Lars Lien

• Abraham, Ruth; Leonhardt, Marja; Lien, Lars; Hanssen, Ingrid; Hauff, Edvard & Thapa, Suraj Bahadur (2021). The relationship between religiosity/spirituality and quality of life among female Eritrean refugees living in Norwegian asylum centres.. International Journal of Social Psychiatry.  ISSN 0020-7640. . doi: 10.1177/00207640211010207 Full text in Research Archive. Show summary

  Background: Women are more vulnerable to mental health problems than men after migration, but little is known about the influence of religiosity/spirituality on their quality of life. The purpose of this study was to explore religiosity/spirituality, in relationships with various domains of quality of life, among female Eritrean refugees staying in Norwegian asylum centres. Method: A questionnaire assessing sociodemographic characteristics was used together with the World Health OrganizationQuality of Life – Spirituality, Religiosity and Personal Beliefs (WHOQOL-SRPB) questionnaire, which assesses religiosity/spirituality and domains of quality of life. A total of 63 adult female Eritrean refugees who had been granted asylum but were still living in asylum reception centres located in southern and central Norway participated. Results: Religiosity/spirituality was independently associated with psychological quality of life (B = 0.367, p < .001), level of independence (B = 0.184, p = .028), social quality of life (B = 0.500, p = .003), environmental quality of life (B = 0.323, p < .001) and overall quality of life (B = 0.213, p < .001), but not with physical quality of life (B = 0.056, p = .679). There were no significant differences between religious affiliations on religiosity/spirituality or quality of life measures. Conclusion: Consistent with previous research, this study highlights the correlation between religiosity/spirituality and overall quality of life. We recommend a longitudinal follow-up study of similar populations, after they are resettled and integrated into their host countries, to understand the associations between quality of life and religiosity/spirituality over time. Keywords Eritrea, refugees, religiosity, spirituality, quality of life, well-being

• Bolstad, Ingeborg; Lien, Lars & Bramness, Jørgen G. (2021). ADHD symptoms as risk factor for PTSD in inpatients treated for alcohol use disorder. Psychiatry Research.  ISSN 0165-1781.  300, s 1- 6 . doi: 10.1016/j.psychres.2021.113904 Show summary

  Attention deficit hyperactivity disorder (ADHD) and post-traumatic stress disorder (PTSD) are more common in alcohol use disorder (AUD) patients than in the general population. Still, there is a lack of knowledge about the relationship between the two conditions in these patients. The main objective of this study was to examine the prevalence of ADHD symptoms, and the relationship between ADHD symptoms and PTSD in AUD inpatients in treatment. Data from 85 AUD patients were collected. The Adult ADHD Self-Report Scale (ASRS) was used to measure ADHD symptoms in all patients. Differences between groups split by PTSD diagnosis and by ASRS clinical cut-off were described, and the relationship between ADHD symptom level and PTSD was tested in a multiple regression model. Almost half the patients scored above ASRS cut-off and 14% had PTSD. Of the patients whose score was above cut-off on the ASRS 23% had PTSD, versus 7% among those below cut-off. Higher ASRS score was associated with PTSD even when age, sex and trauma were adjusted for. This study confirms the high level of ADHD symptoms in AUD patients in treatment. Diagnostic evaluation of PTSD is recommended in patients with ADHD attending inpatient treatment programs for AUD.

• Lien, Lars; Bolstad, Ingeborg & Bramness, Jørgen G. (2021). Smoking among inpatients in treatment for substance use disorders: prevalence and effect on mental health and quality of life. BMC Psychiatry.  ISSN 1471-244X.  21(1) . doi: 10.1186/s12888-021-03252-9 Full text in Research Archive.
• Oerbeck, Beate; Overgaard, Kristin Romvig; Hjellvik, Vidar; Lien, Lars & Bramness, Jørgen G (2021). The Use of Antidepressants, Antipsychotics, and Stimulants in Youth Residential Care. Journal of child and adolescent psychopharmacology.  ISSN 1044-5463.  31(5), s 1- 8 . doi: 10.1089/cap.2020.0123 Full text in Research Archive. Show summary

  Objectives: To assess the use of three commonly prescribed psychotropic medications in youth placed in residential care (RC). Methods: Participants were youth aged 0-20 years placed in RC institutions at least once during 2016. Data on filled prescriptions were taken from the Norwegian Prescription Database to compare the use of antidepressants, antipsychotics, and stimulants in RC with the age and gender adjusted general child population (GenPop) and how this co-varied with reasons for RC placement, age and gender. Results: 1856 children and adolescents were identified in RC, with mean age 14 (range 0-20 years), 46% girls, 81% ≥13 years. Among those, 423 or 23% used any of the three psychotropics, significantly more than the 3.7% in GenPop. The prevalence ratios RC/GenPop were 6.6 for antidepressants, 17.9 for antipsychotics, and 4.4 for stimulants. The median number of days per year for the dispensed defined daily doses varied from 8.3 to 244.0 for the different antipsychotics, indicating short time use for most. Polypharmacy was not frequent in RC, as only 26% used ≥ 2 classes of medication, but still significantly more frequent than the 10% in GenPop. Youth placed in RC for serious behavior problems had significantly higher use of stimulants than those with other placement reasons. Psychotropics were not used below age 6 years, and while the use of antidepressants and antipsychotics overall increased with age, stimulants were mostly used by 6 to16 year olds. The girl/boy ratio for any psychotropic medication use in RC was 1.4 (CI: 1.1-1.6), significantly higher than the corresponding ratio in GenPop: 1.0 (CI: 0.9-1.0). Conclusion: The present findings do not necessarily suggest an overtreatment with medication in RC. However, the frequent short-term use of antipsychotics, presumably for non-psychotic symptoms, is a concern, as it may reflect that the youth are not provided with the recommended first-line psychological treatments.

• Silwal, Sanju; Chudal, Roshan; Dybdahl, Ragnhild; Sillanmaki, Lauri; Lien, Lars & Sourander, A (2021). Post-traumatic Stress and Depressive Symptoms Among Adolescents After the 2015 Earthquake in Nepal: A Longitudinal Study. Child Psychiatry and Human Development.  ISSN 0009-398X. . doi: 10.1007/s10578-021-01136-3 Full text in Research Archive.
• Toft, Helge; Bramness, Jørgen Gustav; Tilden, Terje; Bolstad, Ingeborg & Lien, Lars (2021). Persistent level of mental distress in PTSD patients is not reflected in cytokine levels 1 year after the treatment.. Acta Neuropsychiatrica.  ISSN 0924-2708. . doi: 10.1017/neu.2021.11 Full text in Research Archive. Show summary

  Objective: Cross-sectional data show that post-traumatic stress disorder (PTSD) patients often have increased levels of circulating inflammatory markers. There is, however, still a paucity of longitudinal studies with long follow-up times on levels of cytokines in such patients. The current study assesses patients with and without PTSD diagnosis 1 year after discharge from inpatient treatment. Methods: Patients in treatment for serious non-psychotic mental disorders were recruited at the beginning of their treatment stay at a psychiatric centre in Norway. Ninety patients submitted serum samples and filled out the Hopkins Symptom Checklist-90 Revised Global Severity Index (HSCL-90R GSI) questionnaire during their mainstay and at a follow-up stay 1 year after discharge. Of these patients, 33 were diagnosed with PTSD, 48 with anxiety, depression, or eating disorder, while 9 patients had missing data. The patients were diagnosed using the Mini-International Neuropsychiatric Interview (MINI). Results: At the follow-up stay (T3), PTSD patients had higher levels of GSI scores than non-PTSD patients (p = 0.048). These levels were unchanged from the year before (T2) in both groups. The levels of circulating cytokines/chemokine did not differ between the PTSD and non-PTSD patients at T3. At T2, however, the PTSD and non-PTSD groups exhibited different levels of interleukin 1β (IL-1β) (p = 0.053), IL-1RA (p = 0.042), and TNF-α (p = 0.037), with the PTSD patients having the higher levels. Conclusion: Despite exhibiting different mental distress scores, the PTSD and non-PTSD patients did not differ regarding levels of circulating inflammatory markers at 1-year follow-up.

• Altunay, Ilknur K; Özkur, Ezgi; Dalgard, Florence; Gieler, Uwe; Aragones, Lucia Tomas; Lien, Lars; Poot, Françoise; Jemec, Gregor B.E.; Misery, Laurent; Szabo, Csanad; Linder, Dennis; Sampogna, Francesca; Evers, Andrea W M; Halvorsen, Jon Anders; Balieva, Flora Nicol; Szepietöwski, Jacek C.; Romanov, Dmitry; Marron, Servando E; Finlay, Andrew Y.; Salek, Sam S & Kupfer, Jörg (2020). Psychosocial Aspects of Adult Acne: Data from 13 European Countries. Acta Dermato-Venereologica.  ISSN 0001-5555.  100(4) . doi: 10.2340/00015555-3409 Full text in Research Archive. Show summary

  The link between acne and psychiatric morbidities has been demonstrated in many studies; however, large scale studies aiming to reveal the psychosocial impact of acne are rare. The aim of this study was to assess the psychological burden of adult acne patients. This analysis was based on a multicenter study including 213 acne patients and 213 controls from 13 European countries. The Hospital Anxiety and Depression Scale (HADS), Dermatology Life Quality Index, and EuroQol 5 dimensions 3 levels scores of the patients with acne were analyzed. Patients with acne (n = 213) had higher HADS scores for anxiety (mean ± standard deviation 6.70 ± 3.84) and depression (3.91 ± 3.43) than the controls (p < 0.001 for both). For patients with acne, 40.6% reported that they were very concerned about their skin disease, 12.3% had suicidal ideation, and, among those, 10 (4%) patients implied that acne was the cause of their suicidal thoughts. After adjusting for other variables, patients who had suicidal ideation (p = 0.007, and adjusted odds ratio 3.32 [95% confidence interval (CI): 1.39-7.93]) and stressful life events (p < 0.001, and adjusted OR 5.85 [95% CI: 2.65-12.86]) had a greater chance of fulfilling the HADS criteria for anxiety. This study highlights the need for a psychotherapeutic approach in order to recognize the concerns of acne patients and optimize their treatment. Keywords: anxiety; depression; health concerns; multicenter study; quality of life; acne vulgaris.

• Aye, Win Thuzar; Lien, Lars; Stigum, Hein; Schei, Berit; Sundby, Johanne & Bjertness, Espen (2020). Domestic violence victimisation and its association with mental distress: A cross-sectional study of the Yangon Region, Myanmar. BMJ Open.  ISSN 2044-6055.  10:e037936(9), s 1- 13 . doi: 10.1136/bmjopen-2020-037936 Full text in Research Archive. Show summary

  Objectives To estimate the prevalence of domestic violence, with subgroups of physical, sexual and emotional violence, among men and women and to assess the association between any lifetime domestic violence (DV) and mental distress among ever-married men and women. Design We conducted a cross-sectional study from October to November 2016 using a multistage sampling design. DV questionnaire was adopted from the Demographic and Health Survey programme. Mental distress was estimated using the Hopkins Symptom Checklist-10 (HSCL-10). HSCL-score and DV were the outcome and exposure variables, respectively, in multiple linear regression. Prevalence estimates and associations were presented with a 95% CI and the Wald test. Setting Urban and rural areas of the Yangon region, Myanmar. Participants Men and women ages 18 to 49 years were included. Institutionalised people, monks, nuns and individuals deemed too ill physically and/or mentally to participate were excluded. Results A random sample of 2383 people was included in the analyses. Among ever-married participants, lifetime (LT) and past-12-month (12M) prevalence of any domestic violence victimisation was higher in women compared with men: LT women: 61.8% (95% CI: 54.3 to 68.9) versus LT men: 42.4% (95% CI: 37.5 to 47.5) and 12M women: 51.2% (95% CI: 44.9 to 57.5) versus 12M men: 37.7% (95% CI: 32.9 to 42.7). Among never-married participants, lifetime physical and sexual violence victimisation rates was higher in men (34.3% and 7.9%) compared with women (19.1% and 6.4%). Mental distress was significantly associated with lifetime DV in women who were afraid of their husbands and men who had wives who exhibited controlling behaviours. Conclusions Domestic violence is prevalent among both men and women and is associated with mental distress. The findings highlight an urgent need to prevent domestic violence in both sexes, including through legal and policy reform and improved mental health services for DV victims.

• Aye, Win Thuzar; Lien, Lars; Stigum, Hein; Win, Hla Hla; Oo, Tin & Bjertness, Espen (2020). The prevalence of mental distress and the association with education: a cross-sectional study of 18-49-year-old citizens of Yangon Region, Myanmar. BMC Public Health.  ISSN 1471-2458.  20(1) . doi: 10.1186/s12889-020-8209-8 Full text in Research Archive. Show summary

  Background: Poor mental health is an important contributor to the global burden of disease. Mental health problems are often neglected in communities, and are scarcely studied in developing countries, including Myanmar. This study estimates the prevalence of mental distress by socio-demographic and health related factors, and the association between education and mental distress. As far as the authors are aware, this is the first population-based study in Myanmar estimating the prevalence of mental distress. Methods: Between October and November 2016, a cross sectional study was conducted using a multi-stage sampling design with face-to-face interviews using the Hopkins Symptom Checklist (HSCL-10) for mental distress (symptoms of depression and anxiety). The multivariable analysis strategy was based on Directed Acyclic Graphs (DAGs), to identify confounders, mediators and colliders. Pearson's chi-square was used for testing differences between proportions and multiple linear regression analysis was applied to explore the association between education (years at school) and mental distress (HSCL score). Results: A random sample of 2391 (99.6% response) men and women aged 18-49 years participated in the study. The prevalence of mental distress was 18.0% (95% confidence interval (CI): 14.7-21.9), being higher among women (21.2%; 95% (CI): 16.6-26.6) than men (14.9%; 95% (CI): 11.4-19.2). Older-age, being separated or divorced and having a higher number of children were associated with increased mental distress. In linear regression analyses, adjusted for confounders (age, marital status and income), there was a significant negative association between years at school and mental distress among women and older men (> 30 years), but not among the youngest men. Conclusions: The prevalence of mental distress is high, and there is an association between HSCL-10 score and education. Due to the scarcity of mental health services in Myanmar, the findings indicate a need for a mental health policy to handle the burden of mental health problems in Yangon, a burden which is probably high within the country.

• Brekke, Eva; Ness, Ottar & Lien, Lars (2020). Relational recovery in co-occurring conditions: a qualitative study of first-person experiences. Advances in Dual Diagnosis: Policy, practice and research in mental health and substance use.  ISSN 1757-0972.  13(2), s 89- 100 . doi: 10.1108/ADD-12-2019-0017 Show summary

  Purpose: The purpose of this study was to explore and describe first-person experiences of relational recovery in co-occurring mental health and substance use conditions. Design/methodology/approach: Within a phenomenological and collaborative approach, indepth individual interviews with eight persons with co-occurring conditions were analysed using systematic text condensation. Findings: Participants described interpersonal relationships as both supporting and hindering recovery in fundamental ways. Four categories of experiences of relational recovery were described: (1) Choosing one’s child; (2) Living with loneliness and a painful past; (3) Sacrificing everything for one’s partner; and (4) Regaining trust and support. Originality/value: This article provides an enhanced understanding of how interpersonal relationships may be experienced by persons who live with co-occurring conditions. The results generally support an understanding of recovery as a relational process.

• Johnson, Sverre Urnes; Hoffart, Asle; Tilden, Terje; Toft, Helge Prytz; Neupane, Sudan; Lien, Lars & Bramness, Jørgen Gustav (2020). Circulating cytokine levels in the treatment of comorbid anxiety disorders. Acta Neuropsychiatrica.  ISSN 0924-2708.  s 1- 7 . doi: 10.1017/neu.2020.38 Full text in Research Archive. Show summary

  Psychotherapy research aims to investigate predictors and moderators of treatment outcome, but there are few consistent findings. This study aimed to investigate cytokines in patients undergoing treatment for anxiety disorders and whether the level of cytokines moderated the treatment outcome. Thirty-seven patients with comorbid and treatment-resistant anxiety disorders were investigated using multilevel modelling. Serum cytokine levels were measured three times: pretreatment, in the middle of treatment, and at the end of treatment. Anxiety and metacognitions were measured weekly throughout treatment by self-report. The levels of monocyte chemoattractant protein-1, tumour necrosis factor-alpha, and interleukin-1 receptor antagonist did not change during therapy or were not related to the level of anxiety. Metacognitive beliefs predicted anxiety, but the relationship between metacognitions and anxiety was not moderated by cytokines. Limitations of the study include that the patients were not fasting at blood sampling, and we did not assess body mass index, which may affect cytokine levels. The lack of significance for cytokines as a predictor or moderator may be due to a lack of power for testing moderation hypotheses, a problem associated with many psychotherapy studies. Cytokines did not predict the outcome in the treatment of comorbid anxiety disorders in our sample. Furthermore, cytokines did not moderate the relationship between metacognitions and anxiety. Keywords: anxiety; comorbidity; cytokines; metacognition; psychotherapy.

• Kour, Prabhjot; Lien, Lars; Kumar, Bernadette N.; Biong, Stian & Pettersen, Henning (2020). Coping and Negotiating a Sense of Self: Immigrant Men's Experiences of Living with Co-Occurring Substance Use and Mental Health Disorders in Norway. American Journal of Psychiatric Rehabilitation.  ISSN 1548-7768.  22(1-2), s 43- 63 Show summary

  Recent years have seen an increase in the immigrant population in Norway, and within this population, a considerable rise in substance use disorders (SUDs) and elevated odds of developing mental health disorders (MHDs). Immigrants are thus regarded as an at-risk group for both situations. No studies have been conducted on the subjective understanding of co-occurring SUDs and MHDs among this immigrant population; thus, there is limited knowledge of the field. This qualitative study aims to explore the lived experiences of being an immigrant and living with co-occurring SUDs and MHDs. Individual interviews with 10 persons of immigrant background with co-occurring SUDs and MHDs, and treatment experience in Norway, were conducted. Data were analyzed using a phenomenological approach and systematic text condensation. Analysis yielded three categories, each with two subcategories, of the immigrants’ experiences of living with cooccurring SUDs and MHDs. The overarching theme was how they coped and negotiated a sense of self within the self, within the surrounding culture, and within the structures of society. Subcategories revealed their experiences that necessitated coping and negotiating sense of self within each level. Participants experienced “living a double life” and a “culture clash” along with a sense of belonging to a marginalized group, thus, lacking a sense of belonging in mainstream society. This study provides enhanced understanding of how immigrants with co-occurring SUDs and MHDs experience being an immigrant and having the concurrent disorders.

• Kour, Prabhjot; Lien, Lars; Kumar, Bernadette N.; Biong, Stian & Pettersen, Henning (2020). Treatment Experiences with Norwegian Health Care among Immigrant Men Living with Co-Occurring Substance Use- and Mental Health Disorders. Substance Abuse: Research and Treatment.  ISSN 1178-2218.  14, s 1- 10 . doi: 10.1177/1178221820970929 Full text in Research Archive. Show summary

  Immigrants are considered at risk of psychological distress and therefore involvement in substance abuse, due to a variety of pre- and post-migration factors. Further, there is lower treatment engagement, a higher dropout rate, and less frequent hospitalizations among this group compared to the general population. There are few studies on the subjective understanding of co-occurring substance use disorder (SUD) and mental health disorder (MHD) among immigrants in Norway. This qualitative study aims to explore the treatment experiences of immigrant men living with co-occurring SUD and MHD. Within a collaborative approach, individual interviews were conducted with 10 men of immigrant background, living with co-occurring SUD and MHD, who had treatment experiences from the Norwegian mental health and addiction services. Data were analyzed using a systematic text condensation. The analysis yielded 6 categories where participants described their treatment experiences in mental health and addiction services in Norway as: lack of connection, lack of individually tailored treatment, stigma and discrimination preventing access to treatment, health professionals with multi-cultural competence, care during and after treatment, and raising awareness and reducing stigma. A significant finding was the mention by participants of the value of being seen and treated as a “person” rather than their diagnosis, which may increase treatment engagement. They further mentioned aftercare as an important factor to prevent relapse. This study provides an enhanced understanding of how immigrant men living with co-occurring SUD and MHD experienced being treated in Norwegian healthcare settings. These experiences may add to the knowledge required to improve treatment engagement.

• Sampogna, Francesca; Abeni, Damiano; Gieler, Uwe; Tomas-Aragones, Lucia; Lien, Lars; Poot, Françoise; Jemec, Gregor Borut Ernst; Szabo, Csanad; Linder, Dennis; Van Middendorp, Henriet; Halvorsen, Jon Anders; Balieva, Flora Nicol; Szepietöwski, Jacek C.; Romanov, Dmitry; Marron, Servando E; Altunay, Ilknur K.; Finlay, Andrew Y.; Salek, Sam S; Kupfer, Jörg; Misery, Laurent & Dalgard, Florence (2020). Exploring the EQ-5D Dimension of Pain/Discomfort in Dermatology Outpatients from a Multicentre Study in 13 European Countries. Acta Dermato-Venereologica.  ISSN 0001-5555.  100(8) . doi: 10.2340/00015555-3477 Full text in Research Archive. Show summary

  Pain and discomfort are important symptoms in dermatology. The aim of this cross-sectional, multicentre study was to describe the prevalence of pain/discomfort and its associations in patients with several dermatological conditions across 13 European countries. The outcome was the prevalence of pain/discomfort according to a question of the EQ-5D questionnaire. Data collected from November 2011 to February 2013 were complete for 3,509 consecutive outpatients. Moderate or extreme pain/discomfort was reported by 55.5% of patients and 31.5% of controls with no skin conditions. The highest proportions were reported by patients with hidradenitis suppurativa (92.9%), leg ulcer (81.4%), prurigo (80%) and lichen planus (75.6%). Pain/discomfort was associated with older age, low educational level, clinical severity, flare on scalp or hands, itch, depression, anxiety, low quality of life, and thoughts of suicide. It is important to enquire specifically about pain/discomfort during clinical consultations and to address it when planning a patient's care. Keywords: EQ-5D; discomfort; pain; dermatology.

• Sanhori, Zienat Balla Mohamed Ahmed; Hauff, Edvard; Eide, Arne Henning; Mdala, Ibrahimu; Abdelrahman, Abdullah; Brunborg, Cathrine & Lien, Lars (2020). Changes in prevalence of mental disorders among internally displaced persons in central Sudan: a 1-year follow-up study. Global Mental Health (GMH).  ISSN 2054-4251.  7 . doi: 10.1017/gmh.2020.16 Full text in Research Archive. Show summary

  Background Sudan has one of the largest numbers of internally displaced persons (IDPs) in the world, estimated at five million. The main cause of displacement was the civil war. Attention to the health and in particular the mental health of IDPs has been lacking. That includes limited population longitudinal data describing the “natural” fluctuations of mental morbidity among these groups. The aim of this study is to investigate the level and stability of mental disorders among IDPs over a 1-year period. Method In this 1-year follow-up of IDPs in two settlement areas in central Sudan, 1549 persons 18 years or older were interviewed twice using the MINI International Neuropsychiatric Interview. Trained psychologists collected the data in a random household survey in the selected IDP areas. Results We found overall high stability among those having and those free of mental disorders in this 1-year follow-up study. There were, however, discernible and statistically significant increases in overall new cases of mental disorders from T1 to T2 as major depression increased by 1.4%, generalized anxiety by 2.8% and social phobia by 1.4%. Conclusion The study revealed continued high levels and increases of mental disorders over time, although with a pattern of substantial persistence among those initially ill and limited recovery. This might be due to a complex set of factors such as unavailability of mental health services, poverty, low educational level and social exclusion.

• Stensvehagen, Marianne Torp; Bronken, Berit Arnesveen; Lien, Lars & Larsson, Ulf Gerry (2020). Interrelationship of Posttraumatic Stress, Hassles, Uplifts, and Coping in Women With a History of Severe Sexual Abuse: A Cross-Sectional Study. Journal of Interpersonal Violence.  ISSN 0886-2605. . doi: 10.1177/0886260520935479 Full text in Research Archive. Show summary

  Experiencing trauma, such as sexual abuse, increases the risk of a negative health outcome. The aim of the present study was to compare two groups of female survivors of sexual abuse, one group with a lower indication of posttraumatic stress disorder (L-PTSD) and one with a higher indication of posttraumatic stress disorder (H-PTSD). We hypothesized that, with a history of sexual abuse, higher levels of PTSD symptoms would be associated with more daily hassles, fewer daily uplifts, and more maladaptive coping strategies, and that there would be more reporting of severe types of sexual victimization, less resourceful socioeconomic conditions and a lower level of emotional stability. A questionnaire, including measures of socioeconomic conditions, trauma experience, emotional stability (the Single-Item Measures of Personality), Posttraumatic Stress Disorder Checklist (PCL), daily hassles and uplifts (the Stress Profile), and coping strategies (the Brief Coping Orientation to Problems Experienced [COPE] questionnaire), was completed by 57 female users at nine support centers for survivors of incest and sexual abuse in Norway. The results show that the H-PTSD group reported significantly more daily hassles, fewer daily uplifts, and more use of maladaptive coping strategies. The L-PTSD group reported more emotional stability, fewer daily hassles, and more uplifts, and used more adaptive coping strategies. However, few differences were found between the H-PTSD and the L-PTSD groups with regard to severity of sexual abuse and socioeconomic conditions. The results on the hassle, uplift, and coping scales are potentially interesting from an interventional point of view. Major life events such as sexual abuse may be out of control for the afflicted victim. Appraisal of and coping with everyday events, however, can be affected and offer interesting possibilities for interventions directed at the survivor, her significant others, and professional helpers.

• Toft, Helge Prytz; Lien, Lars; Neupane, Sudan Prasad; Abebe, Dawit Shawel; Tilden, Terje; Wampold, Bruce E. & Bramness, Jørgen Gustav (2020). Cytokine concentrations are related to level of mental distress in inpatients not using anti-inflammatory drugs. Acta Neuropsychiatrica.  ISSN 0924-2708.  32(1) . doi: 10.1017/neu.2019.36 Full text in Research Archive. 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. Keywords: PTSD; anti-inflammatory agents; cytokines; depression; inflammation.

• Vattø, Ingvild E.; Haug, Sigrid H. K.; deMarinis, Valerie; Lien, Lars & Danbolt, Lars Johan (2020). The significance ascribed to contacting a diaconal suicide-prevention crisis line in Norway: a qualitative study. Mental Health, Religion & Culture.  ISSN 1367-4676.  23(2), s 113- 126 . doi: 10.1080/13674676.2020.1763281 Show summary

  Suicide-prevention crisis lines worldwide offer support to individuals in crisis, nonetheless, there is limited in-depth knowledge as to the significance of contacting these services from the service-users’ first-hand perspectives. This study aimed to provide a deeper understanding of the significance ascribed to contacting a diaconal suicide-prevention crisis line in Norway. In-depth qualitative interviews were conducted with nine callers. The material was analysed using systematic text condensation. The analysis revealed three main themes reflecting the crisis line’s emotional, relational and existential support functions in terms of providing: (i) immediate emotional availability, (ii) experiences of connectedness and acceptance, and (iii) a safe space for existential meaning-making processes. The findings point to the need for future research on the value of integrating biopsychosocio-existential perspectives into intervention models within the field of crisis support. KEYWORDS: Crisis lines, suicide prevention, diaconal, culture, existential meaning-making

• Vattø, Ingvild Engh; DeMarinis, Valerie; Haug, Sigrid H. K.; Lien, Lars & Danbolt, Lars Johan (2020). Emotional stressors among volunteers operating a diaconal suicide-prevention crisis line in Norway: a qualitative study. British Journal of Guidance and Counselling.  ISSN 0306-9885.  48(4), s 563- 575 . doi: 10.1080/03069885.2019.1646409 Show summary

  Despite the worldwide proliferation of suicide-prevention crisis-line networks, there is limited in-depth knowledge of how the volunteer call responders experience and manage emotional stressors. The study’s purpose was to explore emotional stressors related to operating a diaconal suicide-prevention crisis line, and how these are managed in daily operations. In this qualitative study, 27 volunteers were interviewed in four focus groups. The material was analysed using systematic text condensation. The participants experienced emotional stressors related to being unable to actively intervene, encountering traumatised callers and feeling uncertain about representing the Church. They used a combination of personal coping strategies and organisational support factors. Implications for training and practice are further discussed.

• Ørbeck, Beate; Øvergaard, Kristin Romvig; Hjellvik, Vidar; Bramness, Jørgen Gustav; Hansen, Berit M Hjelde & Lien, Lars (2020). The Use of Sleep Medication in Youth Residential Care. Journal of child and adolescent psychopharmacology.  ISSN 1044-5463.  30(5), s 335- 341 . doi: 10.1089/cap.2019.0172 Full text in Research Archive. Show summary

  Objectives: To investigate the use of sleep medication and concomitant psychotropic medication in children and adolescents placed under residential care (RC). Methods: Participants were youth 0–20 years of age placed in RC institutions at least once during 2016. Data on filled prescriptions were taken from the Norwegian Prescription Database to compare the use of sleep medication in RC with the general child population (GenPop) and how it covaried with gender, age, reasons for RC placement, and concomitant use of other psychotropic medications (antidepressants, anxiolytics, antipsychotics, and psychostimulants). Results: A total of 2171 youths were identified in RC at mean age 14 years (82% ‡ 13 years). Seventeen percent (371/2171) used sleep medications (melatonin 11%, alimemazine 7%, and benzodiazepines/z-hypnotics 2%) significantly more than the 2.3% who used in GenPop. The girl/boy ratio for medication use in RC was 1.8 (95% confidence interval [CI] = 1.5–2.2), not significantly different from the corresponding ratio in GenPop (1.4; 95% CI = 1.3–1.5). The use of sleep medication increased with age. When comparing reasons for placement in RC, medication use was particularly low among unaccompanied minor asylumseekers (2%). About half of the youths used concomitant psychotropic medication, with clear gender differences; Girls used about twice as much antidepressants, anxiolytics, and antipsychotics, whereas boys used 1.3 times more psychostimulants. Conclusion: Youths in RC used more sleep medication and concomitant psychotropic medication than the GenPop, most likely reflecting the increased psychosocial strain and mental disorders reported in this population. Further studies of prevalence, assessment, and treatment of sleep problems in RC populations are warranted.

• 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 Full text in Research Archive. 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.

• Dalgard, Florence; Svensson, Åke; Halvorsen, Jon Anders; Gieler, Uwe; Schut, Christina; Tomas-Aragones, Lucia; Lien, Lars; Poot, Francoise; Jemec, Gregor Borut Ernst; Misery, Laurent; Szabó, Csanád; Linder, Dennis; Sampogna, Francesca; Koulil, Saskia Spillekom-van; Balieva, Flora Nicol; Szepietöwski, Jacek C.; Lvov, Andrey; Marron, Servando Eugenio; Altunay, Ilknur K.; Finlay, Andrew Yule; Salek, Sam & Kupfer, Jörg (2019). Itch and mental health in dermatological patients across Europe: A cross-sectional study in 13 countries. Journal of Investigative Dermatology.  ISSN 0022-202X.  s 1- 6 . doi: 10.1016/j.jid.2019.05.034 Show summary

  Abstract Itch is a highly prevalent and multidimensional symptom. We aimed to analyze the association between itch and mental health in dermatological patients. This multicenter study is observational and cross-sectional and was conducted in dermatological clinics across 13 European countries. A total of 3,530 patients and 1,094 healthy controls were included. Patients were examined clinically. Outcome measures were itch (presence, chronicity, and intensity), the Hospital Anxiety and Depression Scale, EQ-5D visual analogue scale, sociodemographics, suicidal ideation, and stress (negative life events and economic difficulties). Ethical approval was obtained. Results showed significant association between the presence of itch in patients and clinical depression (odds ratio, 1.53; 95% confidence interval, 1.15-2.02), suicidal ideation (odds ratio, 1.27; 95% confidence interval, 1.01-1.60), and economic difficulties (odds ratio, 1.24; 95% confidence interval, 1.10-1.50). The mean score of reported generic health status assessed by the EQ-5D visual analogue scale was 65.9 (standard deviation = 20.1) in patients with itch, compared with 74.7 (standard deviation = 18.0) in patients without itch (P < 0.001) and 74.9 (standard deviation = 15.7) in controls with itch compared with 82.9 (standard deviation = 15.6) in controls without itch (P < 0.001). Itch contributes substantially to the psychological disease burden in dermatological patients, and the management of patients should include access to multidisciplinary care. Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.

• 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
• Pedersen, Monica Stolt; Landheim, Anne; Møller, Merete & Lien, Lars (2019). First-line managers' experience of the use of audit and feedback cycle in specialist mental health care: A qualitative case study. Archives of Psychiatric Nursing.  ISSN 0883-9417.  33(6), s 103- 109 . doi: 10.1016/j.apnu.2019.10.009 Full text in Research Archive. Show summary

  Abstract Background Audit and feedback was the main strategy to facilitate implementation of The National Guideline for Persons with Concurrent Substance Use Disorders and Mental Disorders in specialist mental health services. Studies have shown that leadership support contributes to implementation success. The aim of the study was to explore how first-line managers in a District Psychiatric Centre experienced using audit and feedback cycle. Method The study had a qualitative case study design with individual interviews with five first-line managers from a District Psychiatric Centre in Norway. Qualitative content analysis was conducted. Results First-line managers were positive to contribute to better practice for the patient group and apply available tools. Four themes emerged: 1) Lack of endurance, where first-line managers saw their role as being process leaders, but failed to persist, 2) Lack of support in the process, where first-line managers called for a stronger organisational focus 3) Lack of ownership, where first-line managers felt the process was imposed on them, and 4) Lack of leader autonomy, where first-line managers seemed insecure about their role between professional leadership and own management. Conclusion First-line managers were not sufficiently experienced or equipped to solve the implementation process satisfactorily. They were torn between different commitments, without the autonomy to act as process drivers or facilitators, and without taking the necessary leadership role. The potential impact of the use of audit and feedback may thus not be fully realized, in part, because of limited organisational support and capacity to respond effectively.

• 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 Full text in Research Archive. 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.

• Titeca, Géraldine; Goudetsidis, Laetitia; Francq, Bernard G.; Sampogna, Francesca; Gieler, Uwe; Tómas-Aragonés, Lucía; Lien, Lars; Jemec, Gregor Borut Ernst; Misery, Laurent; Szabó, Csanád; Linder, Michael Dennis; Evers, Andrea Walburga Maria; Halvorsen, Jon Anders; Balieva, Flora Nicol; Szepietöwski, Jacek Cezary; Romanov, Dmitry V.; Marrón, Servando E.; Altunay, İlknur Kıvanç; Finlay, Andrew Yule; Salek, Sam S.; Kupfer, Jörg P.; Dalgard, Florence & Poot, Françoise (2019). 'The psychosocial burden of alopecia areata and androgenetica': a cross-sectional multicentre study among dermatological out-patients in 13 European countries. Journal of the European Academy of Dermatology and Venereology.  ISSN 0926-9959.  s 1- 6 . doi: 10.1111/jdv.15927 Full text in Research Archive. Show summary

  BACKGROUND: Hair diseases play an important burden on patients' lives, causing significant emotional and psychosocial distress. However, the impairment due to different hair conditions, such as alopecia areata (AA) and androgenetic alopecia (AGA), has rarely been compared. OBJECTIVE: The aim of this study was to assess the psychological burden of subgroups of patients with different hair diseases and to compare them to a healthy population. METHODS: In this study, we analysed a subgroup of patients with hair diseases from patients of a large multicentre study including 3635 dermatological patients and 1359 controls from 13 European countries. In the subgroup of patients with hair diseases, we analysed the socio-demographic characteristics, the stress level, and the impact of hair diseases on quality of life (QoL), anxiety, and depression and we compared them among patients with AA, AGA and healthy controls. RESULTS: The study population included 115 patients (77% women, 23% men) with hair diseases, 37 of whom with AA and 20 with AGA. Patients with hair diseases had a lower education level than healthy controls (medium educational level: 43% vs. 28%). Overall, 41% of the patients reported stressful life events during the last 6 months compared with 31% of the controls. Patients with the same age, sex, depression level and comorbidities had a worse QoL when suffering from AA than from AGA (Mean Dermatology Life Quality Index score: 5.8 vs. 2.5). CONCLUSION: Patients with hair diseases are more anxious, depressed and have a lower QoL than controls.

• 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 Full text in Research Archive.
• 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 Full text in Research Archive.
• 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 Full text in Research Archive.
• 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 (JNRBM).  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.

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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.

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• Bjørkhaug, Steinar Traae; Valeur, Jørgen; Bramness, Jørgen Gustav & Lien, Lars (2020). Alcohol-related alterations of the gut microbial flora.
• Lien, Lars & Stensrud, Bjørn (2020). Samtidig rusmisbruk og psykisk lidelse - "ROP-lidelser", I: Marianne Thorsen Gonzalez (red.),  Psykiske lidelser - Faglig forståelse og terapeutisk tilnærming. Sykepleiefaglige og flerfaglige perspektiver.  Gyldendal Akademisk.  ISBN 9788205516700.  Kapittel 18.  s 177 - 186
• Lien, Lars & Lund, Johan (2019). To 70th Jubilee og professor Gunnar Tellnes. Herald of the International Academy of Science. Russian Section.  ISSN 1819-5733.  (1), s 74- 74
• 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
• Dybdahl, Ragnhild & Lien, Lars (2018). Mental helse er nøkkel til utvikling. Avisa Vårt land.
• 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

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