In loving of memory of my parents
Andrea and Rodolfo
List of Papers
This thesis is based on the following papers, which are referred to in the text
by their Roman numerals.
I
Ramirez A, Ekselius L, Ramklint M. Mental disorders among
young adults self-referred and referred by professionals to specialty mental health care. Psychiatric Serv. 2009;60:1649-55
II
Ramirez A, Ekselius L, Ramklint M. Delimiting depression
with an early onset. Submitted.
III
Ramirez A, Ekselius L, Ramklint M. Axis IV psychosocial and
environmental problems – in the DSM-IV. Submitted.
IV
Ramirez A, Ekselius L, Ramklint M. Axis V – Global Assessment of Functioning Scale (GAF), further evaluation of the selfreport version. Eur Psychiatry. 2008;23:575-79.
Reprints were made with permission from the respective publishers.
Contents
Introduction...................................................................................................11
Classification of Mental Disorders...........................................................11
History .................................................................................................11
Current Classification Systems............................................................12
DSM-IV....................................................................................................13
Axis I clinical syndromes ....................................................................13
Axis II personality disorders................................................................13
Axis III - physical illness / injury ........................................................13
Axis IV - psychosocial and environmental problems ..........................13
Axis V - Global Assessment of Functioning (GAF)............................14
Models for relations between different axes ............................................14
Vulnerability model .............................................................................14
Complication model.............................................................................14
Spectrum model ...................................................................................14
Diagnostic Assessment.............................................................................15
Methods ...............................................................................................15
Psychiatric epidemiology .........................................................................15
Prevalence............................................................................................15
Co-morbidity .......................................................................................15
Age of onset.........................................................................................16
Help-seeking.............................................................................................16
Development of psychiatric disorders......................................................16
Life events ...........................................................................................17
Overall aims of the thesis..............................................................................18
Methodology .................................................................................................19
Design ......................................................................................................19
Participants ...............................................................................................19
Diagnostic procedures ..............................................................................20
Assessments .............................................................................................20
Axis I and axis II .................................................................................20
Axis IV ................................................................................................21
Axis V..................................................................................................22
Life events ...........................................................................................22
Previous child psychiatric symptoms ..................................................22
SSP - personality traits.........................................................................22
Statistics ...................................................................................................23
Ethics........................................................................................................23
Results...........................................................................................................24
Mental disorders among young adults (paper I) ..................................24
Delimiting depression with an early onset (paper II) ..........................25
Axis IV – psychosocial and environmental problems (paper III)........28
Axis V – Global Assessment of Functioning scale (paper IV)............30
Discussion .....................................................................................................32
Methodological considerations.................................................................32
Sample .................................................................................................32
Methods and Procedures......................................................................33
Help-seeking.............................................................................................33
Early onset depression..............................................................................34
Psychosocial stress ...................................................................................35
Global Assessment of Functioning...........................................................36
General discussion and future aspects......................................................37
Conclusion ....................................................................................................38
Acknowledgments.........................................................................................39
References.....................................................................................................42
Abbreviations
ADHD
Attention-Deficit Hyperactivity Disorder
ANOVA
Analysis of Variance
APA
American Psychiatric Association
BP
Bipolar Disorder
CAPSI-R
Child and Adolescent Psychiatric Screening Inventory-Retrospect
DIP-Q
DSM-IV and ICD-10 Personality-Questionnaire
DSM
Diagnostic and Statistical Manual of Mental Disorders
EDE-Q
Eating Disorder Examination-Questionnaire
GAF
Global Assessment of Functioning
ICC
Intra-class Correlation Coefficient
ICD
International Classification of Diseases
MADRS
Montgomery-Åsberg Depression Rating Scale
MDD
Major Depression Disorder
OCD
Obsessive Compulsive Disorder
PABAK
Prevalence & Bias-Adjusted Kappa
PTSD
Posttraumatic Stress Disorder
SCID-I
Structured Clinical Interview for DSM for Clinical Syndromes
SCID-II
Structured Clinical Interview for DSM for Personality Disorders
SIAS
Social Interaction Anxiety Scale
SD
Standard Deviation
SPSS
Statistical Package for the Social Sciences
SPS
Social Phobia Scale
WHO
World Health Organization
Introduction
Adolescence is a time of transition between childhood and adulthood. It is
during this period that most psychiatric disorders have their onset [1, 2].
Moreover, the prevalence of psychiatric illness is highest in young adults [2,
3]. Therefore, as expected, there are more young people in Sweden, compared to older age groups, who seek mental health care [4]. Early and reliable identification of patients’ psychiatric symptoms, as well as various psychosocial risk factors, is crucial for adequate and effective measures. Development and quality assurance of diagnostic methods improve psychiatric
assessments and are the basis for evidence-based treatment. Despite this,
there is limited knowledge about the value of different diagnostic procedures
in clinical psychiatry.
Classification of Mental Disorders
History
The concept of diagnosis derives from the Greek prefix dia, meaning
“through”, and the Greek word gnosis, meaning “knowing”. In the field of
psychiatry, diagnosis means the recognition of a disease through signs or
symptoms. The diagnostic process is as old as medicine since the recognition
of symptoms is a prerequisite for the choice of treatment. Diagnoses are
specific constellations of symptoms.
Although psychiatric conditions have been diagnosed since ancient times, it
was in Germany, in the middle of the 18th century, where the foundation of
modern psychiatric classifications was laid. Moritz Romberg (1795-1873)
and his successor, Wilhelm Griesinger (1817-1868), published early studies
of brain diseases [5]. Emil Kraepelin (1856-1926) continued their neurological work and developed the psychiatric diagnoses by introducing criteria for
distinguishing bipolar disorder from dementia praecox (schizophrenia) [6].
In the late 18th century, on the basis of the works above, there existed the
following diagnostic dichotomies: psychosis versus neurosis, schizophrenia
versus bipolar disorder, and neurosis versus psychopathy and personality
disorder. Thereafter, in 1947, a Swedish professor named Erik Essen-Möller
11
(1901-1992) described the Moller & Wohlfahrt multi-axial diagnostic system, which separated etiology from symptoms by using multiple
axes/assessment areas. The system was based on experiences from the
Lundby study [7], which was one of the world’s first psychiatric epidemiological studies.
Several researchers continued to develop multiaxial assessment systems.
Ottosson and Perris [111] further developed and divided the Moller & Wohlfahrt system into four axes: symptomatology, severity, course and presumed
etiology. At the same time, Strauss [112] presented a system with five axes
that also included social function. Accordingly, Michael Rutter [8] developed a system for child and adolescent psychiatry with four axes: psychiatric
syndromes, intellectual level, biological factors and psychosocial factors.
The official diagnostic classification system, International Classification of
Diseases (ICD) from the World Health Organization (WHO), was initially a
register of causes of death. However, it was not until its sixth version from
1948 that psychiatric disorders were included. ICD was previously criticized
for mixing different classification principles; namely, descriptive and etiological [9, 10]. In 1952, the American Psychiatric Association (APA) presented a new system called the “Diagnostic and Statistical Manual of Mental
Disorders” [11]. It was developed into a multi-axial system in its third version (DSM-III) [12].
Current Classification Systems
Today, therefore, there are two internationally established classification systems for psychiatric disorders: Diagnostics and Statistical Manual of Mental
Disorders, fourth version (DSM-IV) [13, 14] and the International Classification of Diseases, tenth version (ICD-10) [15]. Comparisons of prevalence
rates between countries, as well as development trends, are made possible
through these classification systems. They improve communication within
and between professional groups as well as provide conditions for research
and evidence-based treatments. Both systems are descriptive. Diagnostic
criteria are based on the consensus of leading diagnostic experts. In order for
a condition to be included in a classification system, it has to be valid. It
must have been shown that the untreated condition causes suffering, loss of
function or even death. The diagnosis must be meaningful to identify and
possible to assess in a reliable way. Classification systems undergo regular
scientific and clinical revisions.
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DSM-IV
Axis I clinical syndromes
Psychiatric diagnoses are based on symptom criteria, some of which are
compulsory, and time period criteria. In depression, for example, at least five
depressive symptoms must exist, with at least one belonging to compulsory
criteria. The duration of symptoms must also last for at least two weeks. In
addition, there are exclusion criteria. An example would be that the depression is not better explained by a physical illness. Additionally, the symptoms
must cause significant distress or functional impairment. Clinical syndromes
are defined based on an interpersonal norm.
Axis II personality disorders
Personality Disorders (PD) are defined as a persistent pattern of inner experience and behavior that deviates markedly from what is expected in the
person’s socio-cultural environment. In addition to the general criteria for all
personality disorders, there are criteria for each specific disorder. Personality
disorders are divided into three clusters: cluster A (the odd, eccentric personalities): paranoid, schizoid and schizotypal PD; cluster B (the impulsive,
extrovert personalities): antisocial, borderline, histrionic and narcissistic PD;
and cluster C (the anxious, introvert personalities): avoidant, dependent and
obsessive-compulsive PD.
Axis III - physical illness / injury
Axis III is for reporting current general medical conditions that are potentially relevant to the understanding or management of the individual’s mental disorder.
Axis IV - psychosocial and environmental problems
Psychosocial problems can be risk factors for the development of a psychiatric disorder, target for treatment or influencing prognosis of the current mental disorder. These problems are grouped into nine categories: problems with
primary support group, problems related to the social environment, educational problems, occupational problems, housing problems, economic problems, problems with access to health care services, and problems related to
interaction with the legal system/crime.
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Axis V - Global Assessment of Functioning (GAF)
This GAF rating can be used for planning and evaluation of treatment as
well as predicting outcome. Only disabilities due to mental disorders are
estimated. It is a global rating scale of symptoms and of psychological, social and occupational functioning on a scale between 1-100 [13]. Functioning is measured in relation to different activities. In psychiatry, the patient’s
ability to function in their jobs, in their relationships and in their daily activities is evaluated. There are a limited amount of diagnostic tools for assessing
functionality, such as questionnaires [16, 17].
Models for relations between different axes
Axis I- and axis II disorders often co-occur. This raises several questions. Do
they share the same etiology? Are there implications in terms of causality?
Several models for the relationship have been developed including the vulnerability, the complication and the spectrum models.
Vulnerability model
The vulnerability model assumes that there is a common vulnerability for
both specific clinical syndromes and specific personality disorders [18]. This
vulnerability may be biological and manifested in personality traits. For example, anxious traits increase vulnerability for both avoidant personality
disorder and for depression [19].
Complication model
The complication model assumes that a second condition develops in the
context of, or because of, a first condition [20]. For example, depressed
teenagers might develop an altered self-image if they feel worthless, causing
a change in their behavior. This could have an impact on their personality
development [21]. Mental illness in childhood is related to higher prevalence
of personality disorders [22, 23] high psychiatric co-morbidity [24, 25] less
social support [26-28], lower functional capacity [29, 30], and poorer response to treatment of both mental and somatic illnesses [21, 31].
Spectrum model
The spectrum model assumes that the two clinical syndromes are related, in
terms of etiology and mechanism of action, and exists on a continuum [19,
32-34]. For example, cluster A personality disorders are related to psychotic
disorders [35] and cluster C personality disorders are related to anxiety disorders [36].
14
Diagnostic Assessment
Methods
The clinical evaluation of symptoms is crucial in psychiatric diagnostics
since there are no biological markers, such as blood tests and x-rays, used in
clinical practice. If symptoms are consistent with the description in the classification system, criteria are met. There are diagnostic tools to support the
identification of symptoms, such as structured interviews and questionnaires.
Diagnostic tools have been developed for different purposes - for screening,
for diagnostics, and for ratings of severity or functional level.
There are also instruments used to evaluate risk factors; for example, questionnaires evaluating life events, psychosocial stress or personality traits. An
instrument must be used in accordance with its purpose. A screening instrument, for example, should not be used for diagnostics.
Psychiatric epidemiology
Prevalence
Epidemiological studies show that mental illness is common and that, in any
given year, approximately one quarter of the population is affected [37]. A
smaller proportion, around 7 %, is affected by several disorders [37]. Lifetime prevalence is even higher, around 50 % [2, 3, 38].
Co-morbidity
Co-morbidity means the simultaneous occurrence of different diagnoses.
Distinction is made between current and lifetime co-morbidity, differentiating between how many diagnoses are met currently and how many were met
throughout life [39]. Homotypic continuity means that the diagnosis stays
the same; i.e., those who had depression continue to have depression [40].
Heterotypic continuity is when one diagnosis is followed by another diagnosis [40]. Homotypic continuity exists for most diagnoses, while heterotypic
continuity is more common for some, such as anxiety and depression or
anxiety and substance abuse [40, 41]. Heterotypic continuity makes the distinction between different diagnoses weaker and raises questions about common vulnerabilities.
15
Age of onset
Mental illness has its onset early in life, and at least 75 % experience its onset before the age of 24 [2, 42]. Median age of onset varies between different
diagnoses and was reported from a North-American epidemiological sample
to be 11 years old for anxiety disorders, 20 years old for substance use disorders and 30 years old for mood disorders [2].
Help-seeking
Only a minority of those affected by mental disorders seek care [43, 44].
Early onset and co-morbidity increase health care attendance [42]. This implicates that those who seek help through psychiatry can be expected to have
more complex problems [45]. Different filters between the patient and psychiatry, such as the individual’s own ability to recognize mental illness, referral requirements, primary care physician’s competence to diagnose mental
disorders and willingness to refer them, may also influence the number of
patients in specialized care [46, 47]. Psychiatric services in Sweden, however, usually have no referral requirements. There is no knowledge of how
this ability to refer oneself affects help-seeking.
Development of psychiatric disorders
There are biological, psychological, social and interactional models that try
to explain the development of psychiatric disorders. The biological perspective tries to understand thoughts, feelings and behaviors based on physiological processes. However, biological changes, such as chemical processes
within the nervous system, have both genetic and environmental influences
[48]. Psychological models also include both biological and environmental
influence. For example, Freud (1856-1939) developed the psychodynamic
theory of how mental illness arises. In his model, biology provides us with
drives, but the environment teaches us to deal with them. The cognitive theory by Beck [49] focuses on the way in which people receive information,
evaluate it, and determine how to react. The emotions are influenced by the
interpretation of them. The radical behaviorism by Skinner [50] focuses on
behaviors and what environmental factors that increase the likelihood for a
behavior to occur again. George W. Brown [51] constructed a psychosocial
model for causal connection between social problems and psychiatric disorders. Poverty [52], absences from school [53] and family problems [27, 28,
54] have been shown to be social risk factors that increase the risk for psychiatric diseases. Brown showed that risk factors are nonspecific and not
connected to individual diagnoses [55]. Psychosocial risk factors may be
16
mediating; for example, does early childhood victimization increase the risk
of later psychopathology [56, 57]. Models that describe how both biological
and psychosocial risk factors interact are called interactionistic [48, 58].
According to these models, stress interacts with the individual’s vulnerability through biological mechanisms such as increased cortisol levels, which
affect the hypothalamic-pituitary-adrenocortical (HPA) axis. Research has
shown that high cortisol levels affect the hippocampus and may lead to cell
death [18]. Early development of stress such as child abuse, neglect or parental loss can lead to neurobiological changes underlying the increased risk
of psychopathology [59]. Studies of gene-environment interactions (G X E)
support the stress-vulnerability model. The genotype moderates the sensibility to psychosocial stress [60, 61]. In summary, it is of importance to evaluate biological, psychological and social risk factors as part of the diagnostic
process.
Life events
Events that happen in a person’s life can be positive or negative. An American psychiatrist, L.E. Hinkle Jr., introduced the concept of life events and
described life events that affect the risk for diseases. He identified a number
of people with frequent sick leave without any clear somatic cause. The
characteristic of this group was that they suffered from an unpleasant and
stressful life event before their sick leave. Holmes-Rahe’s schedule of current life events [62] is a scale for measuring life events and dramatic changes
in people’s lives. Coddington’s Life Event Scale is a questionnaire about
significant life events that occurred during childhood [63]. Particularly severe negative life events during childhood affect not only the risk of mental
illness, but also reduce the person’s functional level. This is especially true if
the negative life events (for example, neglect, maltreatment and sexual
abuse) existed for a long period of time [64, 65].
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Overall aims of the thesis
The overall aim was to increase knowledge about young adults with mental
illness in order to improve diagnostic procedures.
The specific aims of the thesis are:
to determine whether patients who refer themselves to specialized mental health care differ from those who are referred by non-psychiatrist
professionals (paper I)
to examine what characteristics delimit depression onset groups from
each other. To investigate whether delayed or abnormal development is
a risk factor for childhood onset of depression (paper II)
to explore the reliability between professional and patient assessment of
present categories of psychosocial stressors and to explore concurrent
validity of axis IV (paper III)
to investigate agreement between patients’ ratings on the GAF, both
before and after treatment (paper IV)
18
Methodology
Design
All studies used a naturalistic and cross-sectional design, and paper IV also
used longitudinal assessments.
Participants
The study was conducted at Flogsta Outpatient Clinic at the Uppsala Department of Psychiatry between October 1, 2002, and September 30, 2004.
At the time of the study, Uppsala was a city with a population of nearly
180,000, whereof 32 % were younger than 25 years old – a great proportion
of them being university students. Young adults between 18-25 years of age,
living in the catchment area and visiting the clinic, were consecutively invited to participate in the study within the first year (until September 30,
2003). During the year of study enrollment, 217 patients (6 % of the population in this age group living in the catchment area) came for an initial appointment. After receiving a complete description of the study, written informed consent was obtained from 200 out of 217 (92 %) patients. Among
participants, there were 161 (80 %) women and 39 (20 %) men. Among the
17 non-participants, i.e., external drop-outs, 13 (76 %) were women and 4
(24 %) were men. There was no significant difference between participants
and non-participants according to sex. Participants’ mean age was 22.4±1.9
years. Non-participants had a mean age of 21.5±1.7 years (t=2.21, df=215,
p=0.04). There were no significant differences between participants and
dropouts according to any diagnoses. The number of patients varies in the
four different studies (I-IV), depending on study purpose (paper II), or because of missing data, i.e., internal drop-outs (paper III & IV), see Table 1.
A majority of the participants, 166 (83 %), had an occupation; forty (20 %)
worked and 126 (63 %) studied. Among those 34 (17 %) without any occupation, there were 14 (7 %) on short-term disability and 20 (10 %) were unemployed. Most of them, 155 (78 %), lived alone, and there were 42 (21 %)
who lived with their parents. Only 3 (2 %) lived in an institution.
19
Table 1. Descriptive data of participants in paper I-IV (N=200).
Paper
Number of
Number of
Rate of
Male/
participants
internal
participation
Female
drop-outs
(%)
Age
mean (SD)
I
200
0
100
39/161
22.4 (1.9)
II
156
0
100
23/133
22.4 (1.8)
III
163
37
82
30/133
22.4 (1.9)
IV
191
9
96
38/153
22.4 (1.9)
Diagnostic procedures
An initial diagnostic assessment of axis I-V according to DSM-IV [13] included three patient visits - two with a doctor and one with a social worker.
This was followed by a team conference. During the first visit, a clinical
interview was performed. On the second visit, a structured diagnostic interview was performed. On the third visit, psychosocial and environmental
problems were assessed by the social worker. During the team conference,
available information was presented and axis I, III, IV and V-diagnoses were
established. Patients were subsequently given appropriate treatment. Finally,
axis II diagnoses were assessed by the doctor who performed the initial appraisal at a suitable time point, such as when axis I symptoms were resolved.
Assessments
Axis I and axis II
Psychiatric disorders were assessed using the Structured Clinical Interview
for DSM-IV axis I disorders, clinical version (SCID-I-CV) [66] and by using
the Structured Clinical Interview for DSM-IV axis II, personality disorders
(SCID-II) [67]. The SCID-I CV provides comprehensive assessment of most
diagnoses, but for some diagnoses there are only screening questions, i.e.,
agoraphobia, social phobia, specific phobia, generalized anxiety disorder,
anorexia nervosa, bulimia nervosa, and somatoform disorders. If screening
questions were assented to, all criteria for the diagnosis were reviewed using
the DSM-IV criteria as a checklist. Furthermore, for those who assented,
either to screening questions for anorexia and bulimia nervosa or to social
phobia, supplementary information was gathered by the use of questionnaires. For eating disorders, the Eating Disorders Examination-Questionnaire
20
(EDE-Q) [68] was used and for social phobia, the Social Phobia Scale (SPS)
and the Social Interaction Anxiety Scale (SIAS) was used [69]. Two of the
authors (MR and AR) performed the SCID interviews. Complete inter-rater
reliability (Kappa 1.0) was obtained for eight randomly selected SCID-I
interviews. Based on six randomly selected SCID-II interviews, the overall
Kappa coefficient was 0.89 concerning categorical personality disorder diagnoses.
Axis IV
Axis IV - Interview
Assessment of psychosocial and environmental problems according to axis
IV was based on a structured interview and performed by a social worker
with considerable clinical experience. The interview covered all nine different areas of psychosocial stress according to DSM-IV: problems with the
primary support group, problems related to the social environment, educational problems, occupational problems, housing problems, economic problems, problems with access to health care services, problems related to interaction with the legal system/crime and other psychosocial and environmental
problems. Since there is no gold standard for assessment of axis IV, the interview was constructed by us as a checklist in order to cover all areas we
needed to ask about, and questions were included if both the last author and
the social worker agreed on their relevance (face validity). During the interview, each area of psychosocial stress was explored and categorized as present or not. The time frame comprised the last year. If problems were considered present, the social worker also made an estimate of the total burden
of stress on a scale from 1 (none) to 6 (catastrophic).
Axis IV - Self-assessment
Assessment of self-reported psychosocial and environmental problems was
performed using the axis IV scale included in the DSM-IV and ICD-10 Personality Questionnaire [70]. It comprises 11 “yes” or “no” questions regarding psychosocial and environmental problems according to the DSM-IV axis
IV categories. If the patient assented to problems in one or several areas
during the last year, he or she was also instructed to estimate the global burden of experienced stress on a scale from 1 (none) to 6 (catastrophic). Before
the interview, each participant completed the self-assessment of axis IV
categories. Both assessments were performed within two weeks for the majority of patients.
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Axis V
Global Assessment of Functioning (GAF) – axis V [71] - is an overall judgment about the patient’s current level of functioning on a scale from 1-100.
GAF ratings were estimated for all patients during a team meeting, after the
diagnostic procedure and prior to treatment. All team members were trained
in the use of GAF and had extensive experience in the procedure. The ratings were based on consensus within the team. Patients were subsequently
given appropriate treatment. After finalizing treatment, patients had a final
visit during which the professional who met the patient made a second assessment of GAF. Each patient’s own GAF rating was performed using a
self-report version [16] at the same time as the assessment by the professional was made. Both patients and professionals were blind to previous
ratings and ratings made by others.
Life events
In paper II, life events were assessed by Coddington’s life event scale - a
questionnaire concerning significant life events that occurred during childhood [63]. The scale is validated by a teenage group in Sweden [72]. The
scale contains 40 questions about life events experienced either during the
last year or previously.
Previous child psychiatric symptoms
In paper II, previous child psychiatric symptoms were assessed by the Child
and Adolescent Psychiatric Screening Inventory-Retrospect (CAPSI-R). This
questionnaire is a screening form for adults of previous child psychiatric
psychopathology [73]. The questions retrospectively assess symptoms such
as delays in language, motor and social development, abnormal impulse
control, attention deficits, and separation anxiety symptoms.
SSP - personality traits
In paper II, personality traits were assessed by the Swedish universities Scales
of Personality (SSP) [74]. The SSP comprises 91 items, divided into 13 scales,
with seven items in each scale. Each item is presented as a statement with a
four-point response format ranging from 1= “does not apply at all” to 4 = “applies completely”. The SSP mean scores were transformed into normative tscores with means of 50 and standard deviations of 10 based on a Swedish
gender-stratified non-patient sample [74]. Factor analysis of the normative
data yielded a three-factor model, whereof one is Neuroticism. The scales
somatic trait anxiety, psychic trait anxiety, lack of assertiveness, stress susceptibility, embitterment, mistrust, and detachment loaded on this factor [74].
22
Statistics
For inter-rater reliability concerning continuous data, the intra-class correlation coefficient (ICC) was used with a two-way mixed effects model. Intraclass correlation coefficients are considered excellent if greater than 0.74,
good if ranging from 0.60 to 0.74, and fair if ranging from 0.40 to 0.59 [75].
Kappa statistics [76, 77] were used for agreement between professional and
self-assessment of different data and groups as well as for inter-rater reliability concerning categorical diagnoses. Kappa was considered slight if
kappa<0.2, fair if kappa is 0.21-0.40, moderate if kappa is 0.41-0.60, substantial if kappa is 0.61-0.80 and, finally, almost perfect if kappa is 0.81-1.0.
When the distribution of reported categories is unevenly distributed to a
large extent, Cohen’s kappa is known to be less reliable [76]. Therefore, we
also used the Prevalence & Bias-Adjusted Kappa (PABAK) [77]. For overview of statistical methods, see Table 2.
Table 2. Statistical analyses.
Paper I
Student’s t-test
Chi square test (Fisher’s exact test)
Logistic regression
Paper II
Student’s t-test
Chi square test (Fisher’s exact test)
One-way ANOVA
Pearson’s correlation
Paper III
Student’s t-test
Chi square test (Fisher’s exact test)
One-way ANOVA
Pearson’s correlation
Mann-Whitney Test
Prevalence & Bias-Adjusted Kappa (PABAK)
Cohen’s Kappa
Paper IV
Intra-class correlation
Student’s t-test
Cohen’s Kappa
Ethics
The study was performed according to the principles of the Helsinki Declaration and was approved by the Uppsala University Ethics Committee.
23
Results
Mental disorders among young adults (paper I)
We hypothesized that self-referred patients would have fewer psychiatric
disorders than those who were referred by professionals.
Mood disorders and specific phobia were more common among self-referred
patients (see paper I, Table 2). There were no other statistically significant
differences between self-referrals and referred according to specific axis I
diagnoses. Co-morbidity among axis I disorders was pronounced with a
mean number of 2.2±1.3 diagnoses, with 68 % fulfilling criteria for more
than one specific disorder. There were seven individuals (4 %) who did not
fulfill criteria for any current diagnosis. However, there was no significant
difference between self-referrals and referred according to number of current
disorders, 2.3±1.3 vs. 2.2±1.3, see Figure 1, nor number of lifetime diagnoses, 2.9±1.7 vs. 2.9±1.6. Neither were there any differences according to
recall of age of onset of first disorder between self-referred and referred,
13.6±4.7 years vs. 13.5±4.2 years. Any personality disorder was present in
53 (28 %) of the assessed patients (n=188). There were no differences according to referral status in prevalence of personality disorders. GAF, before
treatment, did not differ between groups, 54.5±6.5 vs. 54.7±8.0.
There was no significant difference between self-referred and those referred
by medical professionals according to number of previous health service
providers (1.1±1.0 vs. 1.2±0.8). Among the self-referred, there was a larger
proportion of patients who had never had any previous contact with mental
health care ( 2=5.53, df=1, p=0.02).
A logistic regression was performed with referral status as the dependent
outcome variable. Variables with a significant difference between selfreferred and referred were entered into the model as independent predictors:
any mood disorder, any anxiety disorder, any eating disorder and no previous contact with mental health services. Those individuals who did not have
any previous contact with the mental health system were significantly more
likely to refer themselves (OR=2.16; 95 % CI:1.02-4.55). Additionally, having any mood disorder also increased the likelihood for self-referral
(OR=2.36; 95 % CI:1.01-5.54). Having any anxiety or any eating disorder
were not significant predictors of referral-status.
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Figure 1. Number of current axis-I diagnoses among young adult psychiatric outpatients (n=200). Comparisons between self-referrals and referred, percentages within groups.
Delimiting depression with an early onset (paper II)
We hypothesized that age of onset would define different subgroups in
young adults with depression. Early onset was expected to be characterized
by more negative life events, more trauma, childhood developmental delays,
neurotic personality traits, early-onset anxiety disorders and higher rates of
substance use disorders.
Of the 156 patients, 148 (95 %) had major depressive disorder (MDD), and
eight (5 %) patients fulfilled criteria for a bipolar disorder (BP I or II). Average age of first depressive episode was 16.9 years (4.0). The average number of depressive episodes in the entire group was 2.6 (2.9). Recurrent depression was more common among those with childhood and adolescent
onset, and they also had significantly more depressive episodes. There were
43 (29 %) patients fulfilling criteria for a personality disorder. There were
no significant differences between onset groups according to any psychiatric
diagnosis, nor to the number of diagnoses, lifetime or current, nor to the
number of personality disorders (see paper II, Table 1).
25
Three of the SSP neuroticism related scales (somatic trait anxiety, psychic
trait anxiety and stress susceptibility) were, in all groups, higher than one
standard deviation compared to the mean in the normal population. Although
there was a tendency for the childhood onset group to have the highest values, there was no statistically significant difference between the groups.
The rated severity (1-6) of last year’s total psychosocial problems was significantly higher in those with childhood onset (a): 3.9 (1.0) compared to
adolescent onset (b): 3.5 (1.0) and adult onset (c): 2.3 (1.7) (F=4.63,
p=0.011; Post-hoc = a>c; p<0.01). Problems within the social environment
were more common in the adolescent onset group.
The childhood onset group had significantly more total number of trauma
categories and more trauma categories reported in the medical records, but
not from the SCID. Experience of neglect was significantly more common in
the childhood onset group; whereas, parental loss and sexual abuse did not
significantly differ between groups.
The average scores on Coddington’s life event scale were 10.6 (4.8) in the
childhood onset group, 9.7 (4.8) in the adolescent onset group and 8.9 (4.7)
in the adult onset group, with no significant differences (p=0.429) between
groups. Some specific life events were more frequent in the group with
childhood onset; namely, serious illness of father, teenage pregnancy and
abortion.
Those with childhood onset depression reported more developing delays:
reading difficulties, limited social skills and memory deficits. Patients with
childhood and adolescent onset reported more previous symptoms of separation anxiety (see Table 3).
26
27. Were you forgetful and found it difficult to remember
everyday things?
68. As a child, did you worry a great deal about being separated
from your parents, for example, by getting lost or being
kidnapped?
69. Did you often have nightmares about being separated from
your near and dear ones?
1
n=53, *p<0.05, **p<0.01
1. As a child did you have pronounced difficulties learning to
read?
2. As a child did you have pronounced difficulties learning
mathematics?
15. Did others perceive your way of speaking as odd or
longwinded?
17. As a child, did you have interests that you were almost always
busy with and that others looked upon as special and unusual?
21. Did others often complain that you did not listen when they
were talking to you?
25. Did you often lose things?
Question number:
CAPSI-R
8 (12)
6 (11)
15 (28)
1
6 (33)
5 (28)
6 (11)
13 (24)
5 (28)
7 (39)
11 (21)
8 (12)
6 (11)
4 (22)
7 (39)
6 (9)
2 (4) 1
5 (28)
5 (7)
5 (7)
5 (7)
3 (4)
7 (10)
c
18-25 years
n = 69
n (%)
10 (14)
4 (7)
b
13-17 years
n = 54
n (%)
4 (7)
5 (28)
a
0-12 years
n = 18
n (%)
7 (39)
Age of onset of first depressive episode
12.21
5.99
7.30
5.80
9.34
5.82
9.25
3.77
10.57
2
0.002
0.051
0.026
0.055
0.010
0.054
0.010
0.056
0.005
p
a, b>c**
a>c**
a>b*, c**
a>b**, c*
a>b**, c*
Post-hoc
Table 3. Positively assessed questions from the Child and Adolescent Psychiatric Screening Inventory-Retrospect (CAPSI-R), comparing
groups according to age of onset of first depressive episode (n=141).
Axis IV – psychosocial and environmental problems (paper III)
We hypothesized, in accordance with the stress-diathesis model, that patients
with severe and complex symptoms would suffer from more psychosocial
stress. We also hypothesized that agreement between patients’ and professionals’ assessments of categories of psychosocial problems should be at
least moderate.
Psychosocial and environmental problems experienced during the last year,
categorized according to DSM-IV, assessed both by interview and selfassessed, are presented in Table 4. According to the structured interview
performed by the social worker, problems with the primary support group
(67 %) were most common, followed by problems related to the social environment (48 %) and educational problems (44 %).
Agreement between the results of the interview and self-assessment on categories of psychosocial and environmental problems are presented in Table 4.
According to prevalence & bias-adjusted kappa (PABAK), agreement was
0.31-0.83, see Table 4.
The relation between GAF and number of axis IV categories was explored,
showing decreasing GAF values with an increasing number of axis IV categories (F=5.69; df=155; p<0.001).
Exploring the validity of number of categories of psychosocial problems in
patients with or without diagnoses from a specific diagnostic group revealed
significant differences, with disordered patients having more psychosocial
stress. This was true for all groups, but not significant for eating disordered
patients: mood disorders 2.7 (SD=1.6) versus 1.9 (SD=1.6) (Z=2.8;
p=0.006), anxiety disorders 2.8 (SD=1.7) versus 1.9 (SD=1.4) (Z=3.1;
p=0.002), eating disorders 2.2 (SD=1.6) versus 2.7 (SD=1.7) (Z=1.8;
p=0.069), substance use disorders 4.5 (SD=2.2) versus 2.4 (SD=1.5) (Z=3.2;
p=0.001), and personality disorders 3.2 (SD=1.6) versus 2.2 (SD=1.6)
(Z=3.5; p=0.001).
28
80 (62)
39 (24)
13 (8)
9 (6)
57 (44)
28 (38)
47 (29)
40 (24)
16 (10)
21 (13)
12 (7)
Occupational problems
Housing problems
Economic problems
Problems with access to
health care services
Problems related to
interaction with the legal
system/crime
Other psychosocial and
environmental problems
Prevalence & Bias-Adjusted Kappa
*
89 (55)
78 (48)
Problems related to the
social environment
Educational problems
65 (40)
75 (46)
30 (41)
105 (64)
109 (67)
Problems with primary
support group
n (%)
n (%)
Any problem
self-assessed
Axis - IV
Any problem
interview
1 (0.6)
10 (6)
8 (5)
31 (19)
33 (20)
20 (27)
47 (37)
57 (35)
82 (50)
Agreement on
existence of
problems
n (%)
142 (88)
138 (85)
115 (71)
89 (55)
74 (45)
35 (48)
38 (30)
53 (32)
31 (19)
Agreement on
non-existence of
problems
n (%)
0.03
0.54
0.18
0.41
0.29
0.49
0.35
0.35
0.32
Kappa
0.77
0.83
0.52
0.47
0.31
0.51
0.33
0.35
0.39
PABAK*
Overall
agreement
Table 4. Axis IV - agreement on assessments of categories of psychosocial and environmental problems, comparison of assessments performed by interview by a social worker and self-assessments in a group of psychiatric out-patients (n=163).
Axis V – Global Assessment of Functioning scale (paper IV)
We hypothesized that patients’ and staff members’ agreement on the GAF,
before and after treatment, would be at least acceptable.
At the first assessment, overall mean GAF scores obtained by staff members
and patients were 54.6±7.6 and 55.5±11.4, respectively. After treatment, the
corresponding figures were 71.0±11.6 and 72.9±14.4. The ICC coefficient
between staff members’ and patients’ GAF ratings was 0.65 before treatment
and 0.86 after treatment. GAF scores and the ICC in the different diagnostic
groups are shown in Table 5.
In patients with excessive co-morbidity, GAF scores were low and agreement between staff members and patients before treatment was low, see Table 5. However, agreement after treatment increased and was at least good
for those with two or three disorders, see Table 5.
Changes in GAF ratings from initial to final assessments were calculated.
There were 187 patients who had both assessments done by experts, with a
mean change of 14.7±10.4, and 137 patients had done both ratings themselves, with a mean change of 17.0±15.7. Agreement according to GAF
change between patients and staff members in the total group was 0.77.
30
Total group
Diagnostic groups
Mood disorders
Anxiety disorders
Eating disorders
Other Axis I disorders
Substance related disorders
Comorbidity
One axis I disorder group
Two co-morbid axis I disorder groups
Three co-morbid axis I disorder groups
Four co-morbid axis I disorder groups
Personality disorders
No axis II disorder / no PD
Any axis II disorder
Diagnoses according to DSM-IV
Axis I
53.6±7.0
52.4±6.2
53.2±7.3
55.4±8.1
51.1±6.8
58.2±7.6
54.1±7.1
50.9±5.3
50.6±5.0
56.1±7.6
49.8±5.6
191
139
128
55
22
17
56
62
33
34
146
45
56.9±11.0
50.8±11.4
60.1±12.0
55.5±10.4
51.6±9.1
49.9±10.8
53.6±10.9
52.9±9.7
52.9±14.4
56.8±12.6
54.9±13.7
Self
mean±SD
55.5±11.4
0.67
0.36
0.67
0.66
0.32
0.14
0.65
0.50
0.66
0.54
0.57
0.65
ICCs
GAF before treatment (n=191)
Expert
mean±SD
54.6±7.6
N
<0.0001
n.s.
<0.0001
<0.0001
n.s.
n.s.
<0.0001
<0.0001
<0.0001
0.04
n.s.
<0.0001
p
110
28
45
46
26
16
99
86
42
18
138
n
73.4±10.8
60.4±9.5
74.3±10.3
69.2±11.8
69.5±13.8
66.3±9.0
71.1±11.9
68.3±10.8
69.4±13.1
67.1±11.2
Expert
mean±SD
71.0±11.6
75.0±13.1
64.6±16.6
78.3±12.0
70.8±14.8
70.0±15.5
67.9±15.1
73.2±15.3
69.8±13.9
71.0±15.1
71.2±15.9
Self
mean±SD
72.9±14.4
0.84
0.87
0.82
0.88
0.94
0.66
0.86
0.85
0.90
0.78
0.86
ICCs
GAF after treatment (n=138)
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.02
<0.0001
<0.0001
<0.0001
0.002
<0.0001
p
Table 5. GAF scores rated before and after treatment in different diagnostic groups. Comparison of GAF rated by experts and by patients.
Participants (n=191) recruited from a total group of young (18-25 years) adult psychiatric outpatients.
Discussion
The overall aim of the present thesis was to increase knowledge about young
adults with mental illness and about psychiatric assessments in order to improve diagnostic procedures. Mental illness is common, usually starting
early in life, and the prevalence is highest in young adulthood [2, 42]. The
majority of those affected never seek mental health care [43, 44]. Therefore,
it is important to increase help seeking, as well as optimization, in order to
obtain adequate identification of symptoms. This will make it possible for
persons with mental disorders to be offered effective treatments.
Methodological considerations
Sample
All study examinations took place in an ordinary clinical psychiatric setting,
and patients were not recruited for the study. Patients who sought help at the
clinic had no knowledge of the ongoing study before they visited the clinic;
such knowledge could have influenced patterns of referral. All patients were
consecutively invited to participate with a high attrition rate, 92 %. The
drop-out analysis showed no differences between participants and nonparticipants. This all-inclusive approach increases the likelihood that the
sample is representative of other young clinical samples from general psychiatry. Furthermore, this is supported by similar prevalence data of different
axis I disorders as well as level of co-morbidity in a study by Zimmerman et
al. [78] using semi-structured diagnostic interviews, SCID-I and II, in 2,300
psychiatric outpatients. However, there might be limited ability to generalize
the results to other settings such as settings with older patients, with more
men or with more patients with schizophrenia and substance related disorders. Furthermore, the high level of co-morbidity limits the possible analyses of relations between specific diagnostic groups. If there had been a control group, less burdened by psychopathology, this would have increased the
strength of the study.
32
Methods and Procedures
The study analyses were based on careful and comprehensive assessment of
axes I, II, IV and V in DSM-IV. The two doctors who performed the diagnostic SCID-interviews were trained in accordance with the SCID-manual,
and kappa agreement was almost perfect. Inter-rater-reliability was calculated from a limited number of interviews. However, both interviewers (MR
and AR) had their clinical training within the same department by the same
tutors, and both interviewers had previously shown reliable reports by assessing SCID-interviews from audio and videotapes. Personality disorders
were not evaluated until state effects of axis I symptoms were resolved. A
weakness of the study is that problems with recall might influence reports
[79, 80], such as reports on lifetime diagnoses (paper I-IV), age of onset
(paper II), previous symptoms, (paper I-IV), childhood life-events & trauma
(paper II), and reports on previous health care service utilization (paper I).
However, since all participants were young, they were more likely to accurately remember their childhood.
In paper III, the social worker evaluated current psychosocial and environmental problems (axis IV) in a structured manner based on an interviewbased checklist. In a clinical sample of patients with substance use disorders
and schizophrenia studied by Compton et al. [81], using a comparable method, the prevalence of psychosocial problems was similar. The short axis IV
scale, a questionnaire filled in by the patients, is not extensively validated.
However, previous studies using the scale have shown similar results, with
personality-disordered patients being the most psychosocially burdened [23,
82].
In paper IV, professional and patient GAF ratings were compared before and
after treatment. All staff members were trained and well experienced in the
GAF assessment technique. Furthermore, during the whole study period,
staff members performed weekly GAF co-ratings in order to secure interrater reliability. However, it cannot be excluded that the different GAF rating
procedures used at first and second professional assessment has affected the
reliability of the professionals’ GAF ratings.
Help-seeking
Even if psychiatric disorders are prevalent, there is only a minority of those
affected who seek treatment. The consequences of permitting self-referral
have not yet been studied. Even if allowance of the patient to refer him or
herself to specialized care differs between various health care systems, the
proportion of help-seeking persons within this study was similar to figures
33
reported by others [83]. Every twentieth individual in this age group, from
the population in the catchment area, sought help from psychiatric services.
The characteristics of the study group are also in accordance with previous
research about treatment seekers. They have previously been characterized
by an early onset of disorders [42], by being female [84] and by having
mood and anxiety disorders, especially if co-morbid [85].
In Sweden, there is an established public mental health service providing
equality in the opportunity for treatment. Thus, in spite of no requirement of
referral from general practitioners, nor financial difficulties in getting treatment, the rate of help-seeking young adults did not exceed rates from other
populations with other health care systems [86]. Therefore, allowance of the
patient to refer him or herself did not increase the proportion of help-seeking
individuals nor did it alter the pattern of help seeking. Self-referred patients
were equally or more disordered than those referred by mental health professionals. In summary, the findings do not support any overutilization of care
by permitting self-referral.
Early onset depression
The age limit that should be applied to early-onset depression is still unclear.
Zisook et al. [87] examined 1,500 depressed patients between 18 and 75
years old and found an average age of onset of 26 years, distributed with two
incidence peaks: one between 13-15 years old and another between 40-42
years old. Based on the onset distribution of Zisook’s study [87], all patients
within the paper II study group had an early onset. In spite of this, there were
significant differences between age of onset groups according to several
studied variables.
Childhood and adolescent onset was, as expected, associated with a recurrent
course, but since all patients were younger than 25 years old, the course of
the young adult onset group is still unknown. In accordance with previous
findings [87-89], childhood onset of depression was related to more personality disorders, more traumatic experiences, neglect and more negative life
events. Beyond previous findings, childhood developmental delays were also
shown to be more common in the childhood onset group.
The prevalence of personality disorders was, however, lower than in some
previous studies [90-92]. The prevalence of personality disorders increases if
they are self-assessed, compared to assessment with semi-structured diagnostic interviews such as SCID-II [93]. The prevalence also increases if the
investigation of personality traits is done under the influence of axis I symptoms [94]. The thorough assessment by structured interviews, performed
34
when axis I symptoms had resolved, may explain the lower incidence in this
study. It also supports the fact that the prevalence data is true.
It has previously been shown that co-morbidity between ADHD and depression in adolescence is common [95, 96] as well as between autism spectrum
disorders (ASD) and depression [97]. Developmental delays should be able
to affect self-image and self-confidence negatively and is relevant to include
in future research on early-onset depression. Childhood delays in motor,
language and cognitive development have been related to later adult onset of
schizoaffective disorder [98]. However, no comparable study has been performed in patients with depression. In paper II, those with a childhood onset
of depression, compared to those with later onset, affirmed more social and
cognitive difficulties on the CAPSI-R questionnaire. We do not know if they
met criteria for specific diagnoses, such as attention deficit hyperactivity
disorder (ADHD), but they affirmed symptoms included in ADHD and
ASD.
Psychosocial stress is believed to contribute to the onset and exacerbation of
mental disorders [99, 100]. Within the study group, those with the earliest
onset had experienced more severe adverse life events and more traumas.
They also rated severity of last year’s total psychosocial problems significantly higher. Distressing conditions in the family has proven to be more
common among patients with anxiety or depression [101, 102]. Previously
experienced psychosocial problems seem to influence current life. Since
those with the earliest onset experienced more childhood traumas, it is not
surprising that they seem to continue to struggle with social adversity.
Depressive episodes with onset before 15 years of age are related to a higher
prevalence of bipolar disorders [91, 103]. However, neither the presence of
bipolar disorders nor the presence of shorter periods of elevated mood were
more common among those with childhood or adolescent onset in this study.
It is possible that some of the patients with MDD will develop bipolar disorder in the future. All patients are still young, and the course of their mood
disorder is still unknown.
Psychosocial stress
Psychosocial problems can be risk factors for the development of a psychiatric disorder as well as a target for treatment or influencing prognosis of the
current mental disorder. The majority of patients were psychosocially burdened. The results support previous findings [104] that psychosocial stress is
related to psychopathology, co-morbidity and decreasing GAF values. Dur35
ing the last few decades, research has shown that co-morbidity is common in
psychiatric patients [39]. This study expands on previous findings by exploring the relation between axis IV categories and degree of co-morbidity. Comorbid personality disorders were strongly associated with psychosocial
stress. Personality-disordered patients experienced stress within their primary support group, related to their social environment, and they had occupational problems. Therefore, it seems that these axis IV categories capture
the difficulties associated with personality disorders [82]. It also implicates
that mental health services for young people need to have social workers
among the staff, and efforts targeting social problems need to be added to
other treatments.
Agreement on current psychosocial stress between the professional and the
patients was higher for those axis IV categories, with more absolute and less
subjective content; for example, problems related to interaction with the
legal system/crime compared to problems with the primary support group.
Previous studies of patients’ and clinicians’ ratings of stressor severity have
shown fair to good agreement [105, 106]. The result implicates that assessment of categories, compared to ratings such as in DSM-III, might be progress, but only for problems with the legal system/crime.
Global Assessment of Functioning
There is a need for systematic follow-up of patients, and there is increasing
pressure to use outcome measures in routine clinical practice. For obvious
reasons, it is also important to examine patients’ subjective opinions about
how their condition and level of functioning have changed over time. Selfreport and expert evaluations are assumed to be complementary, and there is
no strong evidence that one method is more valid than the other. In paper IV,
the reliability of patients’ and trained staff members’ GAF ratings, before
and after treatment, was examined. Generally, the results demonstrate good
agreement before treatment and excellent agreement after treatment. The
findings support the usefulness of the GAF self-report version for measuring
outcome in routine clinical care. However, in patients with personality disorders, or in those with excessive co-morbidity, only low agreement was
achieved before treatment but improved to good or excellent after treatment.
The GAF scale defines some aspects of functioning and some symptoms at
ten severity levels, but the instructions are incomplete. There are, for example, no instructions about manic symptoms or substance-related symptoms.
This could also explain the greater difficulty in assessing GAF in severely
disordered patients compared to patients in full or partial recovery.
36
The inter-rater reliability of GAF ratings, performed by trained clinicians
and experts, has been shown to be excellent [107, 108]; whereas, agreement
between routine clinical scores and scores done by researchers is low [108].
Previously, only one study has compared GAF ratings of clinicians and psychiatric outpatients [16]. High concordance before treatment was found in
that study, which is in line with our findings.
Several studies have shown that clinicians’ GAF ratings reflect improvements during treatment [109]. According to our results, there was excellent
agreement between experts’ and patients’ opinions on the degree of improvement, measured as an increase in GAF scores (overall ICC=0.77).
However, patients rated their mean increase in GAF slightly higher than
experts in all diagnostic groups. This difference is the opposite of the expected bias caused by those providing treatment [110].
General discussion and future aspects
The results implicate that multi-axial diagnostic evaluation according to
DSM-IV in young adult psychiatric patients provides important information
for treatment planning. The diagnostic procedure needs to include reliable
diagnostic instruments, both in research and in clinical practice. Since helpseeking patients are characterized by co-morbid disorders, but also by previous child-psychiatric symptoms and previous developmental delays, current
psychosocial stress, more childhood life-events and low functioning, there is
a need for thorough assessments. All this information was of clinical importance, since it defined specific subgroups.
Future research is needed on how to reduce the obstacles of help seeking for
mental disorders. There is a need for more research about how childhood
developmental delays influence adult psychopathology and influence age of
onset of psychiatric disorders. There is also a need for more research concerning difficulties in assessing severely disordered patients. It is also important to study implementation of diagnostic procedures in clinical psychiatry.
37
Conclusion
In the present thesis young adults with mental illness were investigated with
respect to self-referral, onset of depression, psychosocial and environmental
problems and global assessment of functioning. This group of young individuals was characterized by an early onset of mental disorders, high comorbidity and by being female. The main conclusions are
Direct self-referral to specialized psychiatric care does not seem to be
associated with overutilization of such care.
Childhood onset of depression is associated with more severe symptoms,
more psychosocial risk factors, and childhood developmental delays.
The revised axis IV according to DSM-IV seems to have concurrent
validity, but is still hampered by limited reliability.
Agreement between patients’ and professionals’ ratings on the GAF
scale was good before treatment and excellent after treatment. The results support the usefulness of the self-report GAF instrument for measuring outcome in psychiatric care.
38
Acknowledgments
In the 1990s, I started out as a young doctor working in psychiatry. It was a
new country, a new language and new cultural codes. The colleague I most
admired, Magnus Almqvist, instilled in me an early interest and desire to
start working with diagnostic procedures and structured meetings with patients. I am deeply thankful that he took me under his wing and gave me the
honor of working under his supervision. I will always be indebted to you.
Thank you!
I would like to express my deep gratitude to everyone who has contributed to
this thesis and to those who have made it possible for me to complete the
doctoral program at the Department of Neuroscience, Psychiatry, at Uppsala
University.
In particular, I would like to thank:
Mia Ramklint, my principal supervisor. Thank you for sharing your outstanding wealth of knowledge, inspiring curiosity, expertise and overwhelming commitment. Thank you for your warmth, patience, encouragement,
unconditional friendship and unpretentious guidance that allowed me to take
the journey that became one of the most thrilling and rewarding experiences
of my life. I am truly, and more than extremely, grateful for having been
given the opportunity to work together with you.
Lisa Ekselius, my co-supervisor. Thank you for encouraging me to write
this thesis, for valuable supervision and the numerous rewarding discussions.
Thank you for always believing in me, for sharing your impressive knowledge and for sharing your valuable time with me. I am truly thankful for
your unpretentious guidance.
Hans Arinell, for your unconditional support with statistics, your teaching
skills and your commitment.
Lena Bohlin, for always caring and for your excellent practical help.
Bengt Gerdin, for your encouragement and generous support.
39
Anders Holmberg, for generously sharing your time and your positive attitude towards my thesis, but mostly - for sharing your wife with me.
To my colleagues in the Psychiatry and Individual Differences group for
interesting discussions, fellowship and joy, and especially to Caisa Öster
and Kristina Haglund for your patience and friendly support.
To Uppsala University Hospital, and more specifically to head of the Division of Psychiatry Karin Norlén, as well as the former heads of the Department of General Psychiatry Ulises Penayo and Birgitta Lanner.
To Lasse Brunn, then-head of the Flogsta clinic, for active support to the
team throughout the project.
To A-C Fält, Ann Olander Bödvarsson and the rest of the project staff for
their decision to participate in the project. Their excellent cooperation and
their strong expertise have enabled this successful work.
To the patients, for their participation that made this work possible.
Dede Fraser, for your skillful linguistic revision and for taking interest in
my work.
To my dear friends, you know who you all are and how much you mean to
me. Your invaluable support means the world to me.
To the children of Mia Ramklint and Anders Holmberg, for your contribution in the collection of data base, for letting me borrow your mother and for
giving my family joy.
To my dear siblings, especially to Sara, Cesar and Jorge, thank you for
being by my side through it all.
Last, but most importantly, I would like to thank my family. To my wonderful husband and life companion Robin, for being my other half and for your
immense love and support. Thank you for always listening, for truly appreciating me and making me remember the important things in life.
To my divine daughter Sindy, for being there for me unconditionally. Thank
you for all your time, for believing in my ability and your never-ending support. Thank you for loving me, helping me with flexibility and for having an
obsessive way of planning, as well as for always being cheerful and throwing me an outstanding party.
40
To my lovely daughter Marlene, for giving me happiness and your youthful
energy. Thank you for your invaluable speech comments, your patience
when I come home late and for having a positive attitude and taking interest
in my thesis.
And for our dog Quique, for not eating or urinating on all my paper that was
lying everywhere.
Generous financial support was provided by The Märta and Nicke Nasvell
Foundation, The Anna-Britta Gustafsson Foundation, The Fredrik and Ingrid
Thuring Foundation, Ratiopharm AB and The Research Council of the Swedish Systembolaget.
41
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