) could be interviewed. There were significant improvements in all but one ASI area (employment), in psychological symptoms and in global functioning. There was a positive correlation between the reductions in severity of alcohol abuse, drug abuse, psychiatric symptoms, relationships (ASI) and psychological symptoms. Forty-eight percent of patients with mainly alcohol-related problems, and 57% of those with mainly drug-related problems were either “abstinent” or using drugs “without impairment” (CRS) after 18 months. Improvement did not differ between psychiatric subgroups. Conclusion: These patients have weak social integration. Alcohol dependence was the most common substance use disorder. In most areas investigated, patients had improved. No substance abuse was found in half of the patients at follow-up.

Acceptance, attrition and outcome of the same outpatient treatment programme for alcoholics was studied first in a non-randomized and later in a randomized study. There was a lower (15%) rate of acceptance and a higher (19%) rate of attrition in the randomized study. Among treatment completers drinking outcome during the third year after commencement of treatment did not differ between the non-randomized and the randomized study. It is concluded that the characteristics of subjects accepting a randomly assigned study should always be clearly presented. The absence of a patient-therapist matching in a randomized design could negatively effect attrition and probably also acceptance of treatment, while it seems to be less influential on outcome in those completing therapy.

The predictors of the long-term outcome in alcoholics (n = 50) who had been treated in a 2-year outpatient treatment program were investigated. Previously, the sample had been followed up personally 2 years after the termination of treatment. This study is a repeated, independent follow-up of the same sample over a 4-year period, 3-6 years after termination of treatment. Outcome could be categorized in 38 subjects. Patients with a favorable outcome during at least 2 years of the 4-year follow-up period (n = 21), who were categorized as a positive outcome group, were compared with the other patients (n = 17). There was no significant correlation between initial patient characteristics and outcome 3-6 years after treatment. Drinking outcome during the 1st half-year of treatment had no correlation to positive drinking outcome in years 3-6, whereas there was a positive correlation for later phases of treatment and outcome reaching a significant level during the 2nd and 4th half-year of treatment. A favorable drinking outcome during years 1-2 after treatment had a positive significant correlation to outcome in years 3-6 after treatment [i.e., 80% of the patients with a favorable outcome during the 1st follow-up period also had a positive outcome during the 2nd follow-up period, and 72% of those who had an unfavorable outcome during the 1st follow-up period had an unfavorable outcome also during the 2nd follow-up period (chi 2 test = 10.4, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Defensive strategies were studied in 72 alcoholics participating in outpatient treatment by using, before the treatment started, the Meta-Contrast Technique, MCT, a percept-genetic method. Alcoholics had less often adaptive strategies than controls. A lack of adaptive defense strategies was related to a more impaired psychic status, more psychological benefits from drinking, and more psychiatric symptoms but not to severity of alcoholism or results of psychometric tests (intellectual level, field-dependence, spatial performance). It does not seem inconceivable that the MCT could be used as a diagnostic tool in treatment planning.

Social characteristics and self-rating of social support by means of the Interview Schedule for Social Interaction were investigated in 75 inpatients after a suicide attempt. We found that very few suicide attempters (13%) had a well functioning relationship, and two-thirds had problems in their occupational situation. Divorced patients had unsatisfactory social interaction compared with those who were married or cohabiting and with those who were single or widowed. Employees and students more often had deep emotional relations than those who were unemployed or in vocational rehabilitation. The latter were also less satisfied with their social interaction than those who were retired or had a disability pension. Poor social interaction was more commonly reported by patients with dysthymia than by those in other diagnostic subgroups. We conclude that an evaluation of the social network should be an integral part of the clinical handling of suicide attempters, since it forms a basis for planning psychiatric treatment.