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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.

This study investigates the incremental validity of changes in ten stress-related acute dynamic risk factors, collected through automated telephony over 30 consecutive days following parole, for predicting time to recidivism during the following year. Before release, the participants completed self-report assessment of some stable risk factors - impulsiveness and history of problematic substance use - as well as an assessment of symptoms of anxiety experienced during the weeks prior to release. Analysis of the baseline assessments showed that impulsiveness and a history of problematic substance use, but not pre-release symptoms of anxiety, were associated with recidivism during the parole year. Growth modelling using a linear mixed model was used to assess whether inmates on parole showed changes in acute dynamic risk factors during the first month following release. Individual growth model slopes and intercept were then extracted and used as covariates in a series of Cox regression analyses to test whether changes in acute dynamic risk factors could provide incremental predictive validity beyond baseline stable risk factors. Changes in five dynamic risk factors were associated with an increased risk of recidivism, of which daily drug use and daily summary score showed incremental predictive improvement beyond impulsiveness and history of problematic drug use.

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.

Prison release planning is rarely based on adequate assessment using evidence-based instruments. This study uses well-established self-reports for screening of problem severity and for predicting recidivism, measured as reconvictions during one-year following release, in prisoners about to be conditionally released on probation in Sweden between 2009 and 2010. One Hundred and six prisoners completed the following measures: Karolinska Scales of Personality, Hopkins Symptom Checklist-25, Alcohol Use Disorders Identification Test, Drug Use Disorders Identification Test. Results show frequent mental health and substance use problems and high scores on the KSP psychopathy factor. Anxiety and problematic drug use were the two most important factors associated with one-year recidivism. Prior to release, self-reports could be useful for screening of problem severity, and for predicting recidivism.

Few studies have assessed acute dynamic risk repeatedly among paroled offenders to investigate the relationship between changes in acute dynamic risk and recidivism in crime. The present study investigates whether one-month changes in ten stress-related acute dynamic risk factors, collected through automated telephony while the participants were still in prison and over 30 consecutive days following parole, predict one-year criminal recidivism, including its predictive accuracy. The study also investigates whether a brief feedback intervention in conjunction with the daily assessments reduces recidivism compared to an assessment-only control group. Changes in five risk factors were found to be associated with increased risk of criminal recidivism after controlling for the results in prison, the initial value after parole, and the intervention. The predictive accuracy is marginally accurate: Summary score (AUC) = .666; Level of stress (AHSS) = .644; Psychiatric symptoms (SCL-8D) = .641; Anxiety symptoms = .673; Severity of most stressful daily event = .690. No differences in one-year recidivism rates were established between the intervention group and the control group. The study shows that daily assessments can usefully be made of dynamic risk factors in paroled offenders.

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.

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.

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.

There is a lack of studies assessing parental awareness of adolescent alcohol, cigarette, and drug use in the general adolescent population. A total of 1,426 adolescents aged 14 to 16, and their parents, answered questions about adolescent substance use annually during junior high school. Sensitivity for parental report of adolescent substance use was low: 5.6% to 26% for drunkenness, 14.3% to 20.6% for cigarettes, and 4.9% to 12% for illicit drugs. Higher age and higher frequency of use were positively associated with parental awareness of drunkenness and cigarette use. Female sex was associated with higher parental awareness of drunkenness. Higher school performance was negatively associated with parental awareness of drunkenness in Grade 9 and with cigarette use in Grades 8 to 9. Parental awareness of adolescent drunkenness, and cigarette and illicit drug use in the general population is low. Factors of importance for parental awareness are identified.

This study analyzed predictors of psychiatric hospitalization in ex-prisoners with substance use problems ( N = 4,081) assessed with the Addiction Severity Index and followed post-release for hospitalizations with psychiatric diagnoses (including suicide attempts). Thirty-four percent were hospitalized, and in Cox regression, several substance-related variables predicted hospitalization, including use of heroin, sedatives, and polysubstance. A secondary analysis, with a psychiatric non-substance focus, excluded hospitalizations involving only substance-related disorders or only a personality disorder in addition to a substance-related disorder. With this definition, 10% were hospitalized, and significant baseline predictors were previous psychiatric hospitalization (hazard ratio [HR] = 1.83), previous suicide attempt (HR = 1.91), depression (HR = 1.33), anxiety (HR = 1.37), sedative use (HR = 1.46), and, negatively, amphetamine use (HR = 0.71). Substance-related variables may predict all-cause psychiatric hospitalizations in prisoners with substance use problems, whereas non-substance-related psychiatric hospitalization may be predicted by baseline psychiatric problems, which calls for attention to psychiatric problems in this setting.

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.

Background. Nonmedical prescription opioid use (NMPOU) is a growing problem and tramadol has been suggested as an emerging problem in young treatment-seeking individuals. The aim of the present study was to investigate, through hair analysis, NMPOU in this group and, specifically, tramadol use. Methods. In a study including 73 treatment-seeking adolescents and young adults at an outpatient facility for young substance users, hair specimens could be obtained from 59 subjects. Data were extracted on sociodemographic background variables and psychiatric diagnoses through MINI interviews. Results. In hair analysis, tramadol was by far the most prevalent opioid detected. Thirty-two percent screened positive for opioids, and of those, all but one were positive for tramadol. Ninety-eight percent reported problematic cannabis use. Significantly more opioid-positive patients also screened positive for other (noncannabis) drugs, compared to nonopioid users. Sixty-four percent fulfilled criteria of DSM-IV psychiatric disorders, other than substance use disorders according to MINI. Fifty-three percent met the symptom criteria count of ADHD above cut-off level. Conclusion. In the present setting, tramadol, along with high rates of cannabis use, may represent a novel pattern of substance use among young treatment-seeking subjects with problematic substance use and high rates of concurrent psychiatric problems.

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.

Background and Objectives: Mental health problems are common in Primary Health care and clinicians require valid and reliable instruments to make good treatment plans for these patients. The Outcome Questionnaire-45 (OQ-45) was developed by Lambert and colleagues in order to help improve outcomes of treatment. The aims of this study were to examine the psychometric properties of the Swedish version of OQ-45 when administered by an automated technique and to evaluate if the OQ-45 uniquely could contribute to the description of the patients’ difficulties and needs beyond demographic characteristics and other instruments. Methods: The study comprised 816 patients with mental ill-health taking part in a large randomized controlled trial, Regassa. The OQ-45 data were collected by Interactive Voice Response IVR, a computerized, automated telephone technique. The OQ-45 consists of 45 items summarized in a total score and in three subscales; Symptoms of distress, SD, Interpersonal relations, IR, and Social role functioning, SR. Depression was measured by MADRS and health-related quality of life by EQ-5D. Results: The OQ-45 total score showed good psychometric properties, but there was little support for its three factor structure. The OQ-45 significantly predicted level of depression and health-related quality of life in patients. Conclusions: The OQ-45 contributed uniquely to the description of the patients´ problems. The results indicate that the total score of the Swedish version of OQ-45 can be valuable to use for clinicians in the field.

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.

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.

This paper explores recovery-promoting care as experienced by persons with concomitant severe mental illness and substance misuse. Sixteen in-depth interviews, based on an interview guide concerning their experiences of health, life situation and care, were held with eight participants in an outpatient treatment programme. The analysis aimed to identify themes reflecting the diversity and complexity of the phenomenon recovery-promoting care. Six themes emerged: “entirety”, “participation and reciprocal relations”, “stability”, “symptom control”, “mindfulness”, and “dignity and autonomy”. The participants reported that care conveying experiences of meaningfulness and providing empowerment increased their motivation and their capacity to take an active part in the recovery process. The findings of the study underscore the importance of incorporating the patients’ perspectives on what promotes recovery when offering mental health services.

Background The first year of university studies is associated with increased levels of alcohol drinking and stress. This study examines the one-year outcome of both primary and secondary interventions of one alcohol programme and one stress intervention programme at an intervention university in comparison with a control university. Methods At the intervention university all freshmen were offered a primary prevention programme for hazardous alcohol use and stress management and, in addition, those who had high ratings for stress and/or hazardous alcohol use were offered a secondary intervention programme for alcohol consumption and/or stress management. Freshmen still attending the two universities one year later responded to follow-up questionnaires. Results The primary alcohol and stress interventions were associated with lower alcohol expectancies and mental symptoms, but no differences in AUDIT scores (- 0.2, CI 95% - 0.5 to 0.1), estimated blood alcohol concentrations or stress in comparison to freshmen at the control university. The secondary alcohol interventions were associated with decreased AUDIT (– 1.1, CI 95% - 2.0 to – 0.2) as well as alcohol expectancies, blood alcohol concentrations, stress and mental symptoms in comparison to high-risk freshmen at the control university. The secondary stress interventions were associated with decreased mental symptoms and alcohol expectancies, but not stress, AUDIT scores (- 0.6, CI 95% - 1.4 to 0.2) and blood alcohol concentrations in comparison to high-risk freshmen at the control university. Conclusion This study suggests that both primary and secondary alcohol and stress interventions have 1-year effects in university freshmen and could be implemented in university settings.

Background: It is well known that severe mental illness (SMI) with concurrent substance use disorders (SUD) commonly occurs. This comorbidity has distressing social, psychological, psychiatric and somatic consequences. Aim: To gain greater understanding of how individuals with SMI and SUD experience the roles of alcohol and other drugs for their health and life situation. Method: Eight individuals were interviewed on two occasions. The semi-structured interviews, which were based on an interview guide, were transcribed verbatim and analysed thematically. Results: Alcohol and drug use influenced the individuals' own experiences of their health and life situation both in a positive and negative way. Substance use had meaning for their: ‘experience of themselves’ – well-being and discomfort, energy and lack of energy, meaningfulness and disorientation, identity and personality change; ‘experiences of relationships’ – affiliation and alienation; ‘experiences of mental health’ – decreased and increased symptom...

The aim of this study is to provide a survey of systematic reviews that have evaluated the effects of psychosocial interventions for adult people with intellectual disabilities and/or an autistic syndrome with concurrent mental health problems. Reviews for inclusion were identified through searches of 10 electronic databases. The authors found that 3 out of 126 published reviews met the inclusion criteria for interventions, population, and being considered a systematic review. The results imply a weak scientific support for behavioral therapy, cognitive-behavioral therapy, and some forms of integrated care and support. However, the primary studies included in the reviews have several methodological shortcomings. The results suggest future research initiatives in the direction of more effectiveness studies of good quality and reproduction of high-quality systematic reviews.

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.

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)

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.

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.

Aim This study aims to investigate suicide risk factors after attempted suicide and whether and how these risk factors differ between the sexes. Method A total of 1052 suicide attempters admitted to the Medical Emergency Inpatient Unit, Lund University Hospital, Sweden were followed up concerning suicide and death from other causes after a median period of 6 years and 5 months. in all, 50 persons committed suicide during follow-up. At the index suicide attempt, socio-demographic data and information about clinical characteristics were gathered in a standardised manner. Risk factors were identified among these data using survival analyses for the whole sample and for each sex separately. Result Men had a higher frequency of suicide and a greater overall mortality than women. Cox regressions showed that suicide attempt(s) prior to the index attempt and the use of a violent method for the index attempt were risk factors for men only, whereas older age and a high suicidal intent (Beck SIS score) were female ones. Major depression was a risk factor for both sexes. Conclusion More attention probably needs to be paid to the importance of gender in assessment of suicide risk and treatment of suicide attempters. (Less)

From a total population of 10,766 Swedish 50- to 59-year-old women, 6,917 (64.2%) participated in the Women’s Health in Lund Area (WHILA) study, and among them 6,623 (95.7%) answered the questions on alcohol consumption. One out of 4 women (26.0%) consumed no alcohol in an ordinary week (non-drinkers), 57.4% consumed not more than 83 g alcohol, 12.5% consumed 84–167 g and 4.2% consumed 168 g or more. The weekly drinkers had a median consumption of 40.0 g alcohol (range 2.5–1,036.0) and the main sort of alcohol was wine. Comparing the four drinking groups, most differences occurred between the non-drinking and the weekly drinking women. The non-drinkers had lower socio-demographic status, poorer health and more symptoms, especially physical symptoms. In a multivariate logistic regression analysis, most associations between non-drinking and lower socio-demographic status remained.

This article represents the proceedings of a symposium at the 2002 annual meeting of the Research Society on Alcoholism in San Francisco, CA, organized and cochaired by Mats Berglund and Sten Thelander. The presentations were (1) Preventive interventions against hazardous consumption of alcohol, by Mikko Salaspuro; (2) Treatment of alcohol withdrawal, by Johan Franck; (3) Psychosocial treatment for alcohol problems, by Sven Andreasson and Agneta Ojehagen; and (4) Pharmacological treatment of alcohol dependence, by Mats Berglund.

This study was designed to investigate the motives patients give for attempting suicide and the associations between these motives and diagnosis, various psychiatric features, suicidal intent and socio-demographic characteristics. The Motives for Parasuicide Questionnaire (MPQ), comprising 14 suggested motives, was presented to 53 patients at a psychiatric ward that specialized in suicide attempters. Escape motives were very common, whereas interpersonal motives were rare. Patients with substance abuse, anxiety, or personality disorders more often chose communicating motives and mentioned higher numbers of motives than those with mood or adjustment disorders. Hopelessness was positively associated with a stated wish to die and with escape motives, and negatively correlated to communicating/unclear motives. Suicidal intent was related to some motives. The psychiatric disorder or mental state seems to be more important than socio-demographic characteristics for the choice of motives. Further studies are required to investigate the associations between psychiatric features and motives, as well as the clinical usefulness of such assessments. (Less)

This study was designed to investigate suicide attempters' views on problems underlying their suicidal behavior. A questionnaire comprising 17 problems was presented to 54 non-consecutive patients (men/women=25/29, mean age 36 ±14 years) admitted to a specialized psychiatric ward following an attempt. (In the large majority of cases the method was self-poisoning. 37% had previously attempted suicide.) The most common problem was 'feelings of loneliness,' followed by 'mental illness or psychiatric symptoms.' Men more often experienced socio-economical problems, whereas women more often mentioned psychiatric problems and interpersonal relation difficulties. Patients diagnosed with adjustment disorder more often experienced recent/current problems in relationships than those with other disorders. High numbers of problems mentioned were related to being "never married/single," having a poor social network and many depressive symptoms. In addition to psychiatric problems, interpersonal problems were in focus to most patients. The importance of listening to the patients' own views on their problems after a suicide attempt is discussed. (Less)

This study investigated attendance of treatment and follow-up characteristics in two samples of suicide attempters with different lengths of follow-up, that is after one month and after three months. They did not differ initially. After one month, most of the treatment non-attenders (32%) had not yet established an outpatient contact after inpatient treatment, while after three months, 38% of the patients had no psychiatric treatment. At one month, the patients more often had sleep disturbances, expressed hopelessness, and they also more often expressed other kinds of problems. After one and three months 36% and 30%, respectively, had suicidal thoughts. In both samples, these patients more often than the others expressed a need of professional help, regardless of ongoing treatment. Probably there is a critical period of time in which to engage the patient in treatment, and perhaps more than one follow-up contact should be made.

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.

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.

Results on the effectiveness of psychosocial treatments for patients with comorbid psychiatric and substance use disorders (dual disorders) will be discussed based on relevant meta-analyses and comprehensive reviews. Findings pertaining to severe (e.g., schizophrenia) and mild to moderate (e.g., anxiety disorders) dual disorders will be presented. The heterogeneity in patient characteristics, treatments, settings, and measured outcomes within the studies hinders the extraction of simple conclusions regarding how to effectively integrate psychiatric and addiction-oriented services into one psychosocial treatment. However, promising treatment strategies and interventions include integrative programs that comprise motivational interviewing; disorder-specific cognitive-behavioral interventions; substance use reduction interventions such as relapse prevention or contingency management; and/or family interventions. Such programs are generally superior to control groups (e.g., waiting list, treatment as usual) and are sometimes superior to other active treatments (e.g., skills training) in outcomes of substance use, psychiatric disorders, and social functioning.

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.

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.

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.