Lars Lien

• Aaseth, Jan; Roer, Grethe Emilie; Lien, Lars & Bjørklund, Geir (2019). Is there a relationship between PTSD and complicated obesity? A review of the literature. Biomedicine and Pharmacotherapy.  ISSN 0753-3322.  117 . doi: 10.1016/j.biopha.2019.108834 Show summary

  Recent research strongly supports the hypothesis that posttraumatic stress disorder (PTSD) can be accompanied by obesity and related metabolic disturbances. The mechanisms of these associations are however still not well defined, although disturbed functions in the sympathetic-adrenergic nervous system together with the disturbed release of hormones via the endocrine HPA (hypothalamic-pituitary-adrenal) axis apparently play a role. Leptin resistance and ghrelin excesses might contribute to a disturbed hypothalamic function, and also disturb other cerebral functions, leading to dysfunctional reward signaling and uncontrolled appetite combined with a tendency to alcohol abuse. Secondarily, cortisol stimulation will contribute to the development of central obesity which is known to facilitate the development of metabolic syndrome, including slightly increased levels of inflammatory biomarkers such as C-reactive protein and fibrinogen. While previous therapeutic strategies have focused on early psychotherapeutic interventions in PTSD, the present review emphasizes the importance of better therapeutic approaches regarding the somatic correlates of the syndrome. Strict regulation of dietary meals and food composition with minimal intake of sweets and saturated fat, as well as alcohol avoidance, can provide a basic therapeutic framework. A cognitive psychotherapeutic approach with graduated desensitization toward trigging factors, combined with pharmacotherapy, is discussed in the present review.

• Leonhardt, Marja & Lien, Lars (2019). Fargerikt og grønt - innvandrere og friluftsliv, I: Gunnar Tellnes (red.),  NaKuHel og folkehelse som bærekraft: Samspillet Natur-Kultur-Helse sett i lys av FNs bærekraftmål.  Det norske medicinske Selskab.  ISBN 978-82-92871-81-2.  Kapittel 10.  s 64 - 69
• Sanhori, Zienat Balla Mohamed Ahmed; Eide, Arne Henning; Ayazi, Touraj; Mdala, Ibrahimu & Lien, Lars (2019). Change in Mental Health Stigma After a Brief Intervention Among Internally Displaced Persons in Central Sudan. Community mental health journal.  ISSN 0010-3853.  55(3), s 534- 541 . doi: 10.1007/s10597-019-00375-y Show summary

  Stigmatizing attitudes towards people with mental illness is a worldwide phenomenon, This Longitudinal study aimed to determine the level of stigma, among the internal displaced persons in central Sudan and explore possible changes in stigma associated with an intervention. 1549 persons were interviewed using standardized stigma attitude tools. The study reveled high level of stigma among our respondents and there was no significant difference in attitudes towards mental illness observed after the intervention. The intervention was not associated with change in stigma. However, the findings can inform policy to create sustainable national mental health strategies to address the stigma.

• Silwal, Sanju; Lehti, Venla; Chudal, Roshan; Suominen, Auli; Lien, Lars & Sourander, Andre (2019). Parental immigration and offspring post-traumatic stress disorder: A nationwide population-based register study. Journal of Affective Disorders.  ISSN 0165-0327.  249, s 294- 300 . doi: 10.1016/j.jad.2019.02.002 Show summary

  Objectives The aim of this study was to investigate the association between parental immigration status and a diagnosis of post-traumatic stress disorder (PTSD) in their offspring. Methods This nested matched case-control study was based on a Finnish national birth cohort for 1987–2010 and cases were diagnosed with PTSD by 2012 from the Care Register for Health Care. We identified 3639 cases and 14,434 controls individually matched for gender, place and date of birth (±30 days). Conditional logistic regression analyses were conducted to examine the association between parental immigration status, parents’ region of birth and time since paternal immigration, and PTSD after controlling for confounding factors. Results The likelihood of being diagnosed with PTSD was significantly increased among children with an immigrant father (OR 1.8, 95% CI 1.3 - 2.4) than those with two Finnish parents and one immigrant mother. There was no significant association between having an immigrant mother or two immigrant parents and receiving a diagnosis of PTSD. The likelihood of being diagnosed with PTSD was increased if the children's fathers had migrated less than five years before their birth (OR 1.4, 95% CI 1.03 - 1.9) and if their immigrant fathers had been born in North Africa or the Middle East (OR 2.1, 95% CI 1.4 - 3.3). Limitations The sample included a heterogeneous migrant group without information on the reason for migration. The cases were identified from hospital diagnosis that may have only included severe cases. Conclusion The increased likelihood of a diagnosis of PTSD underlines the need for psychosocial services among second-generation immigrants.

• Stensvehagen, Marianne Torp; Bronken, Berit Arnesveen; Lien, Lars & Larsson, Ulf Gerry (2019). How women experience and cope with daily hassles after sexual abuse – a retrospective qualitative study. Scandinavian Journal of Caring Sciences.  ISSN 0283-9318. . doi: 10.1111/scs.12649 Show summary

  The impact of stress on health can depend on factors such as frequency, heightening of stress during a given period or the presence of one or a few repeated hassles of psychological importance. The aim of this study was to gain a deeper understanding of how adult women experience and cope with daily hassles after sexual abuse. Ten interviews were analysed using the grounded theory method. The theoretical model of ‘protecting armor in daily life’ emerged. The aftermath of sexual abuse related coping with daily stress can be understood as a three-phase process: (1) avoiding and Introduction Violence against women is a common public health con- cern and one in three women worldwide, experiences physical or sexual violence in their lifetime (1). The World Health Organization (2) defines sexual violence as: Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed against a person’s sexu- ality using coercion, by any person regardless of their relationship to the victim, in any setting including but not limited to home and work. (p. 11) Sexual abuse may include everything from sexualised language/behaviour to more severe abuse like intimate touching and rape (3). According to the World Health Organization (4), one in five women reports having been sexually abused as a child and one in three women has been a victim of physical or sexual violence by an Correspondence to: Marianne Torp Stensvehagen, Inland Norway University of Applied Sciences, Postboks 400, 2418 Elverum, Norway. E-mail: marianne.stensvehagen@inn.no escaping—coping after experiencing sexual abuse; (2) accepting and disclosing—starting a process of recovery; and (3) reconciling and repossessing—living with the experience in the present. The model contributes to a deeper understanding of the everyday life of women who have experienced sexual abuse. Increased knowl- edge of coping behaviours that can be used to deal with daily hassles may also serve as a tool for health professionals, other helpers and family to help these women rebuild a good life. Keywords: sexual abuse, women, daily hassles, daily uplifts, coping strategies, stress reactions.

• Toft, Helge Prytz; Lien, Lars; Neupane, Sudan Prasad; Abebe, Dawit Shawel; Tilden, Terje; Wampold, Bruce E. & Bramness, Jørgen Gustav (2019). Cytokine concentrations are related to level of mental distress in inpatients not using anti-inflammatory drugs. Acta Neuropsychiatrica.  ISSN 0924-2708. . doi: 10.1017/neu.2019.36 Show summary

  Objective: Cross-sectional data show elevated levels of circulating cytokines in psychiatric patients. The literature is divided concerning anti-inflammatory drugs’ ability to relieve symptoms, questioning a causal link between inflammatory pathways and psychiatric conditions. We hypothesised that the development of circulating cytokine levels is related to mental distress, and that this relationship is affected by the use of anti-inflammatory drugs. Methods: The study was a longitudinal assessment of 12-week inpatient treatment at Modum Bad Psychiatric Center, Norway. Sera and self-reported Global Severity Index (GSI) scores, which measure psychological distress, were collected at admission (T0), halfway (T1) and before discharge (T2). Other variables known to distort the neuroimmune interplay were included. These were age, gender, diagnosis of PTSD, antidepressants and anti-inflammatory drugs. A total of 128 patients (92 women and 36 men) were included, and 28 were using anti-inflammatory medication. Multilevel modelling was used for data analysis. Results: Patients with higher levels of IL-1RA and MCP-1 had higher GSI scores (p = 0.005 and p = 0.020). PTSD patients scored higher on GSI than non-PTSD patients (p = 0.002). These relationships were mostly present among those not using anti-inflammatory drugs (n = 99), with higher levels of IL-1RA and MCP-1 being related to higher GSI score (p = 0.023 and 0.018, respectively). Again, PTSD patients showed higher GSI levels than non-PTSD patients (p = 0.014). Conclusions: Cytokine levels were associated with level of mental distress as measured by the GSI scores, but this relationship was not present among those using anti-inflammatory drugs. We found no association between cytokine levels and development of GSI score over time.

• Vattø, Ingvild Engh; Lien, Lars; deMarinis, Valerie; Haug, Sigrid Helene Kjørven & Danbolt, Lars Johan (2019). Caught between Expectations and the Practice Field: Experiences of This Dilemma among Volunteers Operating a Diaconal Crisis Line in Norway. Crisis.  ISSN 0227-5910. . doi: 10.1027/0227-5910/a000573
• Abebe, Dawit Shawel; Elstad, Jon Ivar & Lien, Lars (2018). Utilization of somatic specialist services among psychiatric immigrant patients: the Norwegian patient registry study. BMC Health Services Research.  ISSN 1472-6963.  18:852, s 1- 7 . doi: 10.1186/s12913-018-3672-y Full text in Research Archive.
• Abraham, Ruth; Lien, Lars & Hanssen, Ingrid (2018). Coping, resilience and posttraumatic growth among Eritrean female refugees living in Norwegian asylum reception centres: A qualitative study. International Journal of Social Psychiatry.  ISSN 0020-7640.  64(4), s 359- 366 . doi: 10.1177/0020764018765237 Show summary

  Background: The links between migration and health are well documented. Being a refugee exacerbates migrants’ vulnerability through trauma and loss. The aim of this study is to identify sources of resilience, coping and posttraumatic growth in female Eritrean refugees living in Norwegian asylum reception centres. Method: The study had a qualitative, descriptive and explorative design with two focus group interviews and 10 individual in-depth interviews. Participants included 18 female Eritrean refugees aged 18–60, who had obtained refugee status and were still living in an asylum reception centre. A content-focused hermeneutic analytic approach was used. Results: Interviewees described the challenges of pre-flight and flight trauma, conditions at the refugee centre, communication difficulties and the ‘endless’ waiting for transfer to a municipality. To cope, they found it helpful to focus on the future and to think positively. Fellowship with and support from fellow Eritrean refugees were essential as they became a proxy family and provided a strong ethnic identity. Their religious belief also helped them cope and gave them hope for the future. Discussion: The interviewees in this study perceived their psychological problems as a normal reaction to what they had been through. Religious belief was an important resilience factor, as was social support, especially from peers. Conclusion: The interviewees’ coping was based on the realization of their psychological reactions being normal while doing their utmost to focus on their aims and hopes for the future. Keywords Refugees, resilience, coping, posttraumatic growth, religiosity, positive psychiatry

• Balieva, Flora Nicol; Finlay, Andrew Y.; Kupfer, Jörg; Aragones, Lucia Tomas; Lien, Lars; Gieler, Uwe; Poot, Francoise; Jemec, Gregor B. E.; Misery, Laurent; Kemeny, Lajos; Sampogna, Francesca; Van Middendorp, Henriet; Halvorsen, Jon Anders; Ternowitz, Thomas; Szepietowski, Jacek C.; Potekaev, Nikolay; Marrón, Servando E.; Altunay, Ilknur K.; Salek, Sam S. & Dalgard, Florence (2018). The role of therapy in impairing quality of life in dermatological patients: A multinational study. Acta Dermato-Venereologica.  ISSN 0001-5555.  98(6), s 563- 569 . doi: 10.2340/00015555-2918 Full text in Research Archive. Show summary

  Skin disease and its therapy affect health-related quality of life (HRQoL). The aim of this study was to measure the burden caused by dermatological therapy in 3,846 patients from 13 European countries. Adult outpatients completed questionnaires, including the Dermatology Life Quality Index (DLQI), which has a therapy impact question. Therapy issues were reported by a majority of patients with atopic dermatitis (63.4%), psoriasis (60.7%), prurigo (54.4%), hidradenitis suppurativa (54.3%) and blistering conditions (53%). The largest reduction in HRQoL attributable to therapy, as a percentage of total DLQI, adjusted for confounders, was seen in blistering conditions (10.7%), allergic/drug reactions (10.2%), psoriasis (9.9%), vasculitis/immunological ulcers (8.8%), atopic dermatitis (8.7%), and venous leg ulcers (8.5%). In skin cancer, although it had less impact on HRQoL, the reduction due to therapy was 6.8%. Treatment for skin disease contributes considerably to reducing HRQoL: the burden of dermatological treatment should be considered when planning therapy and designing new dermatological therapies.

• Belfrage, Anna; Grotmol, Kjersti Støen; Tyssen, Reidar; Moum, Torbjørn Åge & Lien, Lars (2018). Factors associated with low vs increased perceived mastery of clinical work over ten years of practice: a prospective study of Norwegian doctors. BMC Medical Education.  ISSN 1472-6920.  18:116(116) . doi: 10.1186/s12909-018-1236-9 Full text in Research Archive. Show summary

  Background A higher sense of mastery of doctors’ clinical work could benefit not only their own mental health but also their work performance and patient care. However, we know little about factors associated with perceived mastery of clinical work among physicians. Our aim was therefore to study characteristics of those with stable low levels and of those with increased levels of mastery over a period of ten years of medical practice. Methods N = 631 doctors were surveyed in their final year of medical school in 1993/94 (T1) and 10 (T2), 15 (T3) and 20 (T4) years later. Low and increased perceived mastery of clinical work were measured between T2, T3 and T4. Response rates for all items measuring low and increased mastery were 238/522 (46%) and 256/522 (49%) respectively. The following explanatory variables were included: demographics, medical school factors, personality and contextual work-related and non-work-related factors. Results N = 73 (31%) of the doctors reported stable low mastery from T2 to T4. The following variables were significantly associated with low mastery in the adjusted analyses: vulnerability (OR: 1.30, P < .000, CI: 1.12 to 1.50), drinking alcohol to cope with stress during medical school (OR: 2.66, P = .04, CI: 1.03 to 6.85) and social support (OR: 0.78, P = .002, CI: 0.66 to 0.91). N = 39 (15%) reported increased mastery during the ten-year period from T2 to T4. Perceived job demands (OR: 0.66, P = .02, CI: 0.45 to 0.98) and taking up a leading position (OR: 3.04, P = .01, CI: 1.31 to 7.07) were associated with increased mastery after adjustment. Conclusions Stable low sense of mastery over time is associated with having a vulnerable personality, a history of having used alcohol to cope with stress during medical school and lack of contemporary social support. Conversely, increased sense of mastery is associated with taking up a leading position and having the perception that job demands are decreasing over time. These findings indicate that perceived mastery of clinical work may not be a trait, but a state modifiable over time

• Brekke, Eva; Lien, Lars; Nysveen, Kari & Biong, Stian (2018). Dilemmas in recovery-oriented practice to support people with co-occurring mental health and substance use disorders: A qualitative study of staff experiences in Norway. International Journal of Mental Health Systems.  ISSN 1752-4458.  12(30) . doi: 10.1186/s13033-018-0211-5 Full text in Research Archive. Show summary

  Background Recovery-oriented practice is recommended in services for people with co-occurring mental health and substance use disorders. Understanding practitioners’ perceptions of recovery-oriented services may be a key component of implementing recovery principles in day-to-day practice. This study explores and describes staff experiences with dilemmas in recovery-oriented practice to support people with co-occurring disorders. Methods Three focus group interviews were carried out over the course of 2 years with practitioners in a Norwegian community mental health and addictions team that was committed to developing recovery-oriented services. Thematic analysis was applied to yield descriptions of staff experiences with dilemmas in recovery-oriented practice. Results Three dilemmas were described: (1) balancing mastery and helplessness, (2) balancing directiveness and a non-judgmental attitude, and (3) balancing total abstinence and the acceptance of substance use. Conclusions Innovative approaches to practice development that address the inherent dilemmas in recovery-oriented practice to support people with co-occurring disorders are called for

• Brénaut, Émilie; Halvorsen, Jon Anders; Dalgard, Florence; Lien, Lars; Balieva, Flora Nicol; Sampogna, Francesca; Linder, Dennis; Evers, Andrea Walburga Maria; Jemec, Gregor Borut Ernst; Gieler, Uwe; Szepietöwski, Jacek Cezary; Poot, Francoise; Altunay, Ilknur K; Finlay, Andrew Y.; Salek, Sam S; Szabo, C; Lvov, Andrey; Marron, Servando E; Tomas-Aragones, Lucia; Kupfer, Joerg & Misery, Laurent (2018). The self-assessed psychological comorbidities of prurigo in European patients: a multicentre study in 13 countries. Journal of the European Academy of Dermatology and Venereology.  ISSN 0926-9959.  33(1), s 157- 162 . doi: 10.1111/jdv.15145 Show summary

  Background Prurigo is defined by the presence of chronic pruritus and multiple localized or generalized pruriginous lesions. Objective The aim of this study was to assess the psychological burden of prurigo in patients of European countries. Methods In this multicentre European study, 3635 general dermatology outpatients and 1359 controls were included. Socio‐demographic data and answers to questionnaires (regarding quality of life, general health, anxiety and depression and suicidal ideation) were collected. Results There were 27 patients with prurigo; of these, 63% were men, and the mean age was 58.6 years. Among patients with prurigo, 10 of 27 (37%) suffered from anxiety and 8 of 27 (29%) from depression. Suicidal ideation was reported in 5 of 27 (19%) patients, and for four of these five patients, suicidal ideation was related to their skin disease. These frequencies were higher in the 10 commonest dermatological diseases (including psoriasis, atopic dermatitis and leg ulcers). The impact on quality of life was severe, with a mean Dermatologic Life Quality Index (DLQI) of 12.4, with an extreme impact on quality of life for 23% of patients and a very large impact for 27% of patients. Conclusion The psychological comorbidities of prurigo are common, greater than those of other skin diseases, and their impact on quality of life is significant. Thus, it is important to study this condition and to find new treatments.

• Dalgard, Florence; Bewley, Anthony; Evers, Andrea W.; Gieler, Uwe; Lien, Lars; Sampogna, Francesca; Ständer, Sonja; Tómas-Aragonés, Lucía; Vulink, Ninke & Kupfer, Jörg (2018). Stigmatisation and body image impairment in dermatological patients: Protocol for an observational multicentre study in 16 European countries. BMJ Open.  ISSN 2044-6055.  8:e024877(12), s 1- 5 . doi: 10.1136/bmjopen-2018-024877
• Dalgard, Florence; Svensson, Åke; Gieler, Uwe; Tómas-Aragonés, Lucía; Lien, Lars; Poot, Françoise; Jemec, Gregor Borut Ernst; Misery, Laurent; Szabó, Csanád; Linder, Dennis; Sampogna, Francesca; Evers, Andrea Walburga Maria; Halvorsen, Jon Anders; Balieva, Flora Nicol; Szepiełöwski, Jacek Cezary; Lvov, Andrey; Marrón, Servando E.; Alturnay, I.K.; Finlay, Andrew Yule; Salek, Sam S. & Kupfer, Jörg (2018). Dermatologists across Europe underestimate depression and anxiety: results from 3635 dermatological consultations. British Journal of Dermatology.  ISSN 0007-0963.  179(2), s 464- 470 . doi: 10.1111/bjd.16250
• Khalifa, Dina Mohammed Sami; Glavin, Kari; Bjertness, Espen & Lien, Lars (2018). Course of depression symptoms between 3 and 8 months after delivery using two screening tools (EPDS and HSCL-10) on a sample of Sudanese women in Khartoum state. BMC Pregnancy and Childbirth.  ISSN 1471-2393.  18(324) . doi: 10.1186/s12884-018-1948-1 Full text in Research Archive. Show summary

  Background Effects of depression on parenting and on cognitive development of newborns are augmented when symptoms continue throughout the first postnatal year. Current classification systems recognize maternal depression as postnatal if symptoms commence within four to six weeks. Traditional cultural rituals in Sudan offer new mothers adequate family support in the first 6–8 weeks postpartum. The course of postnatal depression symptoms beyond that period is not explored in such settings. We therefore aim to investigate the change in screening status and in severity of depression and distress symptoms between three and eight months postpartum among a sample of Sudanese women using the Edinburgh Postnatal Depression Scale (EPDS) and a locally used tool: the 10-items Hopkins Symptoms Checklist (HSCL-10). Methods Three hundred pregnant women in their 2nd or 3rd trimester were recruited from two clinics in Khartoum state. They were followed up and screened for depression symptoms eight months after delivery by EPDS at ≥12, and by HSCL-10 at ≥1.85. The same sample was previously screened for depression at three months after birth. Results Prevalence of postnatal depression symptoms by EPDS was lower at eight months compared to three months after birth (3.6% at eight months (8/223) compared to 9.2% at three months (22/238), p <  0.001). Eight Mothers exhibited depression symptoms eight months after birth. Depressed mothers at three months had a 56% reduction in EPDS mean scores by eight months and 96.4% of participants either remained in the same EPDS category, or improved eight months after birth. Four participants with major depression symptoms at eight months were also depressed three months after birth and four participants had new onset depression symptoms. The HSCL-10 measured higher distress than EPDS across the two screening points (19.3% at three months, 9.1% at eight months postpartum, p <  0.001). Nonetheless, the two tests correlated positively at both points. Conclusions Repeated screenings by EPDS (depression surveillance) is recommended during the first postnatal year because a subset of mothers can have symptoms beyond the early postnatal period. Existing depression screening instruments can be assessed for their validity to detect PND.

• Marrón, Servando E.; Tómas-Aragonés, Lucía; Navarro-Lopez, Jorge; Gieler, Uwe; Kupfer, Jörg; Dalgard, Florence; Lien, Lars; Finlay, Andrew Y.; Poot, Françoise; Linder, Dennis; Szepietöwski, Jacek C.; Misery, Laurent; Jemec, Gregor B.E.; Romanov, Dmitry; Sampogna, Francesca; Szabó, Csanád; Altunay, Ilknur K.; Spillekom-van Koulil, Saskia; Balieva, Flora Nicol; Ali, Faraz M.; Halvorsen, Jon Anders & Marijuan, Pedro C. (2018). The psychosocial burden of hand eczema: Data from a European dermatological multicentre study. Contact Dermatitis.  ISSN 0105-1873.  78(6), s 406- 412 . doi: 10.1111/cod.12973
• Martinez, Priscilla; Lien, Lars; Zemore, Sarah E.; Bramness, Jørgen Gustav & Neupane, Sudan Prasad (2018). Circulating cytokine levels are associated with symptoms of depression and anxiety among people with alcohol and drug use disorders. Journal of Neuroimmunology.  ISSN 0165-5728.  318, s 80- 86 . doi: 10.1016/j.jneuroim.2018.02.011
• Pedersen, Monica Stolt; Landheim, Anne; Møller, Merete & Lien, Lars (2018). Acting on audit & feedback: a qualitative instrumental case study in mental health services in Norway. BMC Health Services Research.  ISSN 1472-6963.  18(71) . doi: 10.1186/s12913-018-2862-y Full text in Research Archive. Show summary

  Background The National Guideline for Assessment, Treatment and Social Rehabilitation of Persons with Concurrent Substance Use and Mental Health Disorders, launched in 2012, is to be implemented in mental health services in Norway. Audit and feedback (A&F) is commonly used as the starting point of an implementation process. It aims to measure the research-practice gap, but its effect varies greatly. Less is known of how audit and feedback is used in natural settings. The aim of this study was to describe and investigate what is discussed and thematised when Quality Improvement (QI) teams in a District Psychiatric Centre (DPC) work to complete an action form as part of an A&F cycle in 2014. Methods This was an instrumental multiple case study involving four units in a DPC in Norway. We used open non-participant observation of QI team meetings in their natural setting, a total of seven teams and eleven meetings. Results The discussions provided health professionals with insight into their own and their colleagues’ practices. They revealed insufficient knowledge of substance-related disorders and experienced unclear role expectations. We found differences in how professional groups sought answers to questions of clinical practice and that they were concerned about whether new tasks fitted in with their routine ways of working. Conclusion Acting on A&F provided an opportunity to discuss practice in general, enhancing awareness of good practice. There was a general need for arenas to relate to practice and QI team meetings after A&F may well be a suitable arena for this. Self-assessment audits seem valuable, particular in areas where no benchmarked data exists, and there is a demand for implementation of new guidelines that might change routines and develop new roles. QI teams could benefit from having a unit leader present at meetings. Nurses and social educators and others turn to psychiatrists or psychologists for answers to clinical and organisational questions beyond guidelines, and show less confidence or routine in seeking research-based information. There is a general need to emphasise training in evidence-based practice and information seeking behaviour for all professional groups

• Pedersen, Monica Stolt; Landheim, Anne; Møller, Merete & Lien, Lars (2018). Audit and feedback in mental healthcare: staff experiences. International Journal of Health Care Quality Assurance.  ISSN 0952-6862.  31(7), s 822- 833 . doi: 10.1108/IJHCQA-08-2017-0142 Full text in Research Archive. Show summary

  Purpose Audit and feedback (A&F) often underlie implementation projects, described as a circular process; i.e. an A&F cycle. They are widely used, but effect varies with no apparent explanation. We need to understand how A&F work in real-life situations. The purpose of this paper, therefore, is to describe and explore mental healthcare full A&F cycle experiences. Design/methodology/approach This is a naturalistic qualitative study that uses four focus groups and qualitative content analysis. Findings Staff accepted the initial A&F stages, perceiving it to enhance awareness and reassure them about good practice. They were willing to participate in the full cycle and implement changes, but experienced poor follow-up and prioritization, not giving them a chance to own to the process. An important finding is the need for an A&F cycle facilitator. Practical implications Research teams cannot be expected to be involved in implementing clinical care. Guidelines will keep being produced to improve service quality and will be expected to be practiced. This study gives insights into planning and tailoring A&F cycles. Originality/value Tools to ease implementation are not enough, and the key seems to lie with facilitating a process using A&F. This study underscores leadership, designated responsibility and facilitation throughout a full audit cycle.

• Schut, Christina; Dalgard, Florence; Halvorsen, Jon Anders; Gieler, Uwe; Lien, Lars; Aragones, Lucia Tomas; Poot, Francoise; Jemec, Gregor B.E.; Misery, Laurent; Kemény, Lajos; Sampogna, Francesca; van Middendorp, Henriët; Balieva, Flora Nicol; Linder, Dennis; Szepietöwski, Jacek C.; Lvov, Andrey; Marrón, Servando E.; Altunay, Ilknur K.; Finlay, Andrew Y.; Salek, Sam & Kupfer, Jörg (2018). Occurrence, chronicity and intensity of itch in a clinical consecutive sample of patients with skin diseases: A multi-centre study in 13 european countries. Acta Dermato-Venereologica.  ISSN 0001-5555.  99(2), s 146- 151 . doi: 10.2340/00015555-3040
• Silwal, Sanju; Dybdahl, Ragnhild; Chudal, Roshan; Sourander, Andre & Lien, Lars (2018). Psychiatric symptoms experienced by adolescents in Nepal following the 2015 earthquakes. Journal of Affective Disorders.  ISSN 0165-0327.  234, s 239- 246 . doi: 10.1016/j.jad.2018.03.002 Show summary

  Background In 2015, Nepal was hit by two major earthquakes, which caused 8900 deaths and displaced more than 450,000 people. We assessed the prevalence of post-traumatic stress symptoms (PTSS) and depressive symptoms and explored potential risk factors among adolescents. Methods This cross-sectional study comprised 893 students aged 11–17 in school grades 7–10. They lived in two districts affected by the earthquakes: Sindhupalchok and Kathmandu. Psychiatric symptoms were assessed using Child PTSD symptom scale and Depression Self-Rating Scale. Multiple logistic regression analysis examined the associations between demographic, earthquake-related factors and psychiatric symptoms. Results The prevalence of PTSS in the Sindhupalchok and Kathmandu districts were 39.5% and 10.7%, and depression symptoms were 40.4% and 23.2% respectively. The moderating effect of gender on the relationship between age and PTSS was significant. In the multivariate logistic analyses, the factors associated with PTSS and depression were: being female, prior exposure to trauma and being directly affected by the earthquakes. Limitations Due to the lack of pre-earthquake prevalence rates, our estimates may have been due to chronic long-lasting problems of poverty and lack of access to physical and mental health services. The use of self-reported questionnaires might have overestimated the prevalence rates compared to psychiatric interviews. Conclusions One year after the earthquakes, adolescents living in Sindhupalchok had a higher prevalence of PTSS and depressive symptoms than those living in Kathmandu. Socio-economic and earthquake-related factors were associated with psychiatric outcomes. The findings indicate the need for early psychosocial interventions, prevention and future research after emergency relief

• Søberg, Ane Inger Bondahl; Haug, Sigrid Helene Kjørven; Danbolt, Lars Johan; Lien, Lars & Sørensen, Torgeir (2018). Existential themes in the treatment of people at suicide risk. Understandings and practices of specialist healthcare professionals. Mental Health, Religion & Culture.  ISSN 1367-4676.  21(6), s 588- 600 . doi: 10.1080/13674676.2018.1524860 Show summary

  This qualitative study focuses on the ways in which existential themes were understood and addressed in therapeutic relationships with patients who had attempted suicide. Health care professionals (HCP) from Norway specialist healthcare participated in focus groups. The interviews were transcribed and analysed by systematic text-condensation through a four-step procedure. We found that the HCPs emphasised the context-specific functions of their departments. They considered these conversations essential but demanding. They indicated existential themes of hope/hopelessness, loneliness, meaning, life/death, shame, religion and suicide. The HCPs’ understandings of themes deemed to be existential and how they should be addressed were primarily based on clinical experience. This appeared to exacerbate the pressure on their personal involvement, leading to the question of whether patients’ existential needs are tackled or instead disappear into a conversational vacuum. The study suggests that HCPs' professional competence of existential themes pertaining to patients at suicide risk needs to be strengthened.

• Sørensen, Torgeir; la Cour, Peter; Danbolt, Lars Johan; Stifoss-Hanssen, Hans; Lien, Lars; deMarinis, Valerie; Pedersen, Heidi Frølund & Schnell, Tatjana (2018). The Sources of Meaning and Meaning in Life Questionnaire in the Norwegian Context: Relations to Mental Health, Quality of Life, and Self-Efficacy. The international journal for the psychology of religion.  ISSN 1050-8619.  s 32- 45 . doi: 10.1080/10508619.2018.1547614
• Toft, Helge Prytz; Bramness, Jørgen Gustav; Lien, Lars; Abebe, Dawit Shawel; Wampold, Bruce E.; Tilden, Terje; Hestad, Knut & Neupane, Sudan Prasad (2018). PTSD patients show increasing cytokine levels during treatment despite reduced psychological distress.. Neuropsychiatric Disease and Treatment.  ISSN 1176-6328.  14, s 2367- 2378 . doi: 10.2147/NDT.S173659 Full text in Research Archive. Show summary

  Background: A reciprocal relationship between activated innate immune system and changes in mood and behavior has been established. There is still a paucity of knowledge on how the immune system responds during psychiatric treatment. We aimed to explore circulating cytokines and assess psychiatric symptom severity scores during 12 weeks of inpatient psychiatric treatment. Methods: The study was a longitudinal assessment of 124 patients (88 women and 36 men) in treatment at Modum Psychiatric Center, Norway. The patient sample comprised a mixed psychiatric population of whom 39 were diagnosed with posttraumatic stress disorder (PTSD). Serum blood samples for cytokine analysis and measures of mental distress using Global Severity Index were collected at admission (T0), halfway (T1), and before discharge (T2). Other factors assessed were age, gender, and the use of antidepressants and anti-inflammatory drugs. Multilevel modeling was used for longitudinal analyses to assess the repeated cytokine samples within each patient. Results: Overall level of IL-1RA was higher in PTSD patients when compared to those without PTSD (P=0.021). The level of IL-1β, MCP-1, and TNF-α increased over time in PTSD compared to non-PTSD patients (P=0.025, P=0.011 and P=0.008, respectively). All patients experienced reduced mental distress as measured by self-reported Global Severity Index scores. Stratified analysis showed that PTSD patients who used anti-inflammatory drugs had higher levels of IL-1β (P=0.007) and TNF-α (P=0.049) than PTSD patients who did not use such drugs. Conclusion: The study indicates that traumatized patients may have a distinct neuroimmune development during recovery. Their activated immune system shows even further activation during their rehabilitation despite symptom reduction.

• Toft, Helge Prytz; Neupane, Sudan Prasad; Bramness, Jørgen Gustav; Tilden, Terje; Wampold, Bruce E. & Lien, Lars (2018). The effect of trauma and alcohol on the relationship between level of cytokines and depression among patients entering psychiatric treatment. BMC Psychiatry.  ISSN 1471-244X.  18(95) . doi: 10.1186/s12888-018-1677-z Full text in Research Archive. Show summary

  Background Depression is associated with immunological responses as reflected by altered levels of circulating cytokines. Alcohol use and trauma may modulate immune activity, and few studies have investigated these factors in depressed patients. We aimed to explore the association between circulating peripheral cytokine levels and degree of depressive symptoms, taking trauma and alcohol into account. Methods The study was a cross-sectional assessment of patients at admission to a specialized psychiatric center in Norway. A total of 128 patients were included. Information was gathered using the self-administered questionnaires Beck Depression Inventory-II (BDI-II) and the Alcohol Use Disorders Identification Test (AUDIT), in addition to clinical interviews recording childhood or adult life trauma. Serum levels of the cytokines Interleukin-1β (IL-1β), Interleukin-1 Receptor Antagonist (IL-1RA), Tumor Necrosis Factor-α (TNF-α) and the chemokine Monocyte Chemoattractant Protein-1 (MCP-1) were assessed. A Luminex bead-based multiplex assay was used for cytokine measurements. Patient cytokine levels were compared to those of healthy volunteers by the Mann-Whitney U test. Results Levels of cytokines did not differ across patients with mild, moderate and severe depression. AUDIT score was not related to cytokine levels, but to level of depression. A history of trauma was related to higher levels of IL-1RA and TNF-α (p = 0.048 and p = 0.033, respectively), especially among the severely depressed. Serum levels of MCP-1 and TNF-α were significantly higher among psychiatric patients than in healthy volunteers. Conclusions Findings indicate that depression was not related to levels of circulating cytokines among patients in treatment, but that traumatized patients had higher levels of IL-1RA and TNF-α than patients without trauma experience. The lack of relationship between cytokine level and depression was evident both in those without and with trauma.

• Abebe, Dawit Shawel; Lien, Lars & Elstad, Jon Ivar (2017). Immigrants’ utilization of specialist mental healthcare according to age, country of origin, and migration history: a nation-wide register study in Norway. Social Psychiatry and Psychiatric Epidemiology.  ISSN 0933-7954.  s 1- 9 . doi: 10.1007/s00127-017-1381-1 Full text in Research Archive. Show summary

  Purpose As the immigrant population rises in Norway, it becomes ever more important to consider the responsiveness of health services to the specific needs of these immigrants. It has been questioned whether access to mental healthcare is adequate among all groups of immigrants. This study aims to examine the use of specialist mental healthcare services among ethnic Norwegians and specific immigrants groups. Methods Register data were used from the Norwegian Patient Registry and Statistics Norway. The sample (age 0–59) consisted of 3.3 million ethnic Norwegians and 200,000 immigrants from 11 countries. Poisson regression models were applied to examine variations in the use of specialist mental healthcare during 2008–2011 according to country of origin, age group, reason for immigration, and length of stay. Results Immigrant children and adolescents had overall significantly lower use of specialist mental healthcare than ethnic Norwegians of the same age. A distinct exception was the high utilization rate among children and youth from Iran. Among adult immigrants, utilization rates were generally lower than among ethnic Norwegians, particularly those from Poland, Somalia, Sri Lanka, and Vietnam. Adult immigrants from Iraq and Iran, however, had high utilization rates. Refugees had high utilization rates of specialist mental healthcare, while labour immigrants had low use. Conclusion Utilization rates of specialist mental healthcare are lower among immigrants than Norwegians. Immigrants from Poland, Somalia, Sri Lanka, and Vietnam, had generally quite low rates, while immigrants from Iran had high utilization rates. The findings suggest that specialist mental healthcare in Norway is underutilized among considerable parts of the immigrant population

• Brekke, Eva; Lien, Lars & Biong, Stian (2017). Experiences of Professional Helping Relations by Persons with Co-occurring Mental Health and Substance Use Disorders. International Journal of Mental Health and Addiction.  ISSN 1557-1874.  16(1), s 53- 65 . doi: 10.1007/s11469-017-9780-9 Full text in Research Archive. Show summary

  Recovery in co-occurring mental health and substance use disorders often involves relationships with professional helpers, yet little is known about how these are experienced by service users. The aim of this study was to explore and describe behaviour and attributes of professional helpers that support recovery, as experienced by persons with co-occurring disorders. Within a collaborative approach, in-depth individual interviews with eight persons with lived experience of co-occurring disorders were analysed using systematic text condensation. The analysis yielded four categories of recovery-supporting behaviour and attributes of professional helpers and the ability to build trust cuts across all of them: Building trust through (a) hopefulness and loving concern, (b) commitment, (c) direct honesty and expectation and (d) action and courage. Services should allow for flexibility and continuity, and training should recognise the importance of establishing trust in order to reach out to this group.

• Brekke, Eva; Lien, Lars; Davidson, Larry & Biong, Stian (2017). First-person experiences of recovery in co-occurring mental health and substance use conditions. Advances in Dual Diagnosis: Policy, practice and research in mental health and substance use.  ISSN 1757-0972.  10(1), s 13- 24 . doi: 10.1108/ADD-07-2016-0015 Full text in Research Archive. Show summary

  Purpose The purpose of this paper is to explore and describe experiences of recovery among people with co-occurring mental health and substance use conditions (co-occurring conditions) in a rural community in Norway. Design/methodology/approach In-depth individual interviews with eight persons with co-occurring conditions were conducted, audiotaped, transcribed and analysed using a phenomenological approach. This study is part of a research project investigating recovery orientation of services in a Norwegian district. Findings The analysis yielded four dimensions of recovery: feeling useful and accepted; coming to love oneself; mastering life; and emerging as a person. Insecure and inadequate housing and limited solutions to financial problems were described as major obstacles to recovery. Research limitations/implications Further research into the facilitation of recovery as defined by persons with concurrent disorders is needed, particularly regarding the facilitation of community participation. Practical implications This study supports an increased focus on societal and community factors in promoting recovery for persons with co-occurring conditions, as well as service designs that allow for an integration of social services and health care, and for collaboration among services. Social implications The results suggest that the community can aid recovery by accepting persons with co-occurring conditions as fellow citizens and welcoming their contributions. Originality/value The paper provides an enhanced understanding of how persons with co-occurring conditions may experience recovery.

• Hanevik, Hilde; Hestad, Knut; Lien, Lars; Joa, Inge; Larsen, Tor Ketil & Danbolt, Lars Johan (2017). Religiousness in First-Episode Psychosis. Archive for the Psychology of Religion/ Archiv für Religionspsychologie.  ISSN 0084-6724.  39(2), s 139- 164 . doi: 10.1163/15736121-12341336 Show summary

  The aim of the present study is to explore the significance of religiousness for patients suffering from first-episode psychosis. Our study is a thematic analysis. The study illustrates how the patients understood their hallucinations as mystical experiences. Even so, many of the patients describe their religiousness to be helpful in coping with their disorder, giving meaning to life as well as a relationship to a sacred figure. However, their religiousness often contained religious omnipotent delusions, and built on hallucinations, displayed an unsecure relationship to the sacred figure. From a psychiatric point of view, the misinterpretation of hallucinations as mystical experiences may reinforce their delusional system and cause an obstacle to recovery. This misinterpretation may also cause problems for patients’ religious coping. Our findings underline the importance of taking patients’ religiousness into account in psychotherapy.

• Lesner, Karolina; Reich, Adam; Szepietowski, Jacek C.; Dalgard, Florence; Gieler, Uwe; Tomasaragones, Lucia; Lien, Lars; Poot, Francoise; Jemec, Gregor B.; Misery, Laurent; Szabó, Csanád; Linder, Dennis; Sampogna, Francesca; Evers, Andrea W.M.; Halvorsen, Jon Anders; Balieva, Flora Nicol; Lvov, Andrey; Marrón, Servando E.; Altunay, Ilknur K.; Finlay, Andrew Y.; Salek, Sam S. & Kupfer, Jörg (2017). Determinants of psychosocial health in psoriatic patients: A multinational study. Acta Dermato-Venereologica.  ISSN 0001-5555.  97(10), s 1182- 1188 . doi: 10.2340/00015555-2760 Full text in Research Archive. Show summary

  There are limited data on the differences in the impact of psoriasis between various countries with respect to quality of life (QoL). The aim of this study was to explore the psychosocial health of patients with psoriasis in different European countries. A total of 682 patients were recruited in 13 European countries. All patients completed a questionnaire regarding sociodemographic information, negative life events, suicidal ideation and satisfaction with their dermatologist. Depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS), and QoL with the Dermatology Life Quality Index (DLQI) and EuroQoL (EQ-5D). The lowest anxiety and depression scoring was noted in patients from Denmark, the lowest level of impairment in QoL in subjects from Spain, and the highest level of impairment in QoL in patients from Italy. The most relevant parameters influencing patients’ well-being were severity of pruritus and satisfaction with their dermatologist. The level of anxiety and depression symptoms correlated significantly with suicidal ideation.

• Neupane, Sudan Prasad; Bramness, Jørgen Gustav & Lien, Lars (2017). Comorbid post-traumatic stress disorder in alcohol use disorder: relationships to demography, drinking and neuroimmune profile. BMC Psychiatry.  ISSN 1471-244X.  17(312), s 1- 10 . doi: 10.1186/s12888-017-1479-8 Full text in Research Archive. Show summary

  BACKGROUND: This study examined how alcohol use disorder (AUD) patients with post-traumatic stress disorder (PTSD) differed from those without PTSD in terms of demography, drinking patterns and C-reactive protein, inflammatory cytokines, tryptophan metabolism parameters, and brain-derived neurotrophic factor (BDNF). METHODS: A consecutive sample (N = 187) of treatment-receiving AUD individuals were recruited from Nepalese facilities. They underwent fully structured psychiatric interviews. Serum levels of inflammatory cytokines [interleukin (IL)-6, IL-1 Receptor antagonist (IL-1Ra), IL-10, tumor necrosis factor-alpha (TNF-α), and interferon-gamma (IFN-γ)] were determined by a multiplex assay, kynurenine and tryptophan levels by high-performance liquid chromatography, and BDNF by enzyme-linked immunosorbent assay (ELISA). RESULTS: The prevalence of exposure to severe trauma and PTSD was 74% and 17%, respectively. PTSD comorbidity was not associated with age, gender, or socioeconomic status, but with co-occurring major depression, history of attempted suicide, earlier peak of drinking problems, higher drinking quantity and withdrawal symptoms, experiencing alcoholic blackouts, and drinking problems among parents. None of the assessed neuroimmune parameters was related to comorbid PTSD. CONCLUSIONS: The findings support routine trauma screening in AUD treatment samples and screening for risky drinking in trauma populations to help guide interventions. The expected aberrations in neuroimmune functioning may not be found when examined in a sample with multiple psychiatric morbidities

• Sampogna, Francesca; Abeni, Damiano; Gieler, Uwe; Tomas-Aragones, Lucia; Lien, Lars; Titeca, Geraldine; Jemec, Gregor B.E.; Misery, Laurent; Szabo, Csanad; Linder, Dennis; Evers, Andrea W M; Halvorsen, Jon Anders; Balieva, Flora Nicolaeva; Szepietowski, Jacek C.; Romanov, Dmitry; Marron, Servando E; Altunay, Ilknur K; Finlay, Andrew Y.; Salek, Sam S; Kupfer, Jörg & Dalgard, Florence J (2017). Impairment of Sexual Life in 3,485 Dermatological Outpatients From a Multicentre Study in 13 European Countries. Acta Dermato-Venereologica.  ISSN 0001-5555.  97(4), s 478- 482 . doi: 10.2340/00015555-2561 Full text in Research Archive. Show summary

  Skin conditions may have a strong impact on patients’ sexual life, and thus influence personal relationships. Sexual issues are difficult to discuss directly in clinical practice, and a mediated instrument may be useful to capture such information. In this study item 9 of the Dermatology Life Quality Index was used to collect information on sexual impact of several skin conditions in 13 European countries. Among 3,485 patients, 23.1% reported sexual problems. The impairment was particularly high in patients with hidradenitis suppurativa, prurigo, blistering disorders, psoriasis, urticaria, eczema, infections of the skin, or pruritus. Sexual impact was strongly associated with depression, anxiety, and suicidal ideation. It was generally more frequent in younger patients and was positively correlated with clinical severity and itch. It is important to address the issue of sexual well-being in the evaluation of patients with skin conditions, since it is often linked to anxiety, depression, and even suicidal ideation.

• Szabo, Csanad; Altmayer, Anita; Lien, Lars; Poot, Francoise; Gieler, Uwe; Tómas-Aragonés, Lucía; Kupfer, Jörg; Jemec, Gregor B E; Misery, Laurent; Linder, Dennis; Sampogna, Francesca; Van Middendorp, Henriet; Halvorsen, Jon Anders; Balieva, Flora Nicol; Szepietowski, Jacek C.; Romanov, Dmitry; Marrón, Servando E.; Altunay, Ilknur K; Finlay, Andrew Y.; Salek, Sam S & Dalgard, Florence (2017). Attachment styles of dermatological patients in europe: A multicentre study in 13 countries. Acta Dermato-Venereologica.  ISSN 0001-5555.  97(7), s 813- 818 . doi: 10.2340/00015555-2619 Full text in Research Archive.
• Ayazi, Touraj; Swartz, Leslie; Eide, Arne Henning; Lien, Lars & Hauff, Edvard (2016). Psychotic-like experiences in a conflict-affected population: a cross-sectional study in South Sudan. Social Psychiatry and Psychiatric Epidemiology.  ISSN 0933-7954.  51(7), s 971- 979 . doi: 10.1007/s00127-016-1243-2 Show summary

  Purpose This study investigates the prevalence of psychotic- like experiences (PLEs) and examines exposure to potentially traumatic events and other relevant risk factors for PLEs in the general population of a conflict-affected, low-income country. Methods We conducted a cross-sectional community based study of four Greater Bahr el Ghazal States, South Sudan (n = 1200). The Harvard Trauma Questionnaire was applied to investigate exposure to potentially traumatic events. The Mini-International Neuropsychiatric Interview was used to detect PLEs. Results The estimated prevalence of lifetime PLEs was 23.3 % and the rate of PLEs which were evaluated as bizarre was 9.5 %. Exposure to higher number of potentially traumatic events, younger age, rural residency, being unemployed, not having a regular income and having traditional religion were significantly associated with having PLEs. PLEs were significantly associated with reporting of psychological distress when controlling for other covariates. Conclusions The finding of association between traumatic exposure and PLEs calls for greater attention to the diversity of negative mental health outcomes in conflictaffected populations.

• Balieva, Flora Nicolaeva; Kupfer, Jörg; Lien, Lars; Gieler, U; Finlay, AY; Tomas-Aragones, Lucia; Poot, Francoise; Misery, Laurent; Sampogna, Francesca; van Middendorp, H; Halvorsen, Jon Anders; Szepietowski, Jacek C.; Lvov, A; Marron, Servando E; Salek, M. S. & Dalgard, Florence (2016). The burden of common skin diseases assessed with the EQ5D™: a European multicentre study in 13 countries. British Journal of Dermatology.  ISSN 0007-0963.  176(5), s 1170- 1178 . doi: 10.1111/bjd.15280 Show summary

  Background Generic instruments measuring health related quality of life (HRQoL), like EQ5D, enable comparison of skin diseases with healthy populations and non-dermatological medical conditions, as well as calculation of utility data. Objectives The aims were to measure HRQoL in patients with common skin diseases and healthy controls across Europe using the EQ5D. Methods This multi-center observational cross-sectional study was conducted in 13 European countries. Each dermatology clinic recruited at least 250 consecutive adult outpatients to complete questionnaires, including the EQ5D. Results There were 5369 participants, 4010 patients and 1359 controls. Mean self-rated health state reported by patients was 69.9 (SD 19.7), controls 82.2 (SD 15.5). When adjusted for confounding factors, including comorbidity, mean patient EQ-VAS scores were 10.5 points lower than for controls (standardized β = −0.23). Odds ratio with 95% confidence interval for impairment in all 5 dimensions of EQ5D adjusted for confounders was doubled for patients compared with controls. Patients with hidradenitis suppurativa (HS), blistering conditions, leg ulcers, psoriasis and eczemas had the highest risk for reduction in HRQoL in most dimensions (two-tenfold). Data on differences of impairment by dimensions offer new insights. Conclusions This study confirms the large impact skin conditions have on patients’ wellbeing, differentiating between aspects of HRQoL. Patients with HS, blistering diseases, leg ulcers, infections and most chronic skin diseases reported reduced HRQoL comparable to patients with chronic obstructive lung disease, diabetes mellitus, cardio-vascular disease and cancers. These findings are important in the prioritization of resource allocation between medical fields and within dermatological sub-specialities.

• Balieva, Flora Nicolaeva; Lien, Lars; Kupfer, Jörg; Halvorsen, Jon Anders & Dalgard, Florence (2016). Are Common Skin Diseases among Norwegian Dermatological Outpatients Associated with Psychological Problems Compared with Controls? An Observational Study. Acta Dermato-Venereologica.  ISSN 0001-5555.  96(2), s 227- 231 . doi: 10.2340/00015555-2200 Show summary

  Dermatological disease has been shown to be associated with psychological comorbidity. The aim of this observational study is to describe the distribution of skin disease and the prevalence of depression, anxiety and stress among Norwegian dermatological outpatients. Thirteen percent of outpatients had clinical anxiety compared with 3.7% of healthy controls, and 5.8% had clinical depression compared with 0.9% of controls. Adjusted odds ratio for clinical anxiety was 4.53 in patients compared with controls, and for clinical depression 6.25, which is much higher than previously described in a larger European study. Patients with tumours had less depression. Chronic inflammatory skin conditions had an especially high impact on patient’s psychological wellbeing and should not be undervalued relative to, for instance, skin cancer in health strategies. These results argue strongly for including skin disease prevention and treatment in future health strategies. Key words: depression; anxiety; psychiatric comorbidity; distribution of dermatological disease; skin cancer; chronic skin diseases.

• Hagen, Christina; Lien, Lars; Hauff, Edvard & Heir, Trond (2016). Is mindfulness protective against PTSD? A neurocognitive study of 25 Tsunami disaster survivors. Journal of Negative Results in Biomedicine.  ISSN 1477-5751.  15(1) . doi: 10.1186/s12952-016-0056-x Show summary

  Background: It has been suggested that mindfulness is a protective factor that buffers individuals from experiencing severe posttraumatic stress following exposure to a trauma. We aimed to examine the association between dispositional (trait) mindfulness and posttraumatic stress in individuals who had been exposed to the trauma of a natural disaster. Method: A disaster group (n = 25) consisting of Norwegian tourists who survived the 2004 South East Asian tsunami at a location with high mortality rates was recruited. Dispositional mindfulness and posttraumatic stress were measured with the Five-Facet Mindfulness Questionnaire and the Impact of Event Scale-Revised Version, respectively. Results: There was no significant association between mindfulness and posttraumatic stress. Moreover, there were no significant associations between posttraumatic stress and the mindfulness sub-facets of observing, acting with awareness, non-judging, and non-reacting. However, there was a significant positive correlation between the descriptive factor of mindfulness and IES-R total. There were no significant linear correlations between the five sub-facets of mindfulness and the three categories of posttraumatic symptoms, intrusion, avoidance and hyper-arousal. Conclusions: Our findings do not indicate a relationship between dispositional mindfulness and posttraumatic stress levels after exposure to a trauma, except for the descriptive sub-facet of mindfulness and here the correlation is positive and not negative as would be expected if mindfulness is a protective factor for posttraumatic stress. Future studies should investigate the relationship between mindfulness and posttraumatic stress while accounting for factors such as trauma history, type of trauma, and individual differences in traumatic stress reactions.

• Hagen, Christina; Lien, Lars; Hauff, Edvard & Heir, Trond (2016). Mindfulness, Sustained Attention and Post-traumatic Stress in Tsunami Survivors. PSYCHOLOGY AND COGNITIVE SCIENCES.  ISSN 2380-727X.  2(2), s 54- 63 . doi: 10.17140/PCSOJ-2-115
• Jaradat, Yousef; Nijem, Khaldoun; Lien, Lars; Stigum, Hein; Bjertness, Espen & Bast-Pettersen, Rita (2016). Psychosomatic symptoms and stressful working conditions among Palestinian nurses: a cross-sectional study. Contemporary Nurse: health care across the lifespan.  ISSN 1037-6178.  52(4), s 381- 397 . doi: 10.1080/10376178.2016.1188018 Show summary

  Background: High levels of perceived stressful working conditions have been found to have an adverse effect on physical and mental health. Objectives: To examine the associations between self-reported stressful working conditions and Psychosomatic Symptoms (PSS), and to investigate possible gender differences. Methods: The present cross-sectional study comprises 430 nurses employed in Hebron district, Palestine. Self-reported stressful working conditions were recorded, and a Psychosomatic Symptoms Check list was used to assess prevalence of PSS. Findings: Median score on the psychosomatic symptom checklist for the group was 11, (range 1–21). Women reported more symptoms than men, with medians 11.6 and 10.0, respectively (p = .0001). PSS were associated with more self-reported stressful working conditions for both men (p < .0001) and women (p < .0001). The association was strongest among men. Conclusions: PSS were associated with high self-reported stressful working conditions, and this association was strongest among the men

• Khalifa, Dina Mohammed Sami; Glavin, Kari; Bjertness, Espen & Lien, Lars (2016). Determinants of postnatal depression in Sudanese women at 3 months postpartum: A cross-sectional study. BMJ Open.  ISSN 2044-6055.  6(3) . doi: 10.1136/bmjopen-2015-009443 Full text in Research Archive. Show summary

  Objectives: Maternal mental health is a neglected issue in Sudanese healthcare. The aim of this study was to explore the factors associated with postnatal depression (PND) at 3 months postpartum in a sample of Sudanese women in Khartoum state. Setting: Recruitment was from two major public antenatal care (ANC) clinics in two maternity teaching hospitals in Khartoum state. The study participants were recruited during their pregnancy and were followed up and screened for PND at 3 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Participants: A sample of 300 pregnant Sudanese women in their second or third trimester was included in the study. The inclusion criteria were Sudanese nationality, pregnancy in the second or third trimester and satisfactory contact information. Outcome measures: PND was assessed using the EPDS at a cut-off score of ≥12. Maternal and sociodemographic factors of interest were illustrated in a directed acyclic graph (DAG) to identify which variables to adjust for in multivariate analyses and to show their type of effect on PND. A forward logistic regression model was built to assess the factors that are independently associated with PND. Results: History of violence increased the odds of PND sevenfold, OR=7.4 (95% CI 1.9 to 27.6). Older age of mothers decreased the odds of PND by almost 20%, OR=0.82 (95% CI 0.73 to 0.92). Exclusive breast feeding and regular prenatal vitamins during pregnancy are associated with an 80% decrease in odds of PND, OR=0.2 (95% CI 0.06 to 0.70) and 0.17 (95% CI 0.06 to 0.5), respectively. Conclusions: Factors associated with PND in this study are comparable to factors from other developing countries, although findings should be judged with caution owing to the high number of women who refused recruitment into the study.

• Lien, Lars (2016). Smoking, Mental Health and Addiction: A Review of the Literature.. Journal of addiction and preventive medicine.  ISSN 2474-5049.  1(1)(105)
• Lien, Lars; Hauff, Edvard; Martinez, Priscilla; Eide, Arne Henning; Swarts, Leslie & Ayazi, Touraj (2016). Alcohol use in South Sudan in relation to social factors, mental distress and traumatic events. BMC Public Health.  ISSN 1471-2458.  16(937) . doi: 10.1186/s12889-016-3605-9 Full text in Research Archive. Show summary

  Background Alcohol use is a major public health problem with vast implications for poor, war-torn countries. The objective of this study was to describe prevalence of alcohol use and risky drinking across socio-demographic factors in South Sudan, and to determine the association between risky drinking, traumatic events and mental distress. Methods This is a randomized, population based, cross-sectional study from the north-western part of South Sudan with nearly 500 participants. We used the Alcohol Use Disorders Identification Test (AUDIT) as main outcome variable, the General Health Questionnaire (GHQ-28) for mental distress and five questions to assess traumatic events. Results The mean AUDIT score was 2.7 (SD 0.3) with 14,2 % in the high risk problem drinking category. Being male, lack of a regular income and psychological distress were significantly associated with higher AUDIT score. Traumatic events, however, was not associated with higher score on AUDIT. Conclusion Despite decades of civil war and great poverty the alcohol use in this population was at the same level as other countries in Southern Africa. Traumatic events were not related to risk of problem drinking.

• Nilsen, Andre Sevenius; Hilland, Eva; Kogstad, Norunn; Heir, Trond; Hauff, Edvard; Lien, Lars & Endestad, Tor (2016). Right temporal cortical hypertrophy in resilience to trauma: an MRI study. European Journal of Psychotraumatology.  ISSN 2000-8066.  7 . doi: 10.3402/ejpt.v7.31314 Full text in Research Archive. Show summary

  Background: In studies employing physiological measures such as magnetic resonance imaging (MRI), it is often hard to distinguish what constitutes risk-resilience factors to posttraumatic stress disorder (PTSD) following trauma exposure and what the effects of trauma exposure and PTSD are. Objective: We aimed to investigate whether there were observable morphological differences in cortical and sub-cortical regions of the brain, 7–8 years after a single potentially traumatic event. Methods: Twenty-four participants, who all directly experienced the 2004 Indian Ocean Tsunami, and 25 controls, underwent structural MRI using a 3T scanner. We generated cortical thickness maps and parcellated sub-cortical volumes for analysis. Results: We observed greater cortical thickness for the trauma-exposed participants relative to controls, in a right lateralized temporal lobe region including anterior fusiform gyrus, and superior, middle, and inferior temporal gyrus. Conclusions: We observed greater thickness in the right temporal lobe which might indicate that the region could be implicated in resilience to the long-term effects of a traumatic event. We hypothesize this is due to altered emotional semantic memory processing. However, several methodological and confounding issues warrant caution in interpretation of the results.

• Sagatun, Åse; Wentzel-Larsen, Tore; Heyerdahl, Sonja & Lien, Lars (2016). Mental health in adolescence and subsequent receipt of medical benefits in young adulthood: The mediating role of upper secondary school completion. Scandinavian Journal of Public Health.  ISSN 1403-4948.  44(4), s 431- 438 . doi: 10.1177/1403494815622309 Show summary

  Background: Mental health problems in adolescence are associated with impaired function in young adulthood. Our aim was to assess how a hypothetical reduction in mental health problems in adolescence was related to medical benefits in young adulthood and to examine the mediating role of completion of upper secondary school. Methods: We used a population-based sample of more than 10,000 10th-grade adolescents with self-reported data on internalizing and externalizing mental health problems. The sample was linked to the Norwegian national registers of education and medical benefits. The mediation analysis was based on a causal inference framework. Results: During a three-year period in young adulthood, 6.4% of men and 5.9% of women received medical benefits. A two-point hypothetical reduction in externalizing problems was related to a lower probability of receiving medical benefits of 1.5 (95% confidence interval (CI) 1.0–2.1) percentage points in young men and 1.8 (95% CI 1.3–2.3) percentage points in young women. The proportion mediated by the completion of upper secondary school was 52% (95% CI 36–76) among boys and 42% (95% CI 29–60) among girls. The corresponding reduction in the probability of receiving medical benefits was 1.8 percentage points for internalizing problems in both sexes (95% CI boys 1.2–2.4 and girls 1.4–2.2). The proportion mediated was lower for internalizing problems and was only significant among girls (19%). Conclusions: Intervention and prevention strategies targeting internalizing and externalizing problems in adolescents may have the potential to reduce the receipt of medical benefits in young adulthood. The completion of upper secondary school seems to be a mechanism for this association, especially for externalizing problems

• Ayazi, Touraj; Swartz, Leslie; Eide, Arne Henning; Lien, Lars & Hauff, Edvard (2015). Perceived current needs, psychological distress and functional impairment in a war-affected setting: a cross-sectional study in South Sudan. BMJ Open.  ISSN 2044-6055.  5(8) . doi: 10.1136/bmjopen-2014-007534 Show summary

  Objectives To examine the current perceived needs of the general population in a war-affected setting, and to study the influence of perceived needs on the participants’ mental health status and functional impairment across genders. Methods A cross-sectional community survey (n=464) was conducted in war-affected South Sudan. Three regression models were analysed. Perceived needs were assessed with the Humanitarian Emergency Settings Perceived Needs Scale. Psychological distress was measured with the General Health Questionnaire and level of functioning by the Short Form Health Survey (SF-12). Results The most frequently expressed needs were related to drinking water, alcohol and drug use in the community and access to sanitation facilities. No gender differences were found regarding the level of perceived needs or the number of traumatic events. Higher level of perceived needs significantly predicted psychological distress and lower level of functioning even when numbers of experienced trauma events were taken into account. Conclusions The associations of higher level of needs and trauma experiences, on the one hand, and negative health outcomes on the other, necessitate a greater integration of interventions directed towards the population's perceived needs and mental health, particularly for those who have been exposed to trauma.

• Bratlien, Unni; Øie, Merete Glenne; Haug, Elisabeth; Møller, Paul; Andreassen, Ole Andreas; Lien, Lars & Melle, Ingrid (2015). Self-reported symptoms and health service use in adolescence in persons who later develop psychotic disorders: A prospective case-control study. Early Intervention in Psychiatry.  ISSN 1751-7885.  9(3), s 221- 227 . doi: 10.1111/eip.12102 Show summary

  Aim To investigate self-reported psychiatric and somatic symptoms and health service use at age 16 in persons who later developed a psychotic disorder compared with a control group from the same geographical areas. Method Responses concerning psychiatric or somatic health and health service use from Norwegian youth studies in a cohort of 15- and 16-year-olds in three Norwegian counties (N = 11 101, 90% response rate) were gathered. The questionnaire responses from persons later identified with a lifetime diagnosis of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) psychotic disorders (n = 30) (confirmed psychosis, CP) were compared with responses from the rest of the group (population control, PC) (n = 11 067). Follow-up analyses were made for cases with a confirmed onset of a psychotic disorder after the time of the survey (n = 21). Results The main significant differences between the CP and PC groups were more self-reported anxiety, depression and ‘feeling in need of treatment for eating disorders’ at age 16 in the CP group. The rate of self-reported eating disorder symptoms alone reached the level of statistical significance in the follow-up analyses. The CP group did not use available health services to a markedly greater extent than the control group. Conclusion We found that, in comparison with others, youths who were later identified with a psychotic disorder reported more symptoms at age 16.

• Dalgard, Florence; Gieler, Uwe; Tomas-Aragones, Lucia; Lien, Lars; Poot, Francoise; Jemec, Gregor B E; Misery, Laurent; Szabo, Csanad; Linder, Dennis; Sampogna, Francesca; Evers, Andrea W M; Halvorsen, Jon Anders; Balieva, Flora Nicolaeva; Szepietowski, Jacek C.; Romanov, Dmitry; Marron, Servando E; Altunay, Ilknur K; Finlay, Andrew Y.; Salek, Sam S & Kupfer, Jörg (2015). The Psychological Burden of Skin Diseases: A Cross-Sectional Multicenter Study among Dermatological Out-Patients in 13 European Countries. Journal of Investigative Dermatology.  ISSN 0022-202X.  135, s 984- 991 . doi: 10.1038/jid.2014.530 Show summary

  The contribution of psychological disorders to the burden of skin disease has been poorly explored, and this is a large-scale study to ascertain the association between depression, anxiety, and suicidal ideation with various dermatological diagnoses. This international multicenter observational cross-sectional study was conducted in 13 European countries. In each dermatology clinic, 250 consecutive adult out-patients were recruited to complete a questionnaire, reporting socio-demographic information, negative life events, and suicidal ideation; depression and anxiety were assessed with the Hospital Anxiety and Depression Scale. A clinical examination was performed. A control group was recruited among hospital employees. There were 4,994 participants––3,635 patients and 1,359 controls. Clinical depression was present in 10.1% patients (controls 4.3%, odds ratio (OR) 2.40 (1.67–3.47)). Clinical anxiety was present in 17.2% (controls 11.1%, OR 2.18 (1.68–2.82)). Suicidal ideation was reported by 12.7% of all patients (controls 8.3%, OR 1.94 (1.33–2.82)). For individual diagnoses, only patients with psoriasis had significant association with suicidal ideation. The association with depression and anxiety was highest for patients with psoriasis, atopic dermatitis, hand eczema, and leg ulcers. These results identify a major additional burden of skin disease and have important clinical implications.

• Homlong, Lisbeth; Rosvold, Elin Olaug; Bruusgaard, Dag; Lien, Lars; Sagatun, Åse & Haavet, Ole Rikard (2015). A prospective population-based study of health complaints in adolescence and use of social welfare benefits in young adulthood. Scandinavian Journal of Public Health.  ISSN 1403-4948.  43(6), s 629- 637 . doi: 10.1177/1403494815589862 Show summary

  Background: There is a lack of knowledge on how health problems in adolescence are connected to work marginalization in adulthood. The aim of this study was to study work marginalization in young adulthood, measured by use of long-term social welfare benefits, and its associations with self-reported health complaints, total symptom burden and self-rated general health at ages 15–16. Methods: We linked data from a youth health survey conducted during 1999–2004 to data from Norwegian registries that followed each participant through February 2010. Cox regression analysis was used to compute hazard ratios (HRs) for the use of long-term social welfare benefits in young adulthood, based on health measures in 15–16 year-olds. Results: During the follow-up, 17% of the study population received some sort of long-term social welfare benefit. In the baseline survey, 95% of the adolescents reported one or more health complaints. The mean number of health complaints was 4.8. Girls reported a significantly higher mean number of complaints (5.7) than did boys (3.8) (p < 0.001). Several individual health complaints were associated with an increased use of long-term social welfare benefits. We found an increasing relative hazard of social welfare usage, depending on the number of complaints reported at baseline. Ill self-perceived general health was found to be strongly associated with the use of benefits during the follow-up: In girls, we found HRs of 1.41 (CI 1.21–1.65), 2.76 (2.29–3.31) and 2.77 (1.51–5.07) for those with good, not so good and bad health, respectively; compared to very good health. The corresponding numbers in boys were 1.41 (1.25–1.59), 1.93 (1.60–2.32) and 1.31 (0.72–2.38), respectively. Conclusions: Several health measures in adolescents were found to be associated with future work marginalization in young adulthood. The associations remained significant, even after correcting for such strong predictors as the parents’ education and family economy. Total symptom burden and self-perceived general health can add additional knowledge onto how adolescent health is related to work marginalization, in a longitudinal perspective

• Khalifa, Dina Mohammed Sami; Glavin, Kari; Bjertness, Espen & Lien, Lars (2015). Postnatal depression among Sudanese women: Prevalence and validation of the Edinburgh Postnatal depression scale at 3 months postpartum. International Journal of Women's Health.  ISSN 1179-1411.  7, s 677- 684 . doi: 10.2147/IJWH.S81401 Full text in Research Archive. Show summary

  Purpose: Postnatal depression (PND) rates in low-resource countries have reached levels between 4.9% and 59%. Maternal mental health has not been researched in Sudan, and there are no existing statistics on prevalence or significant risk factors for PND. Consequently, no screening test has been validated to screen for PND at the primary health care level. This study investigates the 3 months prevalence of PND and validates the Edinburgh Postnatal Depression Scale (EPDS) against the Mini-International Neuropsychiatric Interview (MINI). Methodology: Pregnant Sudanese women in the second and third trimesters were recruited to the study during routine antenatal care visits in two major maternity hospitals in Khartoum state. They were screened for PND at 3 months postpartum using the EPDS. Test positive women were matched with test negative women according to nearest date of birth. A clinical psychologist verified their depression status using the MINI. Results: The follow-up rate was 79%. At a cutoff point of $12, the 3 months prevalence of PND was 9.2%. The sensitivity and specificity of the EPDS were 89% and 82%, respectively. The EPDS and MINI showed a strong positive relationship (odds ratio =36). The positive predictive value and negative predictive value, using this study’s prevalence, were 33% and 98.7%, respectively. The receiver operator characteristic analysis showed an area under the curve of 0.89. The cut-off point $12 was the most acceptable point as it had the lowest number needed to diagnose (1.4) and a false-positive rate of 18%. Conclusion: The EPDS is a valid tool for screening for PND on a Sudanese population. It was accepted, easily administered, and understood by postnatal women. Health care personnel, especially village midwives, should be trained on screening and referral of depressed women for clinical evaluation and management. Due to limited resources available in Sudan, shorter screening tests need to be validated in the future

• Neupane, Sudan Prasad; Lien, Lars; Martinez, Priscilla; Hestad, Knut & Bramness, Jørgen Gustav (2015). The relationship of alcohol use disorders and depressive symptoms to tryptophan metabolism: Cross-sectional data from a nepalese alcohol treatment sample. Alcoholism: Clinical and Experimental Research.  ISSN 0145-6008.  39(3), s 514- 521 . doi: 10.1111/acer.12651 Show summary

  Background Activation of the kynurenine pathway of tryptophan metabolism results in increased production of potentially depressogenic tryptophan catabolites and a reduction in tryptophan availability for serotonin synthesis. As alcohol consumption affects tryptophan metabolism and disposition, we determined serum levels of tryptophan, kynurenine, and an index of tryptophan degradation (kynurenine/tryptophan ratio) in patients with alcohol-use disorder (AUD) and compared their levels considering abstinence duration, AUD severity, and comorbid depression. Methods The study sample included 169 AUD inpatients from 8 alcohol treatment facilities in Kathmandu, Nepal. The Composite International Diagnostic Interview was administered to generate the AUD diagnosis. The Alcohol Use Disorder Identification Test (AUDIT) captured AUD severity and patterns of alcohol use. The Hopkins Symptom Checklist-25 was used to reveal current depressive symptoms. Serum kynurenine and tryptophan levels were determined by high-performance liquid chromatography, and tryptophan degradation was measured by KT ratio (kynurenine/tryptophan × 103). Results Patients with above average AUDIT scores had higher mean serum levels of kynurenine (2.1 μM ± 0.7 vs. 1.8 μM ± 0.6, p = 0.006) and KT ratios (48.6 ± 17.6 vs. 40.4 ± 14.3, p = 0.002) than those with below average scores. Patients with current depressive symptoms had higher mean tryptophan concentrations (49.9 μM ± 13 vs. 45.7 μM ± 14.1, p = 0.047) and lower KT ratios (41.4 ± 14 vs. 47.5 ± 17.6, p = 0.028) compared to patients whose reported depressive symptoms were below the standard cutoff. Higher tryptophan levels and lower KT ratios in the depressed group were specific to patients with longer abstinence and higher AUD severity. Conclusions Depression-related deregulation in tryptophan metabolism was found to depend on length of abstinence and on AUD severity. Together, results suggest that in AUD populations, peripheral tryptophan metabolism is subject to interactions between AUD severity and depressive symptoms

• Neupane, Sudan Prasad; Lien, Lars; Ueland, Thor; Mollnes, Tom Eirik; Aukrust, Pål & Bramness, Jørgen Gustav (2015). Serum brain-derived neurotrophic factor levels in relation to comorbid depression and cytokine levels in Nepalese men with alcohol-use disorders. Alcohol.  ISSN 0741-8329.  49(5), s 471- 478 . doi: 10.1016/j.alcohol.2015.01.012 Show summary

  Neurodegenerative and inflammatory processes are involved separately in major depression (MD) and alcohol-use disorders (AUD). Little is known about the nature of this relationship in the context of comorbid AUD and depression disorders. In this study, we determined brain-derived neurotrophic factor (BDNF) serum levels in patients with AUD and tested whether BDNF levels were related to history of major depression, recent depressive symptoms, AUD severity, and TNF-α and IL-6 levels. Nepalese male AUD inpatients (N = 152) abstinent from alcohol for an average of 34 days were administered structured interviews to assess depression symptoms and pattern and extent of alcohol use, and to generate research diagnoses for AUD and MD. AUD severity was assessed by scores on the Alcohol Use Disorder Identification Test. Serum BDNF and cytokines were measured using ELISA and multiplex technology, respectively. Although serum BDNF levels were unrelated to MD history, patients with recent depressive symptoms (n = 42) had lower (mean ± SD) BDNF serum levels compared to those without (n = 110) (21.6 ± 8.1 ng/mL vs. 26.0 ± 9.6 ng/mL; p = 0.010), and patients with higher AUD severity and binge-drinking patterns had higher mean serum BDNF levels compared to lower AUD severity and non-binging (25.9 ± 9.7 ng/mL vs. 22.1 ± 8.7 ng/mL; p = 0.022 and 25.7 ± 9.3 vs. 21.8 ± 9.7 ng/mL; p = 0.029, respectively). Positive correlations were present between BDNF and TNF-α (r = 0.39, p < 0.001) and IL-6 (r = 0.2, p = 0.027). In particular, TNF-α levels were predictive of BDNF levels after controlling for confounders (B = 0.3 [95% CI = 0.2–0.5], p < 0.001). These findings show that in alcohol-using populations, peripheral BDNF levels are related to severity of AUD as well as presence of depressive symptoms. The significant associations between inflammatory and neurotrophic factors may have implications for neuroadaptive changes during recovery from AUD.

• Sagatun, Åse; Heyerdahl, Sonja; Wentzel-Larsen, Tore & Lien, Lars (2015). Medical benefits in young adulthood: A population-based longitudinal study of health behaviour and mental health in adolescence and later receipt of medical benefits. BMJ Open.  ISSN 2044-6055.  5(5) . doi: 10.1136/bmjopen-2014-007139 Full text in Research Archive. Show summary

  Objectives: To examine the extent to which smoking, alcohol, physical activity and mental health problems in 15–16-year-olds are associated with receipt of medical benefits in young adulthood, after adjustment for confounders. Design: Prospective population-based cohort survey linked to national registers. Participants: In the ‘Youth studies’ from the Norwegian Institute of Public Health, 15 966 10th graders in 6 Norwegian counties answered a health behaviour and mental health questionnaire; 88% were linked to National Insurance Administration Registers (FD-Trygd). Outcome measure: Time to receipt of medical benefits, based on FD-Trygd. Follow-up was from age 18 years until participants were aged 22–26 years. Method: We performed Cox regression analyses to examine the extent to which variations in health behaviour and mental health problems during 10th grade were associated with receipt of medical benefits during follow-up. Results: Daily smoking at age 15–16 years was associated with a significant increase in hazard of receiving health benefits at follow-up compared with not smoking for boys, HR (95% CI) 1.56 (1.23 to 1.98), and for girls 1.47 (1.12 to 1.93). Physical activity was associated with a decrease in hazard compared with inactivity from 23% to 53% in boys and from 21% to 59% in girls, while use of alcohol showed a mixed pattern. The hazard for benefits use rose with increasing levels of emotional symptoms, peer problems, conduct problems and hyperactivity–inattention problems (Strengths and Difficulties Questionnaire) at 15–16 years among both genders. Conclusions: Health behaviour and mental health problems in adolescence are independent risk factors for receipt of medical benefits in young adulthood.

• Salah, Tarig; Ayazi, Touraj; Lien, Lars; Eide, Arne Henning & Hauff, Edvard (2015). Social phobia among long-term internally displaced persons: An epidemiological study of adults in two internally displaced person settlements in Sudan. International Journal of Social Psychiatry.  ISSN 0020-7640.  61(6), s 550- 559 . doi: 10.1177/0020764014564800 Show summary

  Background: Despite the high worldwide prevalence and association with other mental disorders and disability, only few studies are available on social phobia in low-income countries. Aims: This study aims to assess the prevalence, socio-demographic correlates and comorbidity of social phobia and its association with disability among long-term internally displaced persons (IDPs) in one urban and one rural area in Central Sudan. Methods: This cross-sectional study was implemented in two IDP areas in Central Sudan. Data were collected during face-to-face interviews using structured questionnaires to assess socio-demographic factors and the Mini International Neuropsychiatric Interview (MINI) to determine psychiatric diagnoses. A total of 1,876 adults were enrolled from both study areas. Results: The overall lifetime prevalence of social phobia was 14.2%, with higher rates among IDPs in the rural area and among those who were less educated. Social phobia was associated with other mental disorders in both study areas. Disability and prolonged displacement increased the risk of having social phobia in the rural area. Conclusion: Further work needs to be done to improve our understanding and to establish proper interventions in dealing with social phobia, other common mental disorders and disability among long-term IDPs in these impoverished areas.

• Sørensen, Torgeir; Lien, Lars; Landheim, Anne & Danbolt, Lars Johan (2015). Meaning-Making, Religiousness and Spirituality in Religiously Founded Substance Misuse Services—A Qualitative Study of Staff and Patients’ Experiences. Religions.  ISSN 2077-1444.  6(1), s 92- 106 . doi: 10.3390/rel6010092 Show summary

  The Norwegian health authorities buy one third of their addiction treatment from private institutions run by organizations and trusts. Several of these are founded on religious values. The aim of the study was to investigate such value-based treatment and the patients’ experiences of spirituality and religiousness as factors of meaning-making in rehabilitation. The study was performed in an explorative qualitative design. Data were collected through focus-group interviews among therapists and in-patients at a religiously founded substance misuse service institution. The analysis was carried out by content analysis through systematic text-condensation. Through different activities and a basic attitude founded on religious values, the selected institution and the therapists facilitated a treatment framework which included a spiritual dimension and religious activity. The patients appreciated their free choice regarding treatment approaches, which helped them to make meaning of life in various collective and individual settings. Rituals and sacred spaces gave peace of mind and confidence in a situation that up to now had been chaotic and difficult. Sermons and wording in rituals contributed to themes of reflection and helped patients to revise attitudes and how other people were met. Private confessions functioned for several patients as turning point experiences influencing patients’ relations to themselves and their surroundings. Spirituality and religious activity contributed to meaning-making among patients with substance use disorder and had significance for their rehabilitation

• Teodorescu, Dinu-Stefan; Heir, Trond; Siqveland, Johan; Hauff, Edvard; Wentzel-Larsen, Tore & Lien, Lars (2015). Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study. BMC Psychology.  ISSN 2050-7283.  3(1) . doi: 10.1186/S40359-015-0064-5 Show summary

  Traumatized refugees often report significant levels of chronic pain in addition to posttraumatic stress disorder symptoms, and more information is needed to understand pain in refugees exposed to traumatic events. This study aimed to assess the frequency of chronic pain among refugee psychiatric outpatients, and to compare outpatients with and without chronic pain on trauma exposure, psychiatric morbidity, and psychiatric symptom severity. We conducted a cross-sectional study of sixty-one psychiatric outpatients with a refugee background using structured clinical diagnostic interviews to assess for traumatic events [Life Events Checklist (LEC)], PTSD (Posttraumatic Stress Disorder) and complex PTSD [Structured Clinical Interview for DSM-IV PTSD Module (SCID-PTSD) and Structured Interview for Disorders of Extreme Stress (SIDES)], chronic pain (SIDES Scale VI) and psychiatric symptoms [M.I.N.I. International Neuropsychiatric Interview (M.I.N.I.)]. Self-report measures were used to assess symptoms of posttraumatic stress [Impact of Event Scale-revised (IES-R)], depression and anxiety [Hopkins Symptom Checklist (HSCL-25)] and several markers of acculturation in Norway. Of the 61 outpatients included, all but one reported at least one chronic pain location, with a mean of 4.6 locations per patient. Chronic pain at clinical levels was present in 66% of the whole sample of outpatients, and in 88% of the outpatients with current PTSD diagnosis. The most prevalent chronic pain locations were head (80%), chest (74%), arms/legs (66%) and back (62%). Women had significantly more chronic pain locations than men. Comorbid PTSD and chronic pain were found in 57% of the outpatients. Significant differences were found between outpatients with and without chronic pain on posttraumatic stress, psychological distress, and DESNOS severity. Chronic pains are common in multi-traumatized refugees in outpatient clinics in Norway, and are positively related to symptomatology and severity of psychiatric morbidity. The presence of chronic pain, as well as comorbid chronic pain and PTSD, in psychiatric outpatients with a refugee background call for an integrated assessment and treatment for both conditions

• Abebe, Dawit Shawel; Hafstad, Gertrud Sofie; Brunborg, Geir Scott; Kumar, Bernadette. N & Lien, Lars (2014). Binge drinking, cannabis and tobacco use among ethnic Norwegian and ethnic minority adolescents in Oslo, Norway. Journal of Immigrant and Minority Health.  ISSN 1557-1912. . doi: 10.1007/s10903-014-0077-9 Show summary

  The aim of the study was to assess prevalence and factors associated with binge drinking, cannabis use and tobacco use among ethnic Norwegians and ethnic minority adolescents in Oslo. We used data from a school-based cross-sectional survey of adolescents in junior- and senior high schools in Oslo, Norway. The participants were 10,934 adolescents aged 14 to 17 years, and just over half were females. The sample was comprised of 73.2% ethnic Norwegian adolescents, 9.8% 1st generation immigrants, and 17% 2nd generation adolescents from Europe, the US, the Middle East, Asia and Africa. Logistic regression models were applied for the data analyses. Age, gender, religion, parental education, parent-adolescent relationships, depressive symptoms and loneliness were as covariates in the regression models. Ethnic Norwegian adolescents reported the highest prevalence of binge drinking (16.1%), whereas the lowest prevalence was found among 2nd generation adolescents from Asia (2.9%). Likewise, the past-year prevalence for cannabis use ranged from 10.6% among 2nd generation Europeans and those from the US to 3.7% among 2nd generation Asians. For daily tobacco use, the prevalence ranged from 12.9% among 2nd generation Europeans and the US to 5.1% among 2nd generation Asians. Ethnicity, age, gender, religion, parental education, and parent-adolescent relationships and mental health status were significantly associated with binge drinking, cannabis and tobacco use. These factors partly explained the observed differences between ethnic Norwegians and ethnic minority adolescents in the current study. There are significant differences in substance use behaviors between ethnic Norwegian and immigrant youth. Factors like age, gender, religion, parental education and relationships and mental health status might influence the relationship between ethnicity and substance abuse. The findings have implications for planning selective- as well as universal prevention interventions.

• Abebe, Dawit Shawel; Lien, Lars & Hjelde, Karin Harsløf (2014). What We Know and Don't Know About Mental Health Problems Among Immigrants in Norway. Journal of Immigrant and Minority Health.  ISSN 1557-1912.  16(1), s 60- 67 . doi: 10.1007/s10903-012-9745-9 Full text in Research Archive.
• Abebe, Dawit Shawel; Torgersen, Leila; Lien, Lars; Hafstad, Gertrud Sofie & von Soest, Tilmann (2014). Predictors of Disordered Eating in Adolescence and Young Adulthood: A Population-Based, Longitudinal Study of Females and Males in Norway. International Journal of Behavioral Development.  ISSN 0165-0254.  38(2), s 128- 138 . doi: 10.1177/0165025413514871 Full text in Research Archive.
• Ayazi, Touraj; Lien, Lars; Eide, Arne Henning; Swartz, Leslie & Hauff, Edvard (2014). Association between exposure to traumatic events and anxiety disorders in a post-conflict setting: a cross-sectional community study in South Sudan. BMC Psychiatry.  ISSN 1471-244X.  14:6 . doi: 10.1186/1471-244X-14-6 Show summary

  Background The negative effect of exposure to traumatic events on mental health is well known. Most studies of the effects of trauma on mental health in war-affected populations have focused on post-traumatic stress disorder (PTSD) and depression. Although some studies confirm the existence of anxiety symptoms in war-affected populations, the extent to which exposure to traumatic events is independently associated with anxiety diagnoses (other than PTSD) has received less attention. The study aimed to determine whether having an anxiety diagnosis, other than PTSD, was associated with experiencing traumatic events in a post-conflict setting, across genders and after controlling for demographic and socio-economic variables. Methods In this cross-sectional community study (n = 1200), we applied the Harvard Trauma Questionnaire (HTQ) to investigate the extent of trauma exposure and PTSD. The Mini-International Neuropsychiatric Interview (MINI) was used to investigate the prevalence of anxiety disorders: generalized anxiety disorder (GAD), panic disorder (PD), social phobia, obsessive-compulsive disorder (OCD), and agoraphobia. Multinomial logistic regression analyses were conducted to examine the association between these disorders, previous trauma exposure, and socio-economic factors. Results The participants were 56.4% male and 43.6% female. The age ranged between 18 and 73 years old (Mean 34.63, SD = 12.03). The estimated rates of GAD-only and PD-only (without comorbidity with PTSD) were 5.5% and 3.1%, respectively. Exposure to traumatic events and socio-economic disadvantage were significantly associated with having one or more anxiety diagnoses. After controlling for age, sex, rural/urban setting, and socio-economic disadvantage, exposure to trauma was independently associated with anxiety diagnosis. There were gender differences in the pattern of risk factors for having PTSD, GAD or PD. Conclusion In individuals with a history of war-related trauma exposure, attention should be given to symptoms of GAD and PD, in addition to PTSD symptoms

• Bratlien, Unni; Øie, Merete Glenne; Haug, Elisabeth; Møller, Paul; Andreassen, Ole Andreas; Lien, Lars & Melle, Ingrid (2014). Environmental factors during adolescence associated with later. Development of psychotic disorders: a nested case-control study. Psychiatry Research.  ISSN 0165-1781.  215(3), s 579- 585 . doi: 10.1016/j.psychres.2013.12.048 Full text in Research Archive. Show summary

  Etiologies of psychotic disorders (schizophrenia and bipolar disorder) are conceptualized as interplay between genetic and environmental factors. The adolescent period is characterized by changes in social roles and expectations that may interact with biological changes or psychosocial stressors. Few studies focus on the adolescents’ own reports of perceived risk factors. To assess differences at age 16 between persons who later develop psychotic disorders (“Confirmed Psychosis”, CP) and their class-mates (“Population Controls”, PC) we collected information on: (1) Social support factors (size of social network and expectancies of social support from friends), (2) Cognitive functioning (concentrating in the classroom, actual grades and expectancies of own academic achievements) and (3) Problems and stressors in families (illness or loss of work for parents), and in relationship with others (exposure to bullying, violence or sexual violation). Self-reported data from students at 15–16 years of age were linked to the case-registers from the “Thematically Organized Psychosis (TOP) Study”. The CP group reported more economic problems in their families, smaller social network and lower academic expectation than the PC group. The results support the notion that long-term socioeconomic stressors in adolescence may serve as risk factors for the development of psychotic disorders

• Halvorsen, Jon Anders; Lien, Lars; Dalgard, Florence; Bjertness, Espen & Stern, Robert (2014). Suicidal ideation, mental health problems, and social function in adolescents with eczema: A population-based study. Journal of Investigative Dermatology.  ISSN 0022-202X.  134(7), s 1847- 1854 . doi: 10.1038/jid.2014.70 Show summary

  There are few studies on psychosocial problems in adolescents with eczema. We performed a cross-sectional, questionnaire-based study to explore the relationship of suicidal ideation, mental health problems, and social functioning with eczema. A total of 4,744 adolescents (18–19 years) were invited for the study, of whom 3,775 (80%) participated. The overall prevalence of current eczema was 9.7%. Among those with current eczema, 15.5% reported suicidal ideation compared with 9.1% among those without eczema, significantly associated in a multivariate model (odds ratio 1.87, 95% confidence interval 1.31–2.68). In a subgroup analyses, the prevalence of suicidal ideation in those with both eczema and itch was 23.8%, and was significantly associated, compared with those without eczema (3.57, 2.46–5.67). Eczema was associated with mental health problems assessed by the Strength and Difficulties Questionnaire (1.72, 1.21–2.45) and the Hopkins Symptom Checklist 10 (1.63, 1.23–2.16). Five questions assessed social function: feeling attached to family and friends; thriving at school; experiencing bullying; and romantic relationships. Boys with current eczema were less likely to have had romantic relationships (1.93, 1.21–3.08). Eczema in late adolescence is associated with suicidal ideation and mental health problems but rarely with social problems. Our findings point to the importance of addressing mental health issues in adolescents with eczema

• Martinez, Priscilla; Lien, Lars; Landheim, Anne; Kowal, Paul & Clausen, Thomas (2014). Quality of life and social engagement of alcohol abstainers and users among older adults in South Africa. BMC Public Health.  ISSN 1471-2458.  14(316) . doi: 10.1186/1471-2458-14-316 Show summary

  Background: The literature from developed countries suggests a relationship between alcohol use and quality of life and social engagement, where harmful drinkers have lower quality of life and less social engagement. Despite the high rates of harmful alcohol use in South Africa, little is known about the association between drinking pattern and quality of life and social engagement in this context. We aimed to determine if quality of life and social engagement varied across different drinking patterns among older South African adults, contributed to drinking pattern when controlling for socio-demographic factors, and varied differentially between genders. Methods: This is a secondary analysis of data from the Survey on Global Ageing and Adult Health (SAGE). Alcohol use was measured as self-reports of use over the previous seven days, and we constructed gender-specific alcohol variables. The WHO Quality of Life-scale was used to measure quality of life, and social engagement was measured by frequency of participation in social activities. We used ANOVA to observe differences in quality of life and social engagement scores across drinking patterns, and regression models were used to identify factors independently associated with drinking pattern. Results: There were 2572 (84.4%) lifetime abstainers, and 475 (15.6%) persons who had a drink in the last 7 days. In bivariate analysis, quality of life was lowest among at risk drinking men compared to abstainers (OR = 0.21, p = 0.02), although this association was not significant in adjusted analysis. Social engagement did not vary statistically significantly across the drinking patterns in the total sample or within gender. Conclusions: Quality of life and social engagement were not independently associated with drinking pattern among older adults in South Africa in this sample. In order to better understand their alcohol use, further exploratory research is warranted to identify other potentially relevant subjective factors of alcohol use among older adults in South Africa.

• Neupane, Sudan Prasad; Lien, Lars; Martinez, Priscilla; Aukrust, Pål; Ueland, Thor; Mollnes, Tom Eirik; Hestad, Knut & Bramness, Jørgen Gustav (2014). High frequency and intensity of drinking may attenuate increased inflammatory cytokine levels of major depression in alcohol-use disorders. CNS Neuroscience & Therapeutics.  ISSN 1755-5930.  20(10), s 898- 904 . doi: 10.1111/cns.12303 Full text in Research Archive. Show summary

  As major depression (MD) is often comorbid with alcohol-use disorders (AUD) and alcohol itself modulates the immune system, we examined serum levels of interleukin (IL)-6, IL-10, tumor necrosis factor (TNF), and interferon (IFN)-γ in AUD patients with and without MD. Putative interactions between alcohol variables and MD on cytokine levels were also assessed. A consecutive sample of inpatients with AUD (N = 176) from eight alcohol treatment centers in Kathmandu, Nepal, was assessed for alcohol use and depression by administering fully structured psychiatric interviews. Serum cytokine levels were determined using multiplex technology. Alcohol-use disorders patients with a positive history of MD had higher levels of the inflammatory cytokines IL-6 (P = 0.019), TNF (P = 0.020), and IFN-γ (P = 0.001), but not of IL-10 (P = 0.853). AUD patients with MD had higher concentrations of cytokines compared with those without, regardless of the severity of the alcohol problem, but the difference was greater among those drinking in lower frequency and intensity. These findings provide evidence for altered functioning of the immune system in AUD patients with comorbid MD. However, frequent and intense drinking may attenuate the difference in the cytokine profiles between AUD patients with and without MD

• Sagatun, Åse; Heyerdahl, Sonja; Wentzel-Larsen, Tore & Lien, Lars (2014). Mental health problems in the 10th grade and non-completion of upper secondary school: the mediating role of grades in a population-based longitudinal study. BMC Public Health.  ISSN 1471-2458.  14:16 . doi: 10.1186/1471-2458-14-16 Show summary

  Background School drop-out is a problem all over the world with adverse life-course consequences. The aim of this paper is to study how internalising and externalising problems in the 10th grade are associated with non-completion of upper secondary school, and to examine the mediating role of grade points in the 10th grade across general academic and vocational tracks in upper secondary school. We also study the impact of health behaviour. Methods Population-based health surveys were linked with Norwegian registries on education and sociodemographic factors (n?=?10 931). Mental health was assessed by the self-report Strengths and Difficulties Questionnaire. Logistic regression was used to analyse the relations between mental health and health behaviour in 10th grade and non-completion of upper secondary school. The mediating effect of grade points was studied by causal mediation analysis. Results Adolescents not completing upper secondary school reported more externalising problems and girls more internalising problems in the 10th grade, after adjustments. Smoking and physical inactivity increased the odds of non-completion of upper secondary school. Causal mediation analyses showed that a reduction in externalising problems of 10 percentage points led to lower rates of non-completion of 4?5 percentage points, and about three-quarters of this total effect was mediated by grades. For internalising problems the total effect was significant only for girls (1 percentage point), and the mediated effect of grades was about 30%. The effect of mental health problems on school dropout was mainly the same in both vocational and general tracks. Conclusions Assuming a causal relationship from mental health problems to school performance, this study suggests that externalising problems impair educational attainment. A reduction of such problems may improve school performance, reduce school drop-out and reduce the adverse life-course consequences.

• Strømme, Kirsten Kierulf; Strømme, Petter; Bjertness, Espen & Lien, Lars (2014). Intrauterine growth restriction: A population-based study of the association with academic performance and psychiatric health. Acta Paediatrica.  ISSN 0803-5253.  103(8), s 886- 891 . doi: 10.1111/apa.12657 Show summary

  To investigate whether intrauterine growth restriction (IUGR), resulting in small for gestational age (SGA) infants, is associated with increased susceptibility to psychiatric problems and academic impairment in late teens. A cohort of all 10th-grade students in Oslo, Norway, followed up between 2001 and 2004 (n = 2131), was linked with foetal growth data. IUGR was considered equal to SGA at the lowest 2.5th, 5th, and 10th percentiles and appropriate for gestational age (AGA) as the highest 90th percentile. Mental health was evaluated using the Hopkins Symptoms Check List and the Strength and Difficulties Questionnaire, and academic achievements and ambitions were self-reported by the students.Psychiatric problems were equally prevalent in all groups. However, the SGA girls performed inferiorly compared to their AGA peers in the school subjects English [3.6 vs 3.9 (p = 0.03)], mathematics [4.0 vs 4.3 (p = 0.01)] and social science [4.2 vs 4.4 (p = 0.05)], but not for Norwegian. This association was not observed in boys. There was an association between academic impairment and prematurity, occurring more frequently among immigrants (p < 0.001). SGA had a small negative impact on academic achievements in adolescent girls, but not boys. There was no association between SGA and psychiatric problems in either gender

• Zeratsion, Henok Tesfay; Bjertness, Cecilie Bergsmark; Bjertness, Espen; Dalsklev, Madeleine Mahin; Haavet, Ole Rikard; Halvorsen, Jon Anders; Lien, Lars & Claussen, Bjørgulf (2014). The Influence of Parental Divorce on Educational Ambitions of 18/19 Year-Old Adolescents from Oslo, Norway. Journal of Child and Family Studies.  ISSN 1062-1024. . doi: 10.1007/s10826-014-0090-6 Show summary

  Former studies have shown that children and adolescents of divorced parents have significantly poorer educational attainment than their peers from continuously married parents. Educational ambition is important because it has relationship with educational attainment. Our aim was to investigate the associations between parental divorce and educational ambitions among adolescents in the Scandinavian region. Data were used from Young-HUBRO surveys that were conducted in Oslo in the years 2000/2001 and 2004. A change in educational ambition was investigated in a prospective study (n = 1,861) by comparing 18/19 year-olds who experienced late parental divorce with adolescents of continuously married parents. 18/19 year-old adolescents who experienced parental divorce during childhood or adolescence were compared in a cross-sectional study (n = 2,391) with their peers from continuously married parents. Multinomial logistic regression models were fitted to include, among others, mental health problem as a potential confounder. The prospective study showed that a change from ambition for university/college education to having undecided educational ambition was significantly higher among adolescents with experience of late parental divorce than among adolescents of continuously married parents (OR 1.8; 95 % CI 1.1–3.0). In the cross-sectional study, adolescents who experienced parental divorce during childhood or adolescence were more likely to have undecided educational ambition, compared to their peers from continuously married parents (OR 1.3; 95 % CI 1.1–1.8). In conclusion, experience of parental divorce seems to be associated with undecided educational ambition among 18/19 year-old adolescents. Mechanisms that reduce the adverse influence of parental divorce on educational ambitions need to be in place

• Zeratsion, Henok Tesfay; Bjertness, Cecilie Bergsmark; Lien, Lars; Haavet, Ole Rikard; Dalsklev, Madeleine Mahin; Halvorsen, Jon Anders; Bjertness, Espen & Claussen, Bjørgulf (2014). Does parental divorce increase risk behaviors among 15/16 and 18/19 year-old adolescents? A study from Oslo, Norway. Clinical Practice and Epidemiology in Mental Health.  ISSN 1745-0179.  10, s 59- 66 . doi: 10.2174/1745017901410010059
• Ayazi, Touraj; Lien, Lars; Eide, Arne Henning; Shadar, Elizabeth Joseph Shadar & Hauff, Edvard (2013). Community attitudes and social distance towards the mentally ill in South Sudan: a survey from a post-conflict setting with no mental Health services. Social Psychiatry and Psychiatric Epidemiology.  ISSN 0933-7954. . doi: 10.1007/s00127-013-0775-y Show summary

  Purpose This study investigates attitudes and social distance towards the mentally ill in a post-conflict, low-income country. Methods A cross-sectional community survey (n = 1,200) was conducted in South Sudan. Associations between various sociodemographic variables and attitudes toward/social distance from the mentally ill were investigated. Results The regression analysis showed that lower levels of education were positively associated with social distance, and Christian or Muslim beliefs, compared with traditional beliefs, were negatively associated with social distance. Familiarity with mental illness or psychological distress was not significantly associated with social distance. Participants who endorsed community-oriented attitudes (rather than hospital/drug-oriented attitudes) about health care for the mentally ill were more likely show a decreased social distance. Participants who believed that the mentally ill were dangerous had higher scores on the social distance scale. Conclusions A high level of stigma towards the mentally ill exists in South Sudan, especially in the rural areas. Alongside efforts to build up mental health services in South Sudan, the existing stigma needs to be addressed. Information regarding the role of the community both in preventing mental illnesses and in service delivery should be prioritised.

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• Dybdahl, Ragnhild; Lien, Lars; Siem, Harald; Bakke, Hege Helene & Julardzija, Irma (red.) (2019). Asylsøkere og flyktninger. Psykisk helse og livsmestring. Universitetsforlaget.  ISBN 9788215031514.  328 s.
• Danbolt, Lars Johan; Engedal, Leif Gunnar; Stifoss-Hanssen, Hans; Hestad, Knut & Lien, Lars (red.) (2014). Religionspsykologi. Gyldendal Akademisk.  ISBN 978-82-05-41634-5.  387 s. Show summary

  Kan tro forebygge sykdom? Hvordan kan religion motivere til både gode og onde handlinger? Forfatterne av denne boken drøfter dette og flere spørsmål knyttet til religionens betydning for mennesker. Interessen for religion, tro og livssyn er økende. Vårt livssyn har betydning for hvem vi er, hva vi vurderer som viktig, og hvordan vi er i relasjon til andre. Samtidig synes mange det er vanskelig å forholde seg til menneskers tro i profesjonelle sammenhenger. I denne boken presenterer fagpersoner fra flere nordiske land forskning innenfor faget religionspsykologi. Du kan lese om hvordan religion kan motivere til terrorhandlinger, hvorfor vi samles til lystenning og rosetog, og om en kan finne en sammenheng mellom prosesser i hjernen og åndelige erfaringer. Boken gir også et innblikk i hvordan spiritualitet kan være både et problem og en løsning for mennesker med psykiske vansker.

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• Stensvehagen, Marianne Torp; Bronken, Berit Arnesveen; Lien, Lars & Larsson, Ulf Gerry (2019). How women experience and cope with daily hassles after sexual abuse– a retrospective qualitative study..
• Stensvehagen, Marianne Torp; Bronken, Berit Arnesveen; Lien, Lars & Larsson, Ulf Gerry (2019). Hvordan håndterer kvinner som har opplevd seksuelle overgrep hverdagsstress - en retrospektiv kvalitativ studie..
• Toft, Helge; Lien, Lars; Neupane, Sudan Prasad; Abebe, Dawit Shawel; Tilden, Terje & Bramness, Jørgen Gustav (2019). Anti-inflammatory drugs obscure the relationship between mental distress and inflammatory cytokines.
• Abebe, Dawit Shawel & Lien, Lars (2018). Immigrant psychiatric patients and the utilisation of specialist services for circulatory system diseases – a nation-wide register study in Norway. European Journal of Public Health.  ISSN 1101-1262. . doi: 10.1093/eurpub/cky048.231 Show summary

  Background: Circulatory system diseases, particularly cardiovascular diseases, are the leading cause of impaired quality of life and excess premature death among psychiatric patients. Nevertheless, psychiatric patients are subject to unacceptably high levels of disparity in somatic healthcare. Little research has been conducted among immigrant psychiatric patients. This study aims to examine the use of specialist somatic services for circulatory system diseases among psychiatric patients with different countries of origin. Methods: Register data were used from the Norwegian Patient Registry and Statistics Norway. The sample (ages 0-90+) consisted of 317,260 ethnic Norwegians (native-born) and 14,938 immigrants from 11 countries that had contacts with specialist mental healthcare during 2008-2011. Countries of origin included Sweden, Poland, Bosnia-Herzegovina, Russia, Somalia, Turkey, Sir Lanka, Iraq, Iran, Pakistan and Vietnam. Statistical analyses were applied using logistic regression models. A p-value ≤ 0.05 was regarded as statistically significant. Results: There were no overall significant differences in rates of outpatient consultations for circulatory system diseases between immigrant (7%) and Norwegian (7.2%) psychiatric patients. A distinct exception was the high outpatient rate among people from Bosnia-Herzegovina, and the low outpatient rate among those from Somalia, Pakistan and Vietnam. Immigrant psychiatric patients had a lower overall admission rate (3.1%) compared to Norwegian psychiatric patients (4.7%). The majority of immigrant psychiatric patients had statistically significant lower admission rates than Norwegian psychiatric patients, except those from Sweden, Bosnia-Herzegovina and Sir Lanka. Conclusions: The findings suggest that the majority of immigrant psychiatric patients have lower hospitalisation rates for circulatory system diseases than Norwegian psychiatric patients. This suggests that limited access to hospitalisation could be the main possible explanation.

• Bramnes, Jørgen; Westby, Lena Catherine Lossius; Hjellvik, Vidar; Fauske, Halvor & Lien, Lars (2018). Legemidler og deres håndtering i barnverninstitusjoner.
• Dybdahl, Ragnhild & Lien, Lars (2018). Mental health is an integral part of the sustainable development goals. Preventive Medicine and Community Health. . doi: 10.15761/PMCH.1000104
• Brekke, Eva; Lien, Lars; Davidson, Larry & Biong, Stian (2017). Recovery in Co-occurring Mental Health and Substance Use Disorders: First-person Perspectives.
• Dybdahl, Ragnhild & Lien, Lars (2017). The role of trauma interventions in the sustainable global Development agenda.
• Haug, Sigrid Helene Kjørven & Lien, Lars (2017). Implementation of the Cultural Formulation Interview in Norway-aim and scope with an emphasis on its recovery-oriented properties.
• Silwal, Sanju; Dybdahl, Ragnhild; Chudal, Roshan; Sourander, Andre & Lien, Lars (2017). Psychiatric symptoms experienced by adolescents in Nepal following the 2015 earthquake.
• Toft, Helge Prytz; Lien, Lars; Neupane, Sudan Prasad; Tilden, Terje; Wampold, Bruce E. & Bramness, Jørgen Gustav (2017). PTSD Patients in treatment show increasing cytokine levels despite symptom relief.
• Brekke, Eva; Lien, Lars; Biong, Stian & Davidson, Larry (2016). From double trouble to dual recovery: Patient perspectives on recovery in dual disorders..
• Ness, Ewa; Antonsen, Bjørg; Grøvli, Morten; Hymer, Knut-Erik; Lindkvist, Kari-Venke; Lien, Lars; Skåden, Helga; Thomassen, Arne; Torper, Johan; Vethe, Torgeir & Aarøen, Kari (2016). Færre tvangsinnleggelser – dilemmaer og utfordringer :. Tidsskrift for Den norske legeforening.  ISSN 0029-2001.  136(7), s 598- 599 . doi: 10.4045/tidsskr.15.1031
• Øie, Merete Glenne & Lien, Lars (red.) (2016). Hvordan forstå kognisjon ved rusavhengighet? Nasjonal Kompetansetjeneste ROP-TV. http://roptv.no/videoer/psykisk/merete-glenne-oeie-hvordan-forstaa-kognitiv-funksjon-ved-rusavhengighet.
• Elstad, Jon Ivar; Kumar, Bernadette. N; Diaz, Esperanza & Lien, Lars (2015). Innvandring fører ikke til en eksplosjon i helsekostnader. Aftenposten (morgenutg. : trykt utg.).  ISSN 0804-3116.  s Del 2, s.3
• Elstad, Jon Ivar; Kumar, Bernadette. N; Diaz, Esperanza & Lien, Lars (2015). Nei, innvandring fører ikke til en eksplosjon i helsekostnader | Elstad, Kumar, Diaz og Lien. Aftenposten (morgenutg. : trykt utg.).  ISSN 0804-3116.
• Lien, Lars; Huus, Gitte & Morken, Gunnar (2015). L. Lien og medarbeidere svarer :. Tidsskrift for Den norske legeforening.  ISSN 0029-2001.  135(17), s 1535 . doi: 10.4045/tidsskr.15.0924
• Lien, Lars; Huus, Gitte & Morken, Gunnar (2015). L. Lien og medarbeidere svarer:. Tidsskrift for Den norske legeforening.  ISSN 0029-2001.  135(17), s 1535- 1535 . doi: 10.4045/tidsskr.15.0924
• Lien, Lars; Huus, Sigrid Birgitte & Morken, Gunnar (2015). L. Lien og medarbeidere svarer. Tidsskrift for Den norske legeforening.  ISSN 0029-2001.  135(21), s 1923- 1923 . doi: 10.4045/tidsskr.15.1134
• Lien, Lars; Huus, Sigrid Birgitte & Morken, Gunnar (2015). Psykisk syke lever kortere. Tidsskrift for Den norske legeforening.  ISSN 0029-2001.  135(3), s 246- 248 . doi: 10.4045/tidsskr.14.0831
• Lien, Lars & Johannessen, Jan Olav (2015). Re: Flere og gale diagnoser med kriteriebasert diagnostikk. Tidsskrift for Den norske legeforening.  ISSN 0029-2001.  135(19), s 1712- 1772 . doi: 10.4045/tidsskr.15.1022
• Pedersen, Monica Stolt; Landheim, Anne & Lien, Lars (2015). Clinical audit as a basis for improvement in mental health services, a qualitative study.
• Pedersen, Monica Stolt; Landheim, Anne & Lien, Lars (2015). How are clinical audits used in mental health services to implement a national guideline in diual diagnosis: a qualitative study.
• Danbolt, Lars Johan; Engedal, Leif Gunnar; Hestad, Knut; Lien, Lars & Stifoss-Hanssen, Hans (2014). Forord, I: Lars Johan Danbolt; Leif Gunnar Engedal; Hans Stifoss-Hanssen; Knut Hestad & Lars Lien (red.),  Religionspsykologi.  Gyldendal Akademisk.  ISBN 978-82-05-41634-5.  Forord.  s 5 - 6
• Jaradat, Yousef; Nijem, Khaldoun; Kristensen, Petter; Bjertness, Espen; Lien, Lars; Stigum, Hein & Bast-Pettersen, Rita (2014). Psychosomatic symptoms and self-reported stressful working conditions among Palestinian female and male nurses: a cross-sectional study.
• Lien, Lars (2014, 02. april). Røyking tredobler risikoen for frafall i skolen. [Internett].  Forskning.no.
• Martinez, Priscilla; Neupane, Sudan Prasad; Lien, Lars; Aukrust, Pål; Ueland, Thor; Mollnes, Tom Eirik; Hestad, Knut & Bramness, Jørgen Gustav (2014). Alcohol use severity may attenuate elevated cytokine levels associated with depression in Nepalese alcohol-use disorder patients.
• Neupane, Sudan Prasad; Lien, Lars; Martinez, Priscilla; Aukrust, Pål; Ueland, Thor; Mollnes, Tom Eirik; Hestad, Knut & Bramness, Jørgen Gustav (2014). Circulatory cytokine levels in Nepalese alcohol-use disorder patients with and without major depression.
• Pedersen, Monica Stolt; Landheim, Anne & Lien, Lars (2014). Bridging the gap between current practice and recommendations in national guidelines, a qualitative study of mental health services. Show summary

  Pedersen et al. BMC Health Services Research 2014, 14(Suppl 2):P94

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