Setting
The psychiatric acute department at Østmarka, St. Olav's University Hospital Trondheim, Norway had a catchment area of 140.000 inhabitants. About 700 patients above 18 years with acute psychiatric conditions were admitted each year. All patients in the catchment area suffering from acute psychiatric conditions with symptoms to a degree that locked in-patient ward was needed, were admitted to this department. Norwegian acute psychiatric services are public and available to everyone.
Material
All acute admissions to inpatient treatment in a five month period were included. If patients were admitted more than once, all admissions were included.
At admission the patients were systematically asked about use of prescribed and non-prescribed psychotropic medication. All medications used before admission and still being prescribed at the time of admission were recorded. Benzodiazepine derivates sold for oral use in Norway were diazepam, oxazepam, alprazolam, clonazepam, flunitrazepam and nitrazepam. Zopiclone and zolpidem were categorized as non- benzodiazepine hypnotics. Use of benzodiazepines without a prescription is illegal in Norway [18].
The doctor on duty asked all patients at admission if they had used any substances during the last week. The doctor on duty also made an assessment whether the patient were clinically affected by substances or not.
All patients were asked to give urine samples as soon as possible and samples collected within 24 hours after admission were included in the study. Findings of substances used after admissions were not reported. The samples were analyzed with liquid chromatography with mass spectrometry (LC-MS). Substances in urine were reported as present or not present.
Use of substances or medications was defined by either the patient reported use of substances or medication during the last week before admission, the medication was reported used as a prescribed medication, or the substances or medication were detected in urine samples at admission. The following psychotropic medications were recorded: Antiepileptics, lithium, antidepressants, sedatives and anxiolytics, antipsychotics, psychostimulants, methadone and buprenorfin.
Diagnoses according to ICD-10 "Diagnostic criteria for research" [19] were set at discharge in a weekly consensus meeting in the department's staff including the patient's therapist and at least two psychiatrists of whom at least one personally knew the patient. In the present study both main and secondary diagnoses are reported.
The patients were assessed with the Global Assessment Scale Split version (GAF-S) at admittance [20]. GAF-S is based on DSM-4's GAF and is a two-item scale measuring global symptoms (GAF-S-Symptoms) and functioning (GAF-S-Function) separately [21].
In the group of patients with psychotic disorders (ICD-10 F 20.00 - F 29.99) use of antipsychotics in usual clinical doses for psychoses at admission was defined as adequate treatment. In patients with affective disorders (ICD-10 F 30.00 - F39.99) admitted with current episode depression, all antidepressants and mood stabilizing medication were defined as adequate. In addition atypical antipsychotics was defined as adequate treatment for patients with bipolar disorder, and all antipsychotics was defined as adequate treatment of mania [22].
The admissions were divided in legal use of benzodiazepines before admission defined as use of prescribed benzodiazepines, illegal use defined as use of non prescribed benzodiazepines or a combination of prescribed and non prescribed benzodiazepines, and no use of benzodiazepines before admission. Use of benzodiazepine was considered non-prescribed if there was no record of prescribed benzodiazepine for the last year before admission, or if a previous prescription was terminated by a doctor. New information received during the stay at hospital was included in the judgment. All written information from the admitting doctor and the hospital staff for the index admission and admissions from the last year before the index admission was reviewed in order to assure the right group assignment.
Ethics
The study was approved by "The Regional Committee for Medical Research Ethics, Central Norway".
Statistics
Categorical variables were analyzed using Chi- squared test or Fisher's exact test. Ordinal variables were compared using Mann-Whitney U-test/Kruskal Wallis test, and continuous variables were analyzed using Students t-test/ANOVA. Association of frequencies and age groups was analyzed with the Linear-by-linear association test. The α-level was set to 0.05. SSPS version 17.0 for Windows was used.