Birgitta Alakare’s research while affiliated with University of Oulu and other places

Como uma abordagem para o tratamento da psicose, o Diálogo Aberto tem como objetivo iniciar o tratamento dentro de 24 horas do primeiro contato entre o sistema de saúde e o paciente ou a família e, de acordo com princípios construcionistas sociais, inclui a família e a rede social em uma discussão aberta de todas as questões ao longo de todo o tratamento. Como um passo para a avaliação do impacto deste novo modelo de tratamento, foram feitas análises estatísticas e qualitativas de 78 casos de primeiro episódio psicótico consecutivos, diferenciando os casos com resultados bons dos com resultados ruins com base em critérios funcionais e sintomáticos. Os resultados sugeriram diferenças no diagnóstico e na duração dos sintomas prodrômicos e psicóticos, assim como nos processos de tratamento nos dois grupos. A decisão de evitar a hospitalização e o uso ansiolíticos em vez de neurolépticos foram associados a um bom resultado. No geral, os dados sobre a eficácia do Diálogo Aberto foram encorajadores, pois mostraram apenas 22% de pacientes com resultados ruins. No entanto, se a possibilidade de se começar um processo dialógico é mínima, o tratamento pode levar a um resultado ruim, mesmo quando não é precedido por fatores sociais e psicológicos pré-mórbidos.

Open Dialogue (OD) is an integrated approach to mental health care, which has demonstrated promising outcomes in the treatment of first-episode psychosis (FEP) in Finnish Western Lapland region. However, little is known how treatment under OD is retrospectively experienced by the service users themselves. To address this, twenty participants from the original Western Lapland research cohort diagnosed with psychosis (F20-F29) were asked about their treatment of FEP, initiated under OD 10-23 years previously. Thematic analysis was used to explore how the treatment was experienced. Most participants viewed network treatment meetings as an important part of their treatment, as they enabled interactions with other people and the chance to go through difficult experiences. A minority of the participants had mixed experiences regarding family involvement and immediate home visits. OD may have the potential to promote therapeutic relationships, but replica-tions from other catchment areas are needed.

Aim: To evaluate the 10-year treatment outcomes and cost-effectiveness of adolescents' mental health treatment initiated under the social network-oriented open dialogue (OD) approach. Methods: This longitudinal register-based study included all persons who, for the first time, received psychiatric treatment in Finland during the period 1 January 2003-31 December 2008, and who were aged 13-20 at onset (n = 44 868). The OD group included all persons whose treatment commenced in the Western Lapland catchment area (n = 780), this being the only region in Finland where OD covered the entire mental healthcare service at the time of inclusion. The comparison group (CG) included the rest of Finland (n = 44 088). The primary outcome variables were psychiatric treatment and/or disability allowances at the end of the 10-year follow-up, or death. The secondary outcome variables were treatment and disability expenses. Generalized linear models weighted by inverse probability of treatment were used to study the association between OD and the primary outcomes. Population proportions were used to evaluate the cost-effectiveness of the approaches. Results: Treatment that commenced outside OD was associated with higher odds of continuing to receive treatment (adjusted odds ratio [aOR] 1.4; 95%CI 1.2-1.6) and disability allowances (aOR 1.6; 95%CI 1.2-2.1) at the end of the 10-year follow-up. No significant difference in the mortality ratio emerged. The cumulative 10-year expenses per capita were lower under OD. Conclusions: OD associated with favourable long-term outcomes, but due the observational design and possible residual confounding, further studies with a more robust research design are required.

Background: The long-term effectiveness of antipsychotic maintenance treatment after first-episode psychosis (FEP) is contested. In this real-world observational study, we examined how cumulative exposure to antipsychotics within the first 5 years from FEP was associated with the 19-year outcome. Methods: Finnish national registers were used to detect all patients who were hospitalized due to non-affective psychosis in the mid-1990s, and who were treatment naïve prior to the inclusion period (N = 1318). Generalized linear models with logit link function were used to estimate how cumulative exposure to antipsychotics within the first 5 years from onset was associated with mortality, work capability, and the use of psychiatric services at the end of the 19-year follow-up. To adjust for confounding by indication, the primary outcome analyses implemented stabilized inverse probability of treatment weighting using propensity scores. Results: Persons with a higher cumulative exposure to antipsychotics within the first 5 years from FEP were more likely to still be receiving antipsychotics (adjusted odds ratio [OR] = 2.1; 95% CI: 1.5−2.8), psychiatric treatment (OR = 1.4; 95% CI: 1.1−1.7), and disability allowances (OR = 1.3; 95% CI: 1.01−1.6) at the end of the 19-year follow-up, as compared to low/zero-exposure. Higher cumulative exposure was also associated with higher mortality (OR = 1.5; 95% CI: 1.1–2.1). Conclusions: After adjustment for confounders, moderate and high cumulative exposure to antipsychotics within the first 5 years from FEP was consistently associated with a higher risk of adverse outcomes during the 19-year follow-up, as compared to low or zero exposure. Due to potential unmeasured confounding, controlled trials are needed.

Psychosis refers to a severe mental state that often significantly affects the individual’s life course. However, it remains unclear how people with the lived experiences themselves view these phenomena, as part of their life story. In order to evaluate this personal meaning-making process, we conducted in-depth life-story interviews with 20 people who had been diagnosed with non-affective psychosis 10 to 23 years previously in one catchment area. 35% of them were still receiving mental health treatment, and 55% of them were diagnosed with schizophrenia. Only a minority named their experiences as psychosis. On the basis of narrative analysis, two types of stories appeared to encompass how mental health crises and/or related experiences were presented as part of the life story: (i) crisis as a disruptor of the normative course of life (N= 9), and (ii) crisis as an expected reaction to life adversities (N= 7). In the majority of the stories, the mental health crisis was associated with cumulative life adversities in a central life area. Correspondingly, most of the factors that brought relief were narrated as inseparable from social and other real-life environments. We discuss the need for more person-centred and collaborative models of research and treatment.

Open Dialogue (OD) is a family-oriented early intervention approach which has demonstrated good outcomes in the treatment of first-episode psychosis (FEP). Nevertheless, more evidence is needed. In this register-based cohort study the long-term outcomes of OD were evaluated through a comparison with a control group over a period of approximately 19 years. We examined the mortality, the need for psychiatric treatment, and the granting of disability allowances. Data were obtained from Finnish national registers regarding all OD patients whose treatment for FEP commenced within the time of the original interventions (total N = 108). The control group consisted of all Finnish FEP patients who had a follow-up of 19-20 years and who were guided to other Finnish specialized mental healthcare facilities (N = 1763). No difference between the samples was found regarding the annual incidence of FEP, the diagnosis, and suicide rates. Over the entire follow-up, the figures for durations of hospital treatment, disability allowances, and the need for neuroleptics remained significantly lower with OD group. Findings indicated that many positive outcomes of OD are sustained over a long time period. Due to the observational nature of the study, randomized trials are still needed to provide more information on effectiveness of approach.

Open Dialogue is a family-oriented early intervention model for mental health problems developed in the health district of Western Lapland, Finland. In the present study, the aim was to describe how psychiatric services were used in Western Lapland after decades of first-episode psychosis services, and to analyze how baseline characteristics were related to re-admission rates and the total duration of psychiatric treatment in geographical area where Open Dialogue approaches were developed and efforts made to systematically apply them to all psychiatric treatments. The data were obtained from the medical histories of patients who had first-episode psychosis in 1992–2005 and who lived continuously within the catchment area during the observation years (1992–2015) (N = 65). From baseline up to 2015, average length of treatment was 6 ± 2 years, and significant decrease (p < .001) in total use of psychiatric services was observed. The admission rates and duration of treatment were highest with subjects who behaved aggressively (U = 270, p < .005), and/or who were hospitalized (U = 157, p < .001) and medicated (U = 114, p < .001) at onset. Overall, external aggression at onset emerges as a factor that may challenge the application of the OD treatment principles, being associated with a greater need for hospitalization and longer treatment duration.