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Lamb D, Milton A, Forsyth R, Lloyd-Evans B, Akther S, Fullarton K, O'Hanlon P, Johnson S, Morant N. Implementation of a crisis resolution team service improvement programme: a qualitative study of the critical ingredients for success. Int J Ment Health Syst 2024; 18:18. [PMID: 38704589 PMCID: PMC11069280 DOI: 10.1186/s13033-024-00638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Crisis Resolution Teams (CRTs) offer home-based care for people in mental health crisis, as an alternative to hospital admission. The success of CRTs in England has been variable. In response to this, the CRT Optimization and RElapse prevention (CORE) study developed and trialled a 12-month Service Improvement Programme (SIP) based on a fidelity model. This paper describes a qualitative evaluation of the perspectives of CRT staff, managers, and programme facilitators. We identify barriers and facilitators to implementation, and mechanisms by which service improvements took place. METHODS Managers and staff from six purposively sampled CRTs were interviewed, as well as six facilitators who were employed to support the implementation of service improvement plans. Semi-structured focus groups and individual interviews were conducted and analysed using thematic analysis. FINDINGS A majority of participants viewed all components of the SIP as helpful in improving practice, although online resources were under-used. Perceived barriers to implementation centred principally around lack of staff time and ownership. Support from both senior staff and facilitators was essential in enabling teams to undertake the work associated with the SIP. All participating stakeholder groups reported that using the fidelity model to benchmark their CRT work to best practice and feel part of a 'bigger whole' was valuable. CONCLUSION CRT staff, managers and programme facilitators thought that a structured service improvement programme helped to increase fidelity to a best practice model. Flexibility (from all stakeholders) was key to enable service improvement actions to be manageable within time- and resource-poor teams.
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Affiliation(s)
- Danielle Lamb
- Department of Applied Health Research, UCL, Gower Street, London, WC1E 6BT, UK.
| | - Alyssa Milton
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Ruud T, Hasselberg N, Siqveland J, Holgersen KH. Patient-reported outcome, clinician-reported outcome, and patient satisfaction with treatment by crisis resolution teams: a multicenter pre-post study of outcome and associated factors in Norway. BMC Psychiatry 2024; 24:82. [PMID: 38297302 PMCID: PMC10829386 DOI: 10.1186/s12888-024-05543-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/20/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Crisis resolution teams (CRTs) have become a part of mental health services in many high-income countries. Many studies have investigated the impact of CRTs on acute admissions to inpatient units, but very few studies have investigated patient-reported and clinician-reported outcomes for CRT service users. Our aims were to study patient-reported and clinician-reported outcomes of CRT treatment, how the outcomes were associated with characteristics of the service user and the treatment, and whether outcomes were different across CRTs. METHODS The study was a pre-post observational multicenter study of 475 patients receiving treatment from 25 CRTs in urban and rural areas in Norway. There was no control group. Outcomes were change in mental health status reported by service users using CORE-10 and by clinicians using HoNOS. Patient satisfaction was measured using CSQ-8 at the end of the treatment. Components of CRT accessibility and interventions were measured by clinicians reporting details on each session with the service user. CRT model fidelity was measured using the CORE CRT Fidelity Scale version 2. We used paired t-tests to analyze outcomes and linear mixed modeling to analyze associations of the outcomes with the characteristics of service users and the treatment provided. Using independent t-tests, we analyzed differences in outcomes and patient satisfaction between two clusters of CRTs with differences in accessibility. RESULTS The patient-reported outcomes and the clinician-reported outcomes were significantly positive and with a large effect size. Both were significantly positively associated with practical support and medication management and negatively associated with collaboration with mental health inpatient units. Patient satisfaction was high at the end of the treatment. CRTs with higher accessibility had a significantly better clinician-reported outcome, but no significant differences were reported for patient-reported outcomes or patient satisfaction. CONCLUSIONS CRT treatment led to improved symptom status as reported by patients and clinicians, as well as high patient satisfaction. Practical support and medication management were the interventions most strongly associated with positive outcomes. Some of the variations in outcomes were at the team level. Patient- and clinician-reported outcomes should be used more in studies on the effect of treatment provided by crisis resolution teams.
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Affiliation(s)
- T Ruud
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - N Hasselberg
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - J Siqveland
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- National Center for Suicide Research and Prevention, University of Oslo, Oslo, Norway
| | - K H Holgersen
- Nidelv Community Mental Health Centre, Tiller, Department of Mental Health, St. Olavs Hospital, Trondheim, Norway
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
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Le Novere M, Johnson S, Lloyd-Evans B, Marston L, Ambler G, Clarke CS, Osborn D, Lamb D, Hunter RM. Cost-effectiveness of peer-supported self-management for people discharged from a mental health crisis team: methodological challenges and recommendations. Front Psychiatry 2023; 14:1031159. [PMID: 37333912 PMCID: PMC10272352 DOI: 10.3389/fpsyt.2023.1031159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 04/27/2023] [Indexed: 06/20/2023] Open
Abstract
Background Mental health acute crisis episodes are associated with high inpatient costs. Self-management interventions may reduce readmission by enabling individuals to manage their condition. Delivery of such interventions by Peer Support Workers (PSWs) may be cost-effective. CORE, a randomized control trial of a PSW self-management intervention compared to usual care, found a significant reduction in admissions to acute mental healthcare for participants receiving the intervention. This paper aims to evaluate the cost-effectiveness of the intervention over 12 months from a mental health service perspective. Analysis methods of increasing complexity were used to account for data missingness and distribution. Methods Participants were recruited from six crisis resolution teams in England from 12 March 2014 to 3 July 2015 (trial registration ISRCTN: 01027104). Resource use was collected from patient records at baseline and 12 months. The EQ-5D-3L was collected at baseline and 4 and 18 months, and linear interpolation was used to calculate 12-month values for quality-adjusted life-years (QALYs). The primary analysis of adjusted mean incremental costs and QALYs for complete cases are calculated separately using OLS regression. Secondly, a complete-case non-parametric two-stage bootstrap (TSB) was performed. The impacts of missing data and skewed cost data were explored using multiple imputation using chained equations and general linear models, respectively. Results Four hundred and forty-one participants were recruited to CORE; 221 randomized to the PSW intervention and 220 to usual care plus workbook. The probability that the PSW intervention was cost-effective compared with the workbook plus usual care control at 12 months varied with the method used, and ranged from 57% to 96% at a cost-effectiveness threshold of £20,000 per QALY gained. Discussion There was a minimum 57% chance that the intervention was cost-effective compared to the control using 12-month costs and QALYs. The probability varied by 40% when methods were employed to account for the relationship between costs and QALYs, but which restricted the sample to those who provided both complete cost and utility data. Caution should therefore be applied when selecting methods for the evaluation of healthcare interventions that aim to increase precision but may introduce bias if missing data are heavily unbalanced between costs and outcomes.
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Affiliation(s)
- Marie Le Novere
- Research Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Sonia Johnson
- Divison of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Brynmor Lloyd-Evans
- Divison of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Louise Marston
- Research Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Gareth Ambler
- Department of Statistical Science, Faculty of Mathematical & Physical Sciences, University College London, London, United Kingdom
| | - Caroline S. Clarke
- Research Department of Primary Care and Population Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - David Osborn
- Divison of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Danielle Lamb
- Department of Applied Health Research, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Rachael Maree Hunter
- Department of Applied Health Research, Faculty of Population Health Sciences, University College London, London, United Kingdom
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Holgersen KH, Pedersen SA, Brattland H, Hynnekleiv T. A scoping review of studies into crisis resolution teams in community mental health services. Nord J Psychiatry 2022; 76:565-574. [PMID: 35148238 DOI: 10.1080/08039488.2022.2029941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE OF ARTICLE Crisis Resolution Teams (CRT) for rapid assessment and short-term treatment of mental health problems have increasingly been implemented internationally over the last decades. Among the Nordic countries, the CRT model has been particularly influential in Norway, where 'Ambulante akutteam (AAT)' is a widespread psychiatric emergency service for adult patients. However, the clinical practice of these teams varies significantly. To aid further development of the service and guide future research efforts, we carried out a scoping review to provide an up-to-date overview of research available in primary studies focusing on phenomena related to CRTs in English and Scandinavian literature. METHODS A systematic literature search was conducted in the bibliometric databases MEDLINE, Embase, PsychINFO, Scopus, and SveMed+. Included studies were thematically analyzed using a qualitative method. RESULTS The search identified 1516 unique references, of which 129 were included in the overview. Thematic analysis showed that the studies could be assigned to: (1) Characteristics of CRTs (k = 45), which described key principles or specific interventions; (2) Implementation of CRTs (k = 54), which were descriptive about implementation in different teams, or normative about what clinical practice should include; and (3) Effect of CRTs (k = 38). CONCLUSIONS The international research literature on CRTs or equivalent teams is extensive. Many sub-themes have been studied with various research methodologies. Recent studies provide a better evidence base for how to organize services and to select therapeutic interventions, but there is still a need for more controlled studies in the field.
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Affiliation(s)
- Katrine Høyer Holgersen
- Nidelv Community Mental Health Center, Tiller, Clinic of Mental Health, St Olavs Hospital, Trondheim, Norway.,Department of Psychology, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Sindre Andre Pedersen
- Library Section for Medicine and Health Sciences, NTNU University Library, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Heidi Brattland
- Nidelv Community Mental Health Center, Tiller, Clinic of Mental Health, St Olavs Hospital, Trondheim, Norway
| | - Torfinn Hynnekleiv
- Department for Acute Psychiatry and Psychosis Treatment, Psychiatric Health Services Division, Sykehuset Innlandet Trust, Reinsvoll, Norway
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Jacob KS. Acute psychiatric care: the need for contextual understanding and tailored solutions. World Psychiatry 2022; 21:238-239. [PMID: 35524603 PMCID: PMC9077605 DOI: 10.1002/wps.20964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Ruud T, Friis S. Continuity of care and therapeutic relationships as critical elements in acute psychiatric care. World Psychiatry 2022; 21:241-242. [PMID: 35524593 PMCID: PMC9077600 DOI: 10.1002/wps.20966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Clinic of Health Services Research and Psychiatry, Institute of Clinical Medicine, University of Oslo, Blindern, Oslo, Norway
| | - Svein Friis
- Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Mental Health and Addiction, Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
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Johnson S, Dalton‐Locke C, Baker J, Hanlon C, Salisbury TT, Fossey M, Newbigging K, Carr SE, Hensel J, Carrà G, Hepp U, Caneo C, Needle JJ, Lloyd‐Evans B. Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care. World Psychiatry 2022; 21:220-236. [PMID: 35524608 PMCID: PMC9077627 DOI: 10.1002/wps.20962] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap-proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision-making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low- and middle-income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low-resource settings may lead to wider learning from locally embedded strategies.
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Affiliation(s)
- Sonia Johnson
- Division of PsychiatryUniversity College LondonLondonUK,Camden and Islington NHS Foundation TrustLondonUK
| | | | - John Baker
- School of Healthcare, University of LeedsLeedsUK
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College LondonLondonUK,Department of PsychiatrySchool of Medicine, and Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa UniversityAddis AbabaEthiopia
| | - Tatiana Taylor Salisbury
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College LondonLondonUK
| | - Matt Fossey
- Faculty of Health, Education, Medicine and Social CareAnglia Ruskin UniversityChelmsfordUK
| | - Karen Newbigging
- Department of PsychiatryUniversity of OxfordOxfordUK,Institute for Mental Health, University of BirminghamBirminghamUK
| | - Sarah E. Carr
- Health Service and Population Research DepartmentInstitute of Psychiatry, Psychology and Neuroscience, King’s College LondonLondonUK
| | - Jennifer Hensel
- Department of PsychiatryUniversity of ManitobaWinnipegMBCanada
| | - Giuseppe Carrà
- Department of Medicine and SurgeryUniversity of Milano BicoccaMilanItaly
| | - Urs Hepp
- Integrated Psychiatric Services Winterthur, Zürcher UnterlandWinterthurSwitzerland
| | - Constanza Caneo
- Departamento de Psiquiatría, Facultad de MedicinaPontificia Universidad Católica de ChileSantiagoChile
| | - Justin J. Needle
- Centre for Health Services Research, School of Health Sciences, City, University of LondonLondonUK
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Ruud T, Holgersen KH, Hasselberg N, Siqveland J. Accessibility and interventions of crisis resolution teams: a multicenter study of team practices and team differences in Norway. BMC Psychiatry 2022; 22:350. [PMID: 35597926 PMCID: PMC9123690 DOI: 10.1186/s12888-022-03992-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/09/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Components of crisis resolution teams' (CRTs) practices have been defined in recommendations and a fidelity scale, and surveys have reported how team leaders describe CRT practices. However, studies on CRTs have not measured and reported details of the crisis intervention provided to individual service users. The present study aimed to measure how various components of CRT practice were provided to individual service users and differences in practice between CRTs. METHODS The study was exploratory and part of a prospective multicenter pre-post project on outcome of CRT treatment in Norway. Accessibility and intervention components of 25 CRTs were measured for 959 service users at the first contact after referral and in 3,244 sessions with service users. The data on CRT practice components were analyzed with descriptive statistics and factor analyses, and differences between teams were analyzed using ANOVA and calculating the proportion (intraclass correlation coefficient) of total variance that was due to differences between teams. RESULTS One-third of the service users had their first session with the CRT the day of referral and another third the following day. Treatment intensity was mean 1.8 sessions the first week, gradually decreasing over subsequent weeks. Three of ten sessions were conducted in the service user's home and six of ten in the team's location. Eight of ten sessions took place during office hours and two of ten in the evening. The CRT provided assessment and psychological interventions to all service users. Family involvement, practical support, and medication were provided to two of ten service users. Between CRTs, significant differences were identified for a substantial proportion of practice components and especially for several aspects of accessibility. Cluster analysis identified two clusters of CRTs with significant differences in accessibility but no significant differences in the use of intervention components. CONCLUSIONS Measurements of accessibility and interventions provided to individual service users gave a detailed description of CRT practices and differences between teams. Such measurements may be helpful as feedback on clinical practice, for studying and comparing crisis resolution team practices, and in future studies on the association between different outcomes and potential critical elements of crisis interventions.
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Affiliation(s)
- Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Katrine Høyer Holgersen
- grid.52522.320000 0004 0627 3560Nidelv Community Mental Health Center, Clinic of Mental Health, St. Olavs Hospital, Trondheim, Norway ,grid.5947.f0000 0001 1516 2393Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Nina Hasselberg
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Johan Siqveland
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway ,grid.5510.10000 0004 1936 8921National Center for Suicide Research and Prevention, University of Oslo, Oslo, Norway
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Hasselberg N, Klevan TG, Weimand B, Uverud GM, Holgersen KH, Siqveland J, Ruud T. Similarities and differences between service users' and carers' experiences of crisis resolution teams in Norway: a survey. BMC Psychiatry 2022; 22:266. [PMID: 35421950 PMCID: PMC9011940 DOI: 10.1186/s12888-022-03928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 04/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Crisis resolution team (CRT) care in adult mental health services is intended to provide accessible and flexible short-term, intensive crisis intervention to service users experiencing a mental health crisis and involve their carers (next of kin). Research on users' and especially carers' experiences with CRT care is scarce and is mostly qualitative in nature. METHODS Altogether, 111 service users and 86 carers from 28 Norwegian CRTs were interviewed with The Service User and Carer Structured Interviews of the CORE Crisis Resolution Team Fidelity Scale Version 2. Their experiences with different aspects of CRT care were reported with descriptive statistics, and differences between service users' and carers' experiences were analyzed with the Mann-Whitney U Test. RESULTS The service users and carers reported that the CRT care mostly reflected their needs and what they wanted. The experiences of service users and carers were mostly similar, except for significant differences in received information and how the termination of CRT care appeared. Both groups experienced the organization of the CRT care as accessible, with continuity, reliability, and flexibility, but without a high intensity of care. Both groups found the content of the CRT care supportive, sensitive, with a choice of treatment type and a range of interventions beyond medication, but a lack of written treatment plans and discharge plans. Carers were rarely involved in discharge meetings. Regarding the role of CRTs within the care system, both groups agreed upon the lack of facilitation of early discharge from inpatient wards and lack of home treatment, but both groups confirmed some collaboration with other mental health services. CONCLUSION Service users and carers found that the CRTs were accessible, reliable, flexible, supportive, sensitive, and provided a range of interventions beyond medication. Limitations were lack of a high intensity of care, limited written treatment and discharge plans, limited provision of home treatment, and lack of gatekeeping of acute beds. Both groups experienced the CRT care as mostly similar, but with significant differences regarding involvement in care planning and discharge preparation.
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Affiliation(s)
- Nina Hasselberg
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Trude Gøril Klevan
- grid.463530.70000 0004 7417 509XFaculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Bente Weimand
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway ,grid.463530.70000 0004 7417 509XFaculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Gunn-Marit Uverud
- grid.463530.70000 0004 7417 509XUniversity of South-Eastern Norway, Notodden, Vestfold Norway
| | - Katrine Høyer Holgersen
- grid.52522.320000 0004 0627 3560Nidelv Community Mental Health Center, Clinic of Mental Health, St Olavs hospital, Trondheim, Norway ,grid.5947.f0000 0001 1516 2393Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Siqveland
- grid.411279.80000 0000 9637 455XDivision of Mental Health Services, Akershus University Hospital, Lørenskog, Norway ,grid.5510.10000 0004 1936 8921National Center for Suicide Research and Prevention, University of Oslo, Oslo, Norway
| | - Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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