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Electroconvulsive therapy (ECT) is effective and safe for adults with severe depression, but less studied in adolescents. Here, we examined the indications, prevalence, practice, response and remission rates, and side effects in young people treated with ECT in Sweden. We also examined the usage of ECT in the transition to adult psychiatry. Using data from national patient registers and the Swedish National Quality Register for ECT (Q-ECT), we identified patients aged up to 19 years treated with ECT over a 5-year study period. Response and remission rates were analysed using the Clinical Global Impression (7-point scale)-Improvement (CGI-I) and Severity (CGI-S). A total of 118 individuals were identified, of which 105 were also enrolled in the Q-ECT. The most common indication for ECT was depression (68%; n = 80). Adolescents aged P n = 99). Fifty-seven percent (n = 54) of the patients responded (CGI-I, 1–2) to the treatment; remission (CGI-S, 1–2) was achieved by 32% (n = 30). Psychotic symptoms were associated with a higher response rate in patients with depression (P = 0.038). A deterioration of memory compared to pre-treatment was reported in six patients. ECT was associated with high response and remission rates in adolescents with severe psychiatric disorders after non-response to medication.

In Zimbabwe common mental disorders are prevalent among adolescents and the treatment gap is large. The recently introduced Youth Friendship Bench intervention (YouFB) addresses this gap by task-shifting youth lay health workers to offer a culturally contextualised, manual-based, six-session problem-solving therapy to adolescents, 16-19 years of age. The aim of this study was to explore participants´ experiences of YouFB to attain a first insight into this novel intervention. Interviews with nine adolescents were analysed using qualitative content analysis on a latent level. The experience of YouFB was positive, perceived to offer hope and relief from feelings of isolation and uncertainty, increase manageability of problems, and contribute to feelings of autonomy, resulting in a feeling of optimism about the future. The notion among participants that this brief intervention had such a positive influence on their lives, sparks interest because of its applicability in low-resource settings.

Evidence is lacking on how to manage imminent suicidality in adolescents with self-harm. Brief Admission by Self-referral (BA) is a crisis-management intervention, developed for adults with self-harm at risk for suicide. Structured, individualized and based on responsible autonomy, BA aims to provide a respite while minimizing negative effects of hospitalization. This qualitative interview study illuminates adolescents’ experiences of BA, adapted for this target group. Nineteen adolescents aged 14 to 19 years, described BA as helpful for timely rest and recovery to save themselves from impulses to self-harm. The individual contract, which is a prerequisite for access to BA, was perceived to give access to professional support in a safe environment, also among adolescents not using their contract. Being trusted with responsibility to self-admit was also hard work with struggles of self-doubt. Challenges included experiencing distrust from staff and fear of not being able to abstain from self-harm, which BA is conditioned upon. However, this condition was also perceived to induce self-motivation and growth. BA appeared well-adapted to the target group, fulfilling needs of predictability, autonomy, and opportunity for recovery to prevent self-harm. Suggestions for improvement included continually informing staff about important features of BA. To further evaluate benefits and challenges of BA, future research may evaluate clinical and health-economic outcomes and perspectives from parents and caregivers.

Introduction Autoimmune disorders have become increasingly acknowledged as having a more causative role in encephalitis than previously assumed. Anti-N-methyl-d-aspartate receptor encephalitis seems to be the most prevalent disorder. Symptoms of the neuropsychiatric phase in children and adolescents include abnormal behavior, seizures, and neurologic symptoms. We present a report on a teenage girl with predominantly psychiatric symptoms, highlighting the need for awareness of the disease and multidisciplinary collaboration. Case presentation Our patient, a 17-year-old girl of Middle Eastern origin, had no earlier medical history, but a family history of autoimmune disease. One morning, she could not recognize her mother and soon developed increased energy and pressured speech. The condition worsened, with paranoid delusions. In the emergency unit, she ran around speaking incoherently. The condition was interpreted as a full-scale mania. After pediatric clearance, the patient was admitted to the Department of Child and Adolescent Psychiatry. Mood-stabilizing treatment was initiated with second-generation psychotics and lithium, but this brought no improvement. A multidisciplinary discussion was held with physicians from psychiatry and neurology. A lumbar puncture showed N-methyl-d-aspartate receptor antibodies, and autoimmune treatment was initiated. Computed tomography thorax/abdomen revealed a right-sided ovarian tumor. After salpingo-oophorectomy, our patient’s mental status gradually improved, as demonstrated by repeated testing. Seven months post discharge she was in a stable relationship and performing well in school. Conclusion This case underlines the importance of collaboration between child and adolescent psychiatry and pediatrics, and gives pointers for timely diagnosis. Manic adolescents who do not respond to mood-stabilizing treatment should be subjected to further consultations and investigations. Psychiatrists and neurologists should develop an integrated approach to the management of brain disorders.

Introduction. Underage drinking is associated with poor mental health. Early detection for risky alcohol use is recommended, although less implemented in adolescent care. The objective of this study was to investigate the prevalence of risky alcohol use and psychiatric comorbidity. Methods. Over a nine-month period, 145 eligible adolescents admitted to the child and adolescent emergency unit in Malmö, Sweden, were offered computerized screening with Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) and Drug Use Disorders Identification Test (DUDIT). Results. Ninety-six patients (73 girls and 23 boys) agreed to participate. The most common diagnoses were affective disorder (41%) and anxiety disorder (27%). Risky alcohol use was found among 33% of the girls and 22% of the boys ( p = 0.45 ) and did not differ between diagnostic categories. There was a positive correlation between AUDIT-C and DUDIT scores ( p = 0.019 ). Among adolescents with risky alcohol use, 33% of the girls and 60% of the boys also had a risky drug use. Conversely, 47% of the girls and 60% of the boys with risky drug use also had a risky alcohol use. Conclusion. In view of the poor prognosis of risky alcohol use in adolescents, alcohol and drug habits should be assessed when adolescents seek psychiatric emergency care.

Restraints and seclusions are restrictive interventions used in psychiatric inpatient units when there is an imminent risk of harm to the patient or others. Coercive measures are controversial and can lead to negative consequences, including negative emotions, re-traumatization, injuries, or death. The article summarizes the last 10 years of literature regarding methods and strategies used for reducing seclusions and restraints in child and adolescent psychiatric inpatient units, and reports on their outcomes. The literature was reviewed by searching PubMed and PsycInfo for English-language articles published between May 2010 and May 2020. Eighteen articles were found that described methods or strategies aimed at reducing restraint or seclusion utilization in child and adolescent psychiatric inpatient units. The following interventions were evaluated: Trauma-Informed Care (TIC), Six Core Strategies, Child and Family Centered Care (CFCC), Collaborative & Proactive Solutions (CPS), Strength-Based Care, Modified Positive Behavioral Interventions and Supports (M-PBIS), Behavioral Modification Program (BMP), Autism Spectrum Disorder Care Pathway (ASD-CP), Dialectical Behavior Therapy (DBT), sensory rooms, Mindfulness-Based Stress Reduction Training (MBSR) of staff, and Milieu Nurse-Client Shift Assignments. Most of the interventions reduced the use of seclusions and/or restraints. Two child-centered and trauma-informed initiatives eliminated the use of mechanical restraints. This review shows that the use of coercive measures can be reduced and should be prioritized. Successful implementation requires ongoing commitment on all levels of an organization and a willingness to learn. To facilitate comparisons, future models should evaluate different standardized parameters.

Problem: Emergency care in child and adolescent psychiatry often lacks a coherent treatment model. This study reports on the development and implementation of a salutogenic treatment model at the Child & Adolescent Psychiatric Emergency Unit in Malmo, Sweden. Methods: The development and implementation involved all staff categories and was guided by a recognized authority on salutogenesis. Generalized resistance resources (GRR) were identified that could be implemented at the unit to improve patients’ sense of coherence. Findings: Eight GRR were developed and implemented at the unit. During the 6-month period following the implementation, patients (n = 41) and parents reported satisfaction with the treatment, while mental health improved between admission and discharge, and both treatment length and readmission rates were reduced. Conclusion: A salutogenic treatment model involving GRR seems to be a promising approach in child and adolescent psychiatric emergency treatment.

Background Comorbidity of bipolar disorder and obsessive–compulsive disorder is common in adolescence. Obsessive–compulsive disorder symptoms may be episodic and secondary to alterations in mood, and display specific features. Management of pediatric bipolar disorder-obsessive–compulsive disorder is challenging, as pharmacotherapy of obsessive–compulsive disorder may induce or exacerbate manic episodes and there is limited evidence of treatment efficacy. Electroconvulsive therapy is sparsely used in children and adolescents, but is documented to be a safe and efficacious intervention in adults with bipolar disorder. In view of the severity of symptoms in juvenile mania, studies on treatment strategies are warranted. We report a case of an adolescent with bipolar disorder-obsessive–compulsive disorder who was successfully treated with electroconvulsive therapy during an episode of severe mania. Case presentation A 16-year-old girl of Middle East origin first presented to us with depressed mood, irritability, and increased obsessive–compulsive disorder symptoms, which were initially interpreted in the context of acute stress secondary to migration. She had been diagnosed with bipolar disorder and obsessive–compulsive disorder in her previous home country, but had difficulties in accounting for earlier psychiatric history. During hospitalization her mood switched to a manic state with mixed and psychotic features, at times showing aggression toward others. Interruption in her lithium treatment for a short period and possibly the introduction of an atypical antipsychotic could in part have been triggering factors. After 8 weeks of in-patient care and psychotropic drug trials, electroconvulsive therapy was initiated and administered every second or third day for 4 weeks, with marked positive response. No apparent side effects were reported. Conclusions This case demonstrates the need for a detailed medical history, taking special note of periodicity and character of obsessive–compulsive disorder symptoms, in adolescents with mood disorders. When treating culturally diverse patients, extra consideration should be taken. Special concerns in the pharmacological treatment to avoid the patient’s condition from worsening must be addressed, including giving priority to mood stabilization before obsessive–compulsive disorder symptoms. There are potential benefits in considering electroconvulsive therapy in young patients with severe mania where first-line treatment options have failed.

Purpose: Self-harm is common among adolescents, and is even more frequent among psychiatric populations. The aim of this study was to increase knowledge and understanding of different aspects of life for adults who, when adolescents, had engaged in severe self-harm during inpatient stays.Material and methods: Individual semi-structured interviews were held with seven former inpatients with a history of severe self-harm during inpatient stay in their adolescence. The interviews were analysed using a qualitative method, and the results were described in the form of categories and sub-categories.Results: Five categories, with 16 sub-categories, were found to be related to the former patients' experiences of their lives. At the time of the interviews, the subjects were in their early thirties and had no ongoing self-harm. In childhood they had experienced a dysfunctional relationship with one or both of their parents, and self-harm was one of several destructive behaviours. Friendships outside the unit were difficult during adolescence. Soon after admission to the psychiatric inpatient unit, relationships with other patients became important and contributed to them wanting to stay at the unit. Meaningful relationships and being part of a social context with healthy expectations were seen as important factors for stopping self-harm at a later stage. The subjects' experiences of their life today ranged from not enjoying it to accepting their current situation.Conclusion: These findings are based on a small sample, but they indicate the importance of relationships and the social context in contributing to and then ending self-harm.

Background: An infant's development is closely linked to the relationship they have with their parents. Parenting stress, affective disorder, and an upbringing with substance-abusing parents can affect parenting quality and increase the risk of children developing behavioral, mental and social problems. The overall aim of the study was to investigate how parents of children attending an outpatient Infant Mental Health (IMH) unit rate their own psychological health and parenting stress, and to explore predictors of parenting stress.Methods: The sample comprised 197 parents, 129 mothers and 68 fathers, referred with their infant/toddler to an outpatient IMH unit for interplay treatment. On admission, the parents completed self-report questionnaires concerning their own mental health problems and parenting stress.Results: The mothers reported significantly more psychiatric symptoms and parenting stress than the fathers. Fathers with substance-abusing parents had often experienced divorce in the family of origin, had a low level of education, and had often experienced trauma. Depression was a predictor for parenting stress for both mothers and fathers.Conclusion: The parents' situation was strained, presenting a variety of psychiatric symptoms and high levels of parenting stress, making assessment of parental health before starting treatment important. The mothers' situations were more serious compared with the fathers', and for both parents depression was a significant predictor for parenting stress. To increase the chances of a positive treatment outcome for the child, both parents should be included in the treatment.

Emergency care in child and adolescent psychiatry often lacks a coherent treatment model. This study reports on the development and implementation of a salutogenic treatment model at the ChildAdolescent Psychiatric Emergency Unit in Malmö, Sweden.The development and implementation involved all staff categories and was guided by a recognized authority on salutogenesis. Generalized resistance resources (GRR) were identified that could be implemented at the unit to improve patients' sense of coherence.Eight GRR were developed and implemented at the unit. During the 6-month period following the implementation, patients (n = 41) and parents reported satisfaction with the treatment, while mental health improved between admission and discharge, and both treatment length and readmission rates were reduced.A salutogenic treatment model involving GRR seems to be a promising approach in child and adolescent psychiatric emergency treatment.

BACKGROUND New methods are needed for collecting data of in- and outpatients and for improving outpatient compliance after discharge. Mobile technologies, such as smartphone apps, have shown promising results, (eg, helping unwell people by offering support and resources). Screening for the condition, including comorbidities, is a vital part of psychiatric care. Comorbid conditions, especially in emergency evaluation, are often missed, leading to inaccurate diagnosis and treatment. One way of improving diagnostic accuracy is to use a structured diagnostic process. Digitalized screening and follow-up have the advantage of making administration and scoring easier and less time consuming, thereby increasing response rate. To address these problems, we decided to create a smartphone app called The Blue App. The Blue App was developed through 6 steps, described in the manuscript. OBJECTIVE The aim of this paper is to describe (1) the development of The Blue App and (2) 2 planned research studies to evaluate the app. METHODS Two studies will be performed. Study 1 has a descriptive design, mapping comorbidities before and after the introduction of The Blue App. Study 2 has a randomized controlled design, measuring compliance with outpatient treatments as well as depressive symptoms, rated as changes in Montgomery-Åsberg Depression Scale scores during a 1-year follow-up. RESULTS We have described app development. Data collection for Study 1 started in autumn 2017. Study 2 will start in autumn 2018. We expect to have enrolled the 150 patients in Study 2 by December 2019. Final results will be published in a scientific journal. CONCLUSIONS A technically advanced and easy-to-use Web-based mobile phone app corresponding to the unit’s needs was developed, and 2 studies are planned to evaluate its usefulness. INTERNATIONAL REGISTERED REPOR RR1-10.2196/10121

BACKGROUND: New methods are needed for collecting data of in- and outpatients and for improving outpatient compliance after discharge. Mobile technologies, such as smartphone apps, have shown promising results, (eg, helping unwell people by offering support and resources). Screening for the condition, including comorbidities, is a vital part of psychiatric care. Comorbid conditions, especially in emergency evaluation, are often missed, leading to inaccurate diagnosis and treatment. One way of improving diagnostic accuracy is to use a structured diagnostic process. Digitalized screening and follow-up have the advantage of making administration and scoring easier and less time consuming, thereby increasing response rate. To address these problems, we decided to create a smartphone app called The Blue App. The Blue App was developed through 6 steps, described in the manuscript. OBJECTIVE: The aim of this paper is to describe (1) the development of The Blue App and (2) 2 planned research studies to evaluate the app. METHODS: Two studies will be performed. Study 1 has a descriptive design, mapping comorbidities before and after the introduction of The Blue App. Study 2 has a randomized controlled design, measuring compliance with outpatient treatments as well as depressive symptoms, rated as changes in Montgomery-Asberg Depression Scale scores during a 1-year follow-up. RESULTS: We have described app development. Data collection for Study 1 started in autumn 2017. Study 2 will start in autumn 2018. We expect to have enrolled the 150 patients in Study 2 by December 2019. Final results will be published in a scientific journal. CONCLUSIONS: A technically advanced and easy-to-use Web-based mobile phone app corresponding to the unit's needs was developed, and 2 studies are planned to evaluate its usefulness. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/10121.

BACKGROUND: Pervasive refusal syndrome (PRS) is a rare but severe condition, characterised by social withdrawal and a pervasive active refusal in terms of eating, mobilisation, speech and personal hygiene. PRS has been proposed as a new diagnostic entity in child and adolescent psychiatry, although the diagnostic criteria are debated. In the past 10 years there has been an increase in PRS symptoms among asylum-seeking children and adolescents in Sweden. Here, we describe five cases of PRS among asylum-seeking children and adolescents. METHOD: Three females and 2 males, 7-17 years of age with the clinical picture of PRS, treated as inpatients at the Department of Child and Adolescent Psychiatry, Malmö, Sweden, 2002-2010, were analysed on the basis of their medical records. Subjects were diagnosed using previously suggested criteria for PRS. At follow-up, a semi-structured interview focusing on the inpatient stay and current status was performed. The subjects were assessed with Global Assessment of Functioning (GAF) and self-rating questionnaires regarding depression and post-traumatic stress disorder (PTSD). RESULTS: The pattern of refusal varied among the five subjects. All subjects originated from former Soviet republics, indicating a possible cultural factor. Mean period of inpatient treatment was 5 months. All subjects received intense nursing and were treated with nasogastric tube feeding. Parents were involved and were given support and instructions. All subjects gradually improved after receiving permanent residency permits. Depression and PTSD were co-morbid states. At follow-up, 1-8 years after discharge, all subjects were recovered. CONCLUSION: Although a severe condition, our five cases suggest a good prognosis for PRS among asylum-seeking children and adolescents.

The two aims of this study were to analyse the impact of methadone on outcome, and to confirm the results from previous meta-analyses by using a different methodology. The literature on randomized controlled trials (RCT) of methadone as maintenance treatment for opioid dependence was systematically reviewed. Eight studies involving 1511 patients were included. Both dichotomous and continuous variables were transformed into the standardized effect size (d). Homogeneity was analysed. A random effect model was used in all calculations. The combined analyses for retention, abuse and criminality were all significant: d=0.90, d=0.61, and d=0.35, respectively. A test of heterogeneity was significant for all three outcomes: P0.01 for all comparisons. The type of study design was a significant moderator in five of nine comparisons: for retention in all three comparisons, concerning abuse in gradual detoxification vs. untreated controls and concerning criminality in placebo vs. untreated controls. In these sub-groups, three of six studies were homogeneous. In one study, methadone maintenance treatment reduced abuse of illegal opioids in prisoners. We conclude that methadone maintenance treatment in opioid dependence shows positive effects on retention, opioid abuse and criminality compared with non-active controlled conditions. Type of study design could explain some of the heterogeneity found. A different meta-analytical approach made it possible to confirm effects of methadone on retention and opioid abuse from previous studies and document effect on criminality.

Background Unaccompanied refugee minors (URMs) have high levels of psychiatric symptoms, and concerns for their access to mental health services have been raised. From the mid-2000s, an increasing number of asylum-seeking URMs, mainly adolescent boys from Afghanistan, have been referred to the Child & Adolescent Psychiatry emergency unit in Malmö, Sweden. The aim of the study was to compare inpatient psychiatric care between URMs and non-URMs. Findings All admissions in 2011 at the emergency unit were identified and divided into URMs (n = 56) and non-URMs (n = 205). On the basis of unique patients’ first treatment occasion, a group level analysis was performed on gender, age, treatment duration, additional treatment occasions/patient, involuntary care, involuntary care by gender, and ICD-10 principal diagnosis. To retrieve further sample characteristics, a questionnaire was administered to the physicians responsible for admitting patients in 2011. More URMs than non-URMs exhibited self-harm or suicidal behaviour in conjunction with referral. 86% of URMs were admitted with symptoms relating to stress in the asylum process. In the catchment area, 3.40% of the URM population received inpatient care and 0.67% inpatient involuntary care, compared to 0.26% and 0.02% respectively of the non-URM population, both comparisons p Conclusion From an epidemiological perspective, URMs were overrepresented in inpatient psychiatric care.

Aims: Dependence on legal psychotropic drugs (PTD) has been reported to have increased in alcoholics, but previous studies report conflicting results concerning the rate of increase and clinical characteristics. The aim of the present study was first, to assess the dependence rate of PTD among alcoholics in open and institutionalized care, and to compare these populations with the general population, and second, to assess rates and doses of high- and low-dose PTD-dependence among alcoholics. Methods: In 1997, alcoholics in open and institutionalized care were asked to anonymously fill in a questionnaire on their drug use and dependence. Healthy controls were included. The number of attending subjects was 130 open-care alcoholics at the Department of Alcohol and Drug Diseases in Malmo, Sweden; 23 alcoholics in institutionalized care at Karlsvik Rehabilitation Centre in Hoor, Sweden; and 120 healthy controls at Vardcentralen Kirseberg, a primary health care centre located in a Malmo area. The approximate attendance rate was 75, 70 and 95%, respectively. The questionnaire was based on DSM-IV criteria for dependence. Results: The total rate of PTD-dependent alcoholics was higher in the institutionalized group (35%) than in the open-care setting (14%): difference in proportions (p1–p2 21%; 95% CI: 1%, 41%). Alcoholics were more often PTD-dependent (17%) than were healthy controls (2%), (p1–p2 15%; 95% CI: 9%, 21%). Benzodiazepines (BZD) were the most common PTD. Only four out of a total of 23 BZD-dependent alcoholics developed high-dose BZD-dependence. Those subjects were also misusing other drugs, including cannabis. Conclusions: We conclude that alcoholism is associated with legal PTD-dependence and illegal drug misuse. High-dose BZD-dependence is infrequent among BZD-dependent alcoholics. ( Received 8 April 2002; first review notified 14 May 2002; in revised form 4 July 2003; accepted 5 August 2003 )

Introduction Adolescents with psychoses usually have full recovery from their first psychotic episode, but the first relapse often arises within 2 years of the first episode. Cannabis-related psychoses are difficult to distinguish from schizophrenic psychoses. Here, we describe a particularly severe clinical case, with a first psychotic episode occurring after heavy cannabis smoking, an atypically long symptom-free duration, and a subsequent non-substance-related episode. Case presentation A 17-year-old male adolescent of Middle-East origin presented with delusions and hallucinations after extensive cannabis smoking. His first psychotic episode, with paranoid delusions and hallucinations, progressed into severe catatonic symptoms. His symptoms were treated with electroconvulsive therapy and risperidone and he was transferred to a residential substance abuse treatment center. He remained drug-free and non-psychotic for 3.5 years. Given the temporal association with extensive cannabis use, and his full remission of symptoms lasting several years, a cannabis-induced psychosis—though atypically extended—could be suspected. However, after 3.5 years without psychiatric care, and in a drug-free state, our patient again presented with positive psychotic symptoms, possibly induced by a period of severe psychosocial stress. Conclusion We here discuss whether a primary schizophrenic episode possibly induced by cannabis can increase the risk of subsequent non-drug-related schizophrenic episodes.

Systematic evaluation of child and adolescent psychiatric outpatient treatment is important but time-consuming. The aim of this paper was to study whether Interactive Voice Response (IVR) is a more effective method than a questionnaire sent by post when following up outpatient treatment in child and adolescent psychiatry. Eighty patients were recruited from a child and adolescent psychiatric outpatient unit in Sweden. One parent of each of the patients was randomized to complete the BCFPI follow-up form, using either IVR (n = 40) or postal survey (n = 40) one month after discharge. The response rate for complete answers was 65% in the IVR group and 38% in the postal survey group (p = 0.014). There was less need for reminders in the IVR group (p = 0.000). IVR is a promising and cost-effective method for evaluating evidence-based treatment in child and adolescent psychiatric care.

The aim of this pilot study was to investigate clinical symptoms during a 10-day benzodiazepine (BZD) taper procedure. Twenty-one BZD-dependent patients attended a fixed 10-day inpatient tapering program. The patients developed mild to moderate withdrawal symptoms. Concomitant codeine dependence and initially high BZD serum levels were associated with a worse prognosis.

Follow-up methods must be easy for young people to handle. We examine Interactive Voice Response (IVR) as a method for collecting self-reported data. Sixty inpatients were recruited from a child and adolescent psychiatric emergency unit in Malmö, Sweden and called every second (N = 30) or every fourth (N = 30) day from discharge until first visit in outpatient care. A pre-recorded voice asked them to evaluate their current mood using their mobile phones. Average response rate was 91%, and 71% had a 100% response rate. Gender, age and length of inpatient treatment did not affect response rate, nor did randomisation. Boys estimated their current mood on average as 3.52 units higher than girls, CI = (2.65, 4.48). Automated IVR is a feasible method of collecting follow-up data among adolescents discharged from a psychiatric emergency unit.

Objective: The aim of this study was to document physicians' opinions on inpatient rehabilitation care for working-age patients in vegetative state after new acquired brain injury, given the absence of an established standard of post-acute care. Design: A postal survey of 3259 Swedish physicians was conducted. Results: Survey response rate was 33%. Of survey respondents, 51% reported that they knew the definition of vegetative state. Transfer of vegetative patients from acute care to inpatient rehabilitation was considered always warranted by 54% and never or only sometimes warranted by 31% of survey respondents, whereas 15% did not know or did not answer. Rehabilitation physicians most often considered an inpatient rehabilitation stay of around 3 mos to be appropriate, but there was a lack of consensus. Discharge from acute care direct to social care at least sometimes was reported by 39% of physicians. Conclusions: Physicians' opinions vary considerably on appropriate post-acute care for patients in vegetative state after acquired brain injury. This may impact on rates of referral and admission to rehabilitation units. Consensus is needed on a minimum period for and extent of rehabilitation interventions. Educational interventions should be targeted broadly to reach the wide range of specialties that may have responsibility for acute care of these patients.

Aims To determine the efficacy of naltrexone in reducing illicit opioid use and the potential moderating role of treatment retention. Design First, randomized controlled trials (RCTs) comparing the regimens of treatment using the opioid antagonist, naltrexone, with controls were analysed by meta-analysis for treatment effect with regard to a range of outcome criteria. The degree of heterogeneity was also determined. The moderating effect of other interventions during naltrexone maintenance was then estimated, particularly with regard to their effect on treatment retention. Participants Fifteen studies involving 1071 patients were found. Measurements All available outcomes were analysed in 10 studies of naltrexone versus control (seven placebo) and six studies of randomized psychosocial/psychopharmacological interventions. Findings Significant heterogeneity was found in the efficacy of naltrexone. Level of retention in treatment was found to be a moderator, explaining most of the heterogeneity found. Overall, naltrexone was significantly better than control conditions in reducing the number of opioid-positive urines. This effect was only present in the high retention subgroup for differences in retention. Contingency management (CM) increased retention and naltrexone use, resulting in a reduced number of opioid-positive urines. Conclusion Retention is important to the effect of naltrexone in treating opioid dependence. Contingency management is a promising method of increasing retention.

Diagnostic considerations and treatment strategies in adolescents with partial complex epilepsy and emerging psychosis are discussed. We will argue for considering clozapine early in treatment if other antipsychotics have failed based on two cases; these patients both developed epilepsy in early childhood and schizophrenia in mid adolescence. Their partial complex epilepsy were unsuccessfully treated with different antiepileptic drugs. Clozapine was tried with a distinct improvement in psychotic symptoms and functional level. In both cases there was an early unexpected improvement in seizure control on clozapine. It appears that a reduction of psychotic activity improved seizure control. Later on, there appeared to be a trade off between clozapines effect on psychotic symptoms and recurrence of seizure activity.A schizophrenic development must be taken into consideration if psychiatric symptoms emerge in adolescents with a partial complex epileptic disorder. Clozapine treatment can be considered if other antipsychotic drugs are ineffective or cause motor side effects.