Mulder, C.L.

Is Vitamin D Deficiency a Confounder in Alcoholic Skeletal Muscle Myopathy? (Article)

2013-01-01T00:00:00Z

Background: Excessive intake of alcohol is often associated with low or subnormal levels of vitamin D even in the absence of active liver disease. As vitamin D deficiency is a well-recognized cause of myopathy, alcoholic myopathy might be related to vitamin D deficiency. Chronic alcoholic myopathy affects approximately half of chronic alcoholics and is characterized by the insidious development of muscular weakness and wasting. Although alcohol or its metabolites may have a direct toxic effect on muscles, the relationship between alcoholic myopathy and vitamin D deficiency has not been examined extensively. Methods: We reviewed the literature on alcoholic myopathy and hypovitaminosis D myopathy and compared the pathophysiological findings to designate possible mechanisms of vitamin D action in alcohol-related myopathy. Results and Conclusions: Given the strong interdependency of suboptimal levels of vitamin D, phosphate, and magnesium in chronic alcohol abuse, we hypothesize that combined deficiencies interfere with membrane and intracellular metabolic processes in chronic alcohol-related myopathy; however, it is not yet possible to define exact mechanisms of interaction.

Motivation and treatment engagement intervention trial (MotivaTe-IT): The effects of motivation feedback to clinicians on treatment engagement in patients with severe mental illness (Article)

2012-11-24T00:00:00Z

Background: Treatment disengagement and non-completion poses a major problem for the successful treatment of patients with severe mental illness. Motivation for treatment has long been proposed as a major determinant of treatment engagement, but exact mechanisms remain unclear. This current study serves three purposes: 1) to determine whether a feedback intervention based on the patients' motivation for treatment is effective at improving treatment engagement (TE) of severe mentally ill patients in outpatient psychiatric treatment, 2) to gather insight into motivational processes and possible mechanisms regarding treatment motivation (TM) and TE in this patient population and 3) to determine which of three theories of motivation is most plausible for the dynamics of TM and TE in this population.Methods/design: The Motivation and Treatment Engagement Intervention Trial (MotivaTe-IT) is a multi-center cluster randomized trial investigating the effectiveness of feedback generated by clinicians regarding their patients' treatment motivation upon the patients' TE. The primary outcome is the patients' TE. Secondary outcomes are TM, psychosocial functioning and quality of life. Patients whose clinicians generate monthly motivation feedback (additional to treatment as usual) will be compared to patients who receive treatment as usual. An estimated 350 patients, aged 18 to 65 years, with psychotic disorders and/or severe personality disorders will be recruited from outpatient community mental health care. The randomization will be performed by a computerized randomization program, with an allocation ratio of 1:1 (team vs. team or clinician vs. clinician) and patients, but not clinicians, will be blind to treatment allocation at baseline assessment. Due to the nature of the trial, follow-up assessment can not be blinded.Discussion: The current study can provide important insights regarding motivational processes and the way in which motivation influences the treatment engagement and clinical outcomes. The identification of possible mechanisms through which changes in the outcomes occur, offers a tool for the development of more effective future interventions to improve TM and TE.Trial registration: Current Controlled Trials NTR2968.

Symptomatic and functional remission and its associations with quality of life in patients with psychotic disorder in assertive community treatment teams (Article)

2012-11-01T00:00:00Z

Objectives: The aims of the present study were (1) to determine the proportion and characteristics of patients treated in Assertive Community Treatment teams who achieve symptomatic remission (SR) and/or functional remission (FR) and (2) to explore the association between both types of remission and (3) their bearing on quality of life (QoL). Methods: Data comprised assessments from 278 patients who were repeatedly assessed using the Positive and Negative Syndrome Scale to assess SR, the Health of the Nation Outcome Scales to assess FR, and a shortened version of the Manchester Short Assessment to assess QoL. χ2Tests and a logistic regression analysis were used to analyze the relation between patient and treatment characteristics and achieving SR or FR. A Kruskal-Wallis test, Mann-Whitney U tests, and a logistic regression analysis were used to analyze the relationship between remission status and QoL. Results: After a mean treatment duration of 2.4 years, 26% met the criteria for SR and 30% for FR. Prescription of antipsychotic medication was associated with achieving both SR and FR. Approximately half of the patients who achieved SR also achieved FR. Achieving FR was associated with better QoL. Patients in SR did not have better QoL than did patients not in SR. Conclusions: Remission of symptoms in patients treated in Assertive Community Treatment teams was not a prerequisite for FR or vice versa. FR, not SR, was associated with better QoL. © 2012 Elsevier Inc.

Aggression and seclusion on acute psychiatric wards: Effect of short-term risk assessment (Article)

2011-12-01T00:00:00Z

Background: Short-term structured risk assessment is presumed to reduce incidents of aggression and seclusion on acute psychiatric wards. Controlled studies of this approach are scarce. Aims: To evaluate the effect of risk assessment on the number of aggression incidents and time in seclusion for patients admitted to acute psychiatric wards.Method: A cluster randomised controlled trial was conducted in four wards over a 40-week period (n = 597 patients). Structured risk assessment scales were used on two experimental wards, and the numbers of incidents of aggression and seclusion were compared with two control wards where assessment was based purely on clinical judgement. Results: The numbers of aggressive incidents (relative risk reduction 768%, P<0.001) and of patients engaging in aggression (relative risk reduction RRR =-50%, P<0.05) and the time spent in seclusion (RRR =745%, P<0.05) were significantly lower in the experimental wards than in the control wards. Neither the number of seclusions nor the number of patients exposed to seclusion decreased. Conclusions: Routine application of structured risk assessment measures might help reduce incidents of aggression and use of restraint and seclusion in psychiatric wards.

Does Treatment Adherence Therapy reduce expense of healthcare use in patients with psychotic disorders? Cost-minimization analysis in a randomized controlled trial (Article)

2011-10-12T00:00:00Z

Background: Adherence interventions in psychotic disorders have produced mixed results. Even when an intervention improved adherence, benefits to patients were unclear. Treatment Adherence Therapy (TAT) also improved adherence relative to Treatment As Usual (TAU), but it had no effects on symptoms or quality of life. TAT may or may not reduce healthcare costs. Aim: To determine whether TAT reduces the use of healthcare resources, and thus healthcare costs. Method: Randomized controlled trial of TAT versus TAU with 98 patients. Interviews were conducted at baseline (T0), six months later, when TAT had been completed (T1) and at six-month follow-up (T2). We have used admission data and part of the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P). We compared total costs in the TAT group with those in the control group with the help of multivariate analysis of covariance. Results: TAT did not significantly minimize total costs. In the TAT group, the mean one-year health-treatment cost per patient (including TAT sessions) was € 23 003.64 (SD = 19 317.95), whereas in the TAU group it was € 22 489.88 (SD = 25 224.57) (F(1) = .652, p = .42). However, there were two significant differences at item-level, both with higher costs for the TAU group: psychiatric nurse contacts and legal proceedings for court-ordered admissions. Conclusions: Because TAT did not reduce total healthcare costs, it did not contribute to cost-minimization. Its benefits are therefore questionable. No other adherence intervention has included analysis of cost-effectiveness or cost-minimization.

Why do patients with schizophrenia who Have poor insight still take antipsychotics? Memory deficits as moderators between adherence belief and behavior (Article)

2011-09-01T00:00:00Z

While lack of insight is often predictive of antipsychotic nonadherence, some inconsistency in the literature remains unexplained. Verbal memory deficits may moderate the association between insight and adherence. Based on cross-sectional data, outpatients treated with antipsychotics for a psychotic disorder were divided into those with good (n=53) and poor (n=59) memory. Poor insight predicted nonadherence only among the subgroup with relatively good memory (r=0.43; P<0.01), but had no effect in the subgroup with worse memory (r=0.08; ns). Structural equation modelling revealed significant moderation (χ=4.72; df=1; P<0.05), which means that a significantly better model fit was found by allowing the analysis to differentiate between the two memory groups. Thus, poor insight was only associated with poor medication adherence among patients with relatively good memory. We speculate that memory deficits commonly associated with schizophrenia may partly explain why poor insight does not always lead to poor medication adherence. Copyright

The Effects of Assertive Community Treatment Including Integrated Dual Diagnosis Treatment on Nuisance Acts and Crimes in Dual-Diagnosis Patients (Article)

2011-05-10T00:00:00Z

We investigated whether Assertive Community Treatment (ACT) combined with Integrated Dual Diagnosis Treatment (IDDT) is associated with a decrease in nuisance acts and crime convictions in dual-diagnosis repeated offenders. Forty-three patients were monitored from 21 months before until 12 months after the start of ACT-IDDT, using police data and the Health of the Nation Outcome Scales (HoNOS). Results show that while nuisance acts and convictions increased in the 21 months before the start of ACT-IDDT, nuisance acts decreased and convictions stabilized during the next 12 months. The decrease in nuisance acts was associated with a decrease in substance abuse.

Recovery style predicts remission at one-year follow-up in outpatients with schizophrenia spectrum disorders (Article)

2011-05-01T00:00:00Z

Although people with schizophrenia use various coping strategies, it is largely unknown how their coping style contributes to remission of the illness. The concept of recovery style-either by sealing over or integrating-reflects an important distinction. We wanted to examine whether recovery style predicts remission at a 1-year follow-up. We examined the recovery style, insight, therapeutic alliance, and symptoms in 103 patients with psychotic disorders. To assess the remission status, the symptoms were measured at 6 and 12 months. Logistic regression analyses were used. Results showed that scoring an extra category toward integration (six categories exist) increased the odds of remission 1.84-fold (95% confidence interval, 1.11 to 3.03). Insight and therapeutic alliance were not predictive. Although remission was also predicted by positive symptom levels at baseline, this did not influence the effect of recovery style. In conclusion, independently of symptom levels, insight, or therapeutic alliance, an integrating recovery style increases the odds of remission at a 1-year follow-up.

Op maat gesneden interventie bevordert therapietrouw bij psychotische patiënten: een RCT* (Article)

2011-03-10T00:00:00Z

Doel: Het vergelijken van de effecten van ‘Treatment adherence therapy’ (TAT) en van reguliere behandeling op therapietrouw, symptomen, kwaliteit van leven en aantal al dan niet gedwongen opnames bij patiënten met psychotische stoornissen. TAT is een nieuwe behandeling die rekening houdt met de per patiënt verschillende oorzaken van therapieontrouw. Opzet: Gerandomiseerde, gecontroleerde studie bij 109 poliklinische patiënten die niet goed aan hun behandeling meewerkten. Deze RCT is gemeld bij het Nederlands trialregister: NTR1159. Methode: Vóór de interventie (t0), direct na 6 maanden interventie (t1), en na nog eens 6 maanden follow-up (t2) namen we verschillende tests af om therapietrouw, symptomen en kwaliteit van leven te bepalen. Dit werd meestal gedaan door geblindeerde interviewers. We gebruikten een ‘intention to treat’-multivariate analyse. Resultaten: TAT had in vergelijking met de standaardbehandeling significant gunstiger effecten op medicatietrouw (cohen-d = 0,43) en op de medewerking aan de behandeling (cohen-d = 0,48). De resultaten bleven bij een follow-up van 6 maanden significant voor medicatietrouw. Een trend werd ook gevonden voor gedwongen opnames (1,9% versus 11,8%). Psychiatrische symptomen en kwaliteit van leven verbeterden niet. Conclusie: Treatment adherence therapy (TAT) verbeterde therapietrouw en voorkwam mogelijk gedwongen opnames.

Treatment adherence therapy in people with psychotic disorders: randomised controlled trial (Article)

2010-12-01T00:00:00Z

Interventions to improve adherence to treatment in people with psychotic disorders have produced inconclusive results. We developed a new treatment, treatment adherence therapy (TAT), whose intervention modules are tailored to the reasons for an individual's non-adherence. Aims To examine the effectiveness of TAT with regard to service engagement and medication adherence in out-patients with psychotic disorders who engage poorly. METHOD: Randomised controlled study of TAT v. treatment as usual (TAU) in 109 out-patients. Most outcome measurements were performed by masked assessors. We used intention-to-treat multivariate analyses (Dutch Trial Registry: NTR1159). RESULTS: Treatment adherence therapy v. TAU significantly benefited service engagement (Cohen's d = 0.48) and medication adherence (Cohen's d = 0.43). Results remained significant at 6-month follow-up for medication adherence. Near-significant effects were also found regarding involuntary readmissions (1.9% v. 11.8%, P = 0.053). Symptoms and quality of life did not improve. CONCLUSIONS: Treatment adherence therapy helps improve engagement and adherence, and may prevent involuntary admission.

Treatment outcome in patients receiving assertive community treatment (Article)

2010-08-01T00:00:00Z

In an observational study of severely mentally ill patients treated in assertive community treatment (ACT) teams, we investigated how treatment outcome was associated with demographic factors, clinical factors, and motivation for treatment. To determine psychosocial outcome, patients were routinely assessed using the Health of the Nation Outcome Scales (HoNOS). Trends over time were analyzed using a mixed model with repeated measures. The HoNOS total score was modeled as a function of treatment duration and patient-dependent covariates. Data comprised 637 assessments of 139 patients; mean duration of follow-up was 27.4 months (SD = 5.4). Substance abuse, higher age, problems with motivation, and lower educational level were associated with higher HoNOS total scores (i.e., worse outcome). To improve treatment outcome, we recommend better implementation of ACT, and also the implementation of additional programs targeting subgroups which seem to benefit less from ACT.

Ethnicity and dangerousness criteria for court ordered admission to a psychiatric hospital (Article)

2010-02-01T00:00:00Z

Background: Black and minority ethnic (BME) populations are disproportionately detained in psychiatric hospitals. Aim: To examine the dangerousness criteria for compulsory court ordered admission to a psychiatric hospital in White and BME persons. Method: We examined the psychiatric examinations for court ordered compulsory admissions in 506 White and 299 BME persons from October 2004 until January 2008 in Rotterdam, the Netherlands. The White and BME groups are compared using Chi-square tests and in case of significant differences with logistic regression models adjusted for age, gender, mental disorders and socio-economic background. Results: In BME persons, violence towards others and neglect of relatives were more often reasons to request court order admission as compared with Whites (39.8 vs. 25.3%, P < 0.001, respectively, 6.4 vs. 2.4%, P = 0.01). This remained true after adjustment for age, gender, mental disorders and socio-economic background [OR 1.56 (95% CI 1.12-2.18), P = 0.01, respectively; OR 3.08 (95% CI 1.31-7.26), P = 0.01]. The other reasons for a request of court order admission had a similar prevalence in both groups (suicide or self-harm, social decline, severe self-neglect, arousal of aggression of others, danger to the mental health of others, and the general safety of persons and goods). Conclusion: Violence towards others and neglect of relatives are more often a reason to request court ordered admission in BME than in White persons. BME patients are more often perceived as potentially dangerous to others.

The PCLO gene and depressive disorders: replication in a population-based study (Article)

2010-02-01T00:00:00Z

Abstract: Previous genome-wide association analysis revealed a new putative candidate gene for major depression: the PCLO gene. Replication in one population-based cohort did not yield genome-wide significance and further replication efforts in clinical studies were unsuccessful. We aimed to validate the association of single-nucleotide polymorphism (SNP) rs2522833 in the PCLO gene with depression in the Rotterdam Study, a prospective population-based cohort of elderly persons. In the Rotterdam Study, we identified 579 persons with a broad depression phenotype (depressive syndromes) of whom 178 cases with DSM-defined depressive disorder. The control group consisted of 912 persons free of depression during the follow-up period and in their histories. Logistic regression analysis showed an association between rs2522833 and depressive disorders (P = 0.0025). However, no association between the broader depressive syndrome group and this SNP was observed (P = 0.20). A meta-analysis combining all studies from the original publication and our study yielded a P-value of 2.16 x 10(-3) for the association between SNP rs2522833 and depressive disorders. However, as in the previous publication, high heterogeneity between studies was observed. Thus, a meta-analysis with the findings from three population-based studies was performed. This demonstrated a genome-wide significant P-value (P = 1.93 x 10(-9)). In conclusion, this study provides additional evidence for an association between PCLO and depressive disorders in a population-based study; no association with a broader syndromal phenotype was observed.

Involuntary admission of emergency psychiatric patients: Report from the Amsterdam study of acute psychiatry (Article)

2009-11-01T00:00:00Z

Objective: This brief report presents initial data from the Amsterdam Study of Acute Psychiatry (ASAP-I) about factors associated with the decision to admit patients compulsorily (involuntarily) to emergency psychiatric services in the Amsterdam region of the Netherlands. Methods: The study was a prospective cohort study of 1,970 consecutive patients who came into contact with the Psychiatric Emergency Service Amsterdam. Results: A history of more than 14 outpatient contacts the previous year was associated with a low risk of compulsory admission (OR=.3). An involuntary admission in the previous five years was associated with a higher risk (OR=3.7). Referral by a general practitioner was associated with a low risk compared with referral by police (OR= 2.4) or by mental health services (OR=2.3). Conclusions: The hypothesis that outpatient treatment may help to prevent compulsory admission found some support in this study. More research is needed to understand the mechanisms of the associations so that an intervention study can be developed to test this hypothesis.

Does mental health service integration affect compulsory admissions? (Article)

2009-09-01T00:00:00Z

Abstract. BACKGROUND: Over recent years, the number of compulsory admissions in many countries has increased, probably as a result of the shift from inpatient to outpatient mental health care. This might be mitigated by formal or collaborative relationships between services. METHODS: In a retrospective record linkage study, we compared two neighboring districts, varying in level of service integration. Two periods were combined: 1991-1993 and 2001-2003. We included patients aged 18-60, who had a first emergency compulsory admission (n=830). Their psychiatric history was assessed, and service-use after admission was monitored over a 12-month follow-up. RESULTS: Over a 10-year period, compulsory admission rates increased by 47%. Difference in relative increase between the integrated and non-integrated services was 14%. Patient characteristics showed different profiles in the two districts. Length of stay was >10 days shorter in the integrated district, where the proportion of involuntary readmissions decreased more, and where aftercare was swift and provided to about 10% more patients than in the non-integrated district. CONCLUSIONS: Services outcomes showed better results where mental healthcare was more integrated. However, limited effects were found and other factors than integration of services may be more important in preventing compulsory admissions.

Fewer symptoms vs. more side-effects in schizophrenia? Opposing pathways between antipsychotic medication compliance and quality of life (Article)

2009-08-01T00:00:00Z

Abstract BACKGROUND: Non-compliance with medication often has long-term detrimental effects in patients with schizophrenia. However, when patients are compliant, it is not certain whether they experience short-term improved quality of life. By simultaneously reducing symptoms and increasing side-effects, compliance with antipsychotics may have opposing effects on a patient's perceived quality of life. AIM: This study aimed to identify any clinical-empirical evidence for two pathways between compliance and quality of life. METHOD: To evaluate various pathways between compliance (Service Engagement Scale plus a one-item rating), psychotic symptoms (Positive and Negative Syndromes Scale), adverse medication effects (Subjective Wellbeing under Neuroleptics scale), and quality of life (EQ-5D), we used Structural Equation Modeling on cross-sectional data of 114 patients with a psychotic disorder. RESULTS: Compliance was not directly related to quality of life (r=0.004). The best-fitting model (chi(2)=1.08; df=1) indicated that high compliance was associated with fewer psychotic symptoms (beta=-0.23) and more adverse medication effects (beta=0.22). Symptoms (beta=-0.17) and adverse medication effects (beta=-0.48) were both related to lower quality of life. DISCUSSION: Our results suggest that compliance with antipsychotics has two opposing pathways towards quality of life, albeit indirect ones. While compliance was associated with less severe psychotic symptoms, and was thus related to higher quality of life, it was also associated with more adverse medication effects, and was thus related to lower quality of life. However, due to our study design, we cannot draw firm conclusions on causality. Two possible clinical implications of the results for compliance and interventions are discussed.

The effects of crisis plans for patients with psychotic and bipolar disorders: A randomised controlled trial (Article)

2009-07-09T00:00:00Z

Background: Crises and (involuntary) admissions have a strong impact on patients and their caregivers. In some countries, including the Netherlands, the number of crises and (involuntary) admissions have increased in the last years. There is also a lack of effective interventions to prevent their occurrence. Previous research has shown that a form of psychiatric advance statement - joint crisis plan - may prevent involuntary admissions, but another study showed no significant results for another form. The question remains which form of psychiatric advance statement may help to prevent crisis situations. This study examines the effects of two other psychiatric advance statements. The first is created by the patient with help from a patient's advocate (Patient Advocate Crisis Plan: PACP) and the second with the help of a clinician only (Clinician facilitated Crisis Plan: CCP). We investigate whether patients with a PACP or CCP show fewer emergency visits and (involuntary) admissions as compared to patients without a psychiatric advance statement. Furthermore, this study seeks to identify possible mechanisms responsible for the effects of a PACP or a CCP. Methods/Design: This study is a randomised controlled trial with two intervention groups and one control condition. Both interventions consist of a crisis plan, facilitated through the patient's advocate or the clinician respectively. Outpatients with psychotic or bipolar disorders, who experienced at least one psychiatric crisis during the previous two years, are randomly allocated to one of the three groups. Primary outcomes are the number of emergency (after hour) visits, (involuntary) admissions and the length of stay in hospital. Secondary outcomes include psychosocial functioning and treatment satisfaction. The possible mediator variables of the effects of the crisis plans are investigated by assessing the patient's involvement in the creation of the crisis plan, working alliance, insight into illness, recovery style, social support, locus of control, service engagement and coping with crises situations. The interviews take place before randomisation, nine month later and finally eighteen months after randomisation. Discussion: This study examines the effects of two types of crisis plans. In addition, the results offer an understanding of the way these advance statements work and whether it is more effective to include a patients' advocate in the process of creating a psychiatric advance statement. These statements may be an intervention to prevent crises and the use of compulsion in mental health care. The strength and limitations of this study are discussed.

Stigma moderates the associations of insight with depressed mood, low self-esteem, and low quality of life in patients with schizophrenia spectrum disorders (Article)

2009-07-01T00:00:00Z

Abstract BACKGROUND: Good insight into illness in patients with schizophrenia is related not only to medication compliance and high service engagement, but also to depression, low self-esteem, and low quality of life. The detrimental effects of insight pose a problem for treatment. AIM: To investigate whether the negative associations of good insight are moderated by perceived stigma. METHOD: Respondents were 114 patients with schizophrenia spectrum disorders. We used Analyses of Variance (ANOVA) and Structural Equation Modeling (SEM) to test moderation. RESULTS: Good insight was associated with high service engagement and high compliance. Also, good insight was associated with depressed mood, low quality of life, and negative self-esteem. This association was strong when stigma was high and weak when stigma was low. SEM showed that the constrained model performed significantly worse than the unconstrained model, in which detrimental associations of insight were free to vary across stigma groups (chi(2)=19.082; df=3; p<.001). CONCLUSIONS: Our results suggest that the associations of insight with depression, low quality of life, and negative self-esteem are moderated by stigma. Patients with good insight who do not perceive much stigmatization seem to be best off across various outcome parameters. Those with poor insight have problems with service engagement and medication compliance. Patients with good insight accompanied by stigmatizing beliefs have the highest risk of experiencing low quality of life, negative self-esteem, and depressed mood. A clinical implication is that when it is attempted to increase insight, perceived stigma should also be addressed.

Involuntary admission may support treatment outcome and motivation in patients receiving assertive community treatment (Article)

2009-01-01T00:00:00Z

Objective: Patients with severe mental illness who are treated in assertive community treatment (ACT) teams are sometimes involuntarily admitted when they are dangerous to themselves or others, and are not motivated for treatment. However, the consequences of involuntary admission in terms of psychosocial outcome and treatment motivation are largely unknown. We hypothesized that involuntary admission would improve psychosocial outcome and not adversely affect their treatment motivation. Methods: In the context of routine 6-monthly outcome monitoring in the period January 2003-March 2008, we used the Health of the Nation Outcome Scales (HoNOS) and a motivation-for-treatment scale to assess 260 severely mentally ill patients at risk for involuntary admission. Mixed models with repeated measures were used for data analyses. Results: During the observation period, 77 patients (30%) were involuntarily admitted. Relative to patients who were not involuntarily admitted, these patients improved significantly in HoNOS total scores (F = 17,815, df = 1, p < 0.001) and in motivation for treatment (F = 28.139, df = 1, p < 0.001). Patients who were not involuntarily admitted had better HoNOS and motivation scores at baseline, but did not improve. Conclusions: Involuntary admission in the context of ACT was associated with improvements in psychosocial outcome and motivation for treatment. There are no indications that involuntary admission leads to deterioration in psychosocial outcome or worsening of motivation for treatment.

Veranderingen in crisisinterventie en acute psychiatrie; Amsterdamse consulten in 1983 en 2005 (Article)

2009-01-01T00:00:00Z

ACHTERGROND Sinds 1992 stijgt het aantal inbewaringstellingen (ibs’en) in Nederland opvallend. In Amsterdam is er zelfs sprake van een verdrievoudiging. Psychiatrische behandeling in de Amsterdamse klinieken dreigt gedomineerd te worden door dwang. DOEL Een beeld krijgen van de veranderingen in de acute psychiatrie die hebben bijgedragen aan de stijging van het aantal dwangopnames met ibs. METHODE Vergelijken van een cohort (n = 460) consulten verricht door de stedelijke crisisdienst in 1983 met een cohort (n = 436) consulten verricht in 2004-2005 op de volgende variabelen: werkwijze van de crisisdienst, kenmerken van de patiënten, diagnose en uitkomst van de consulten. RESULTATEN Vergeleken met 1983 waren er in 2004-2005 meer diensten betrokken bij psychiatrische patiënten in acute situaties in het publieke domein. Het aantal patiënten dat via de politie kwam, verdubbelde. De consulten, die in 1983 uitsluitend werden gedaan op de plek waar de patiënt verbleef, werden in 2004-2005 voor 60% op het bureau van de dienst gedaan. Het aantal patiënten met een psychose in de cohort nam toe van 52,0 naar 63,3%. Er was een toename van ibsopnames (van 16,7 naar 20,0% van de interventies) en een scherpe daling van vrijwillige opnames (van 25,7 naar 7,6%). Het totale aantal opnames na een consult daalde van 42 naar 28%. CONCLUSIE De outreachende dienst met een eerstelijnskarakter van 1983 is veranderd in een gespecialiseerde psychiatrische ehbo met een bescheiden outreachende functie. De vrijwillige opname is vrijwel verdwenen bij de crisisdienst. Nader onderzoek naar de kenmerken van de consulten en naar de variabelen die een rol spelen bij het toepassen van dwang is noodzakelijk.

Bijna altijd toekennen en weinig twijfel: overwegingen van onafhankelijke psychiaters tijdens de beoordeling rechterlijke machtiging (Article)

2009-01-01T00:00:00Z

Achtergrond: Sinds een aantal jaren is er een sterke stijging te zien van het aantal gedwongen opnamen, vooral van de rechterlijke machtigingen. Er is weinig bekend over het beslissingsproces dat voorafgaat aan het verkrijgen van een rechterlijke machtiging. Doel: Meer inzicht krijgen in de overwegingen van de onafhankelijke psychiater bij de beslissing tot het uitschrijven van een geneeskundige verklaring voor een rechterlijke machtiging. Methode: Van 862 eerste beoordelingen werd prospectief informatie verzameld over demografische en klinische patiëntkenmerken en het oordeel (toekennen, twijfel of afwijzen) van de onafhankelijke psychiater over de noodzaak tot het uitschrijven van een geneeskundige verklaring. Resultaten: Bij 9% van alle beoordelingen twijfelde de psychiater over de noodzaak, maar schreef wel een geneeskundige verklaring uit. In 3% van het aantal beoordelingen wees de psychiater de aanvraag af. Het gevaarscriterium ‘direct fysiek gevaar voor zichzelf of een ander’ hing samen met minder vaak afwijzen of twijfelen. De belangrijkste reden om een aanvraag af te wijzen was de mogelijkheid van een alternatieve behandeling. Conclusie: In de praktijk schrijft de onafhankelijke psychiater vrijwel altijd een geneeskundige verklaring uit wanneer de behandelaar een rechterlijke machtiging aanvraagt. Meer en eerder gebruik maken van mogelijkheden zoals intensieve bemoeizorg, bewindvoering of curatele ter voorkoming van gevaar zou kunnen bijdragen aan een vermindering van het aantal machtigingen.

Beliefs about mental health problems and help-seeking behavior in Dutch young adults (Article)

2009-01-01T00:00:00Z

Abstract BACKGROUND: Mental health problems in young adults are frequent and impairing, but are often left untreated. This study among young adults with self-perceived mental health problems examines beliefs about mental health problems (i.e. their cause, consequences, timeline, and controllability) and help-seeking behaviour. METHOD: A cross-sectional population survey (n = 2,258) in the south-west Netherlands. Participants were included who reported having mental health problems during the past year (n = 830). Beliefs about cause, consequences, timeline, and controllability of self-perceived mental health problems were assessed with the Illness Perception Questionnaire. Internalizing and externalizing psychopathology was assessed with the Adult Self-Report. RESULTS: A multivariate logistic regression analysis indicates that independent of sex, age, and severity of psychopathology, higher levels on the intra-psychic causes scale (OR = 1.95, 95%CI = 1.48-2.58), the consequences scale (OR = 1.81, 95%CI = 1.40-2.33), and the treatment control scale (OR = 1.97, 95%CI = 1.60-2.41) are associated with an increased likelihood of mental health service use, while higher levels of personal control (OR = 0.76, 95%CI = 0.62-0.93) are associated with a decreased likelihood. CONCLUSIONS: Beliefs that may encourage young adults with mental health problems to seek professional help include the beliefs that mental health problems have adverse consequences and that treatment can help. Since these beliefs are related to young adults' knowledge of mental health problems, help-seeking behavior may be encouraged by educating young adults about mental health problems and the effective mental health treatments which are available.

Reconstructing continuity of care in mental health services: a multilevel conceptual framework (Article)

2009-01-01T00:00:00Z

Abstract Continuity of mental health care is a key issue in the organization and evaluation of services for patients with disabling chronic conditions. Over many years, health services researchers have been exploring the conceptual boundaries between continuity of care and other service characteristics. On the basis of papers published over the past decade, we argue that while conceptual consensus is growing, there is room to improve continuity measures, and the development of practical interventions is still at an early stage. There is growing consensus that continuity of care is a multidimensional concept. We identified four core elements: continuous care; care of an individual patient; cross-boundary care; and care recorded objectively. These elements help clarify conceptual boundaries, and incorporate measurement guidelines. With reference to these core elements, we define types of continuity of care, including informational continuity, management continuity, relational continuity and contact continuity. In order to improve continuity of care, better understanding is needed of the complex inter-relationship of core elements and types of continuity. A multilevel perspective on continuity of care can guide research to develop and evaluate new interventions. Achieving continuity of care is hindered by the lack of standard measures and administrative data appropriate to assessing continuity. Account should be taken not only of the nature of the patient population, but also of local conditions. To address these topics and identify best practices, research should be multidisciplinary and take a comparative, naturalistic form.

Young adults face major barriers to seeking help from mental health services (Article)

2008-10-01T00:00:00Z

Objective: Mental health problems often emerge in young adulthood. Although effective treatments are available, young adults are unlikely to seek professional help. This study examined barriers-to-care in young adults with serious internalizing or externalizing problems. Methods: Population-based study among 2258 19-32-year olds in the south-west region of the Netherlands. Barriers-to-care were examined in participants with serious internalizing or externalizing problems who did not seek professional help. A potential barrier was that participants denied that they had mental health problems. In those admitting problems, barriers were assessed with the Barriers-to-Care checklist and analyzed with Latent Class Analysis. Results: Of 362 participants with serious internalizing or externalizing problems 237 (65.5%) did not seek professional help. Of non-help-seeking young adults 36% denied having problems; additionally Latent Class Analysis revealed that 37% Perceived Problems as Self-Limiting (e.g., they believed that problems were not serious) and 24% Perceived Help-Seeking Negatively (e.g., they believed that treatment would not help). Conclusions: Young adults' barriers-to-care reflect limitations in their knowledge of mental health problems and available treatments, but possibly also a failure of existing mental health services to engage young people. More knowledge is urgently needed about the effectiveness of mental health treatments for young adults specifically. Practice implications: Treatment accessibility for young adults may be augmented by improving their mental health literacy.

Associations between ethnicity and self-reported hallucinations in a population sample of young adults in The Netherlands (Article)

2008-08-01T00:00:00Z

Background: Psychotic disorders are more common in people from ethnic minorities. If psychosis exists as a continuous phenotype, ethnic disparities in psychotic disorder will be accompanied by similar ethnic disparities in the rate of psychotic symptoms. This study examined ethnic disparities in self-reported hallucinations in a population sample of young adults. Method: A cross-sectional population survey (n=2258) was carried out in the south-west Netherlands. Seven ethnic groups were delineated: Dutch natives, Turks, Moroccans, Surinamese/Antilleans, Indonesians, other non-Western immigrants (mostly from Africa or Asia) and Western immigrants (mostly from Western Europe). Self-reported auditory and visual hallucinations were assessed with the Adult Self-Report (ASR). Indicators of social adversity included social difficulties and a significant drop in financial resources. Results: Compared to Dutch natives, Turkish females [odds ratio (OR) 13.48, 95% confidence interval (CI) 5.97-30.42], Moroccan males (OR 8.36, 95% CI 3.29-21.22), Surinamese/Antilleans (OR 2.19, 95% CI 1.05-4.58), Indonesians (OR 4.15, 95% CI 1.69-10.19) and other non-Western immigrants (OR 3.57, 95% CI 1.62-7.85) were more likely to report hallucinations, whereas Western immigrants, Turkish males and Moroccan females did not differ from their Dutch counterparts. When adjusting for social adversity, the ORs for self-reported hallucinations among the non-Western immigrant groups showed considerable reductions of 28% to 52%. Conclusions: In a general population sample, several non-Western immigrant groups reported hallucinations more often than Dutch natives, which is consistent with the higher incidence of psychotic disorders in most of these groups. The associations between ethnicity and hallucinations diminished after adjustment for social adversity, which supports the view that adverse social experiences contribute to the higher rate of psychosis among migrants. Copyright

Changing patterns in emergency involuntary admissions in the Netherlands in the period 2000-2004 (Article)

2008-08-01T00:00:00Z

Background: In England, rates of involuntary admissions increased in subgroups of patients. It is unknown whether this is true in other European countries. Aims: To establish whether the increase in emergency commitments was uniform across subgroups of patients and dangerousness criteria used to justify commitment in The Netherlands. Method: National data on all commitments in the period 2000-2004. Results: Commitments increased from 40.2 to 46.5 (16%) per 100,000 inhabitants. Controlling for population changes in age and sex, relatively large increases were found in patients over 50 years (25-40% increase), in patients with dementia (59%), 'other organic mental disorders' (40%) and substance abuse (36%). 'Arousing aggression', increased most strongly as a dangerousness criterion for commitment (30%). Conclusion: Changing patterns of commitments in The Netherlands and England might indicate a wider European shift in diagnoses and reasons for admission of committed patients.

Case registers in psychiatry: Do they still have a role for research and service monitoring? (Article)

2008-07-01T00:00:00Z

PURPOSE OF REVIEW: To follow up on reviews of case register research. Literature searches over a 2-year period were conducted to determine whether psychiatric case registers still have a role for research and service monitoring. RECENT FINDINGS: Case register research covers a wide range of topics, and is most often found in Denmark where national databases support all kinds of record linkage studies. Typically, case registers are used in studies of treated prevalence and incidence of psychiatric disorders, in research on patterns of care, as sampling frames in epidemiological studies, and in studies on risk factors and treatment outcome. SUMMARY: Despite a wide range of research based on administrative data, stakeholders in most countries are probably not well served by current priorities. Few studies investigate longitudinal patterns of service use to evaluate healthcare policies. There is a lack of comparative record linkage studies to inform local authorities on the cooperation between mental healthcare and public services. Implementing standard tools and procedures for routine outcome assessment seems still to be in an early phase in most register areas. When case register staff can capitalize on new opportunities, old and new case registers will continue to be important for research and service monitoring.

The Amsterdam studies of acute psychiatry I (ASAP-I); A prospective cohort study of determinants and outcome of coercive versus voluntary treatment interventions in a metropolitan area (Article)

2008-05-14T00:00:00Z

Background: The overall number of involuntary admissions is increasing in many European countries. Patients with severe mental illnesses more often progress to stages in which acute, coercive treatment is warranted. The number of studies that have examined this development and possible consequences in terms of optimizing health care delivery in emergency psychiatry is small and have a number of methodological shortcomings. The current study seeks to examine factors associated with compulsory admissions in the Amsterdam region, taking into account a comprehensive model with four groups of predictors: patient vulnerability, social support, responsiveness of the health care system and treatment adherence. Methods/Design: This paper describes the design of the Amsterdam Study of Acute Psychiatry-I (ASAP-I). The study is a prospective cohort study, with one and two-year follow-up, comparing patients with and without forced admission by means of a selected nested case-control design. An estimated total number of 4,600 patients, aged 18 years and over, consecutively coming into contact with the Psychiatric Emergency Service Amsterdam (PESA) are included in the study. From this cohort, a randomly selected group of 125 involuntary admitted subjects and 125 subjects receiving non-coercive treatment are selected for further evaluation and comparison. First, socio-demographic, psychopathological and network characteristics, and prior use of health services will be described for all patients who come into contact with PESA. Second, the in-depth study of compulsory versus voluntary patients will examine which patient characteristics are associated with acute compulsory admission, also taking into account social network and healthcare variables. The third focus of the study is on the associations between patient vulnerability, social support, healthcare characteristics and treatment adherence in a two-year follow-up for patients with or without involuntarily admittance at the index consultation. Discussion: The current study seeks to establish a picture of the determinants of acute compulsory admissions in the Netherlands and tries to gain a better understanding of the association with the course of illness and patient's perception of services and treatment adherence. The final aim is to find specific patient and health care factors that can be influenced by adjusting treatment programs in order to reduce the number of involuntary admissions.

Langdurig zorgafhankelijke patiënten in de ggz: samenhang met verstedelijking (Article)

2008-01-01T00:00:00Z

Uitgaande van de verhoogde psychiatrische morbiditeit in stedelijke gebieden kan men een samenhang verwachten tussen de omvang van het zorggebruik en verstedelijking. De vraag is of dat in het bijzonder geldt voor langdurig zorgafhankelijke patiënten in de ggz (lza-patiënten). doel Onderzoeken of er een samenhang bestaat tussen het vóórkomen van lza-patiënten en de mate van verstedelijking en of er in dit opzicht verschillen zijn tussen typen lza-patiënten onderling en ten opzichte van de overige patiënten in de ggz. methode Onderzocht werden gegevens die waren verkregen uit drie psychiatrische casusregisters en van het cbs. Er werden daarbij drie typen lza-patiënten onderscheiden: 'longstay', 'verblijf en ambulant' en 'ambulant'. De onderzoekspopulatie werd verdeeld in vijf stedelijkheidscategorieën. In de toegepaste poisson-regressieanalyse werd gecorrigeerd voor verschillen in leeftijd, geslacht en burgerlijke staat en in omvang van het zorgaanbod. resultaten De 'incidence rate ratio's' (irr's) waren voor de categorieën 'verblijf en ambulant', 'ambulant' en voor de overige patiënten bij elke stedelijkheidscategorie significant hoger dan die voor de niet-stedelijke gemeenten. Er was eveneens een significant positief lineair verband. Voor de longstaypatiënten werd geen significant verband met de mate van verstedelijking gevonden. De ratio's voor de hele groep lza-patiënten waren hoger dan die voor de overige, niet-lza- patiënten. De ratio's voor 'verblijf en ambulant' waren hoger dan die voor 'ambulant'. conclusie De prevalentie van langdurig zorgafhankelijke patiënten in de ggz neemt toe met de mate van verstedelijking, en deze toename is sterker dan die van overige patiënten. Verder is het verband met verstedelijking voor de categorie 'verblijf en ambulant' sterker dan voor de ambulante lza-patiënten.

Psychiatrie voor mensen die er niet om vragen: naar een wetenschappelijke (Inaugural Lecture)

2007-09-14T00:00:00Z

De laatste jaren is het steeds gebruikelijker geworden dat hulpverleners zich actief bemoeien met mensen met wie het volgens hen niet goed gaat of die voor overlast zorgen. Zo wil het Rijk en de gemeentes van de vier grote steden alle zwervers van straat halen en onder dak brengen. Dit zou desnoods onder dwang moeten gebeuren, wanneer het gaat om dakloze mensen met ernstige psychiatrische aandoeningen.

Dissemination of assertive community treatment in the Netherlands (Article)

2007-08-01T00:00:00Z

Objective: This study examined the adoption of the principles of assertive community treatment (ACT) by case management teams for severely mentally ill adults in the Netherlands. Methods: Using an email-survey, we obtained information from 39 program leaders who completed a 25-item checklist assessing adoption of the ACT principles. Respondents also indicated their intention to become a high-fidelity ACT program user. Results: Sixteen (41%) program leaders indicated their intention to implement ACT with at least moderate fidelity. Intention to implement ACT was associated with location in an urban area and caseloads with high rates of homelessness. Conclusions: Dissemination of ACT seems to be in an early stage in the Netherlands. Ongoing training, consultation, and research are necessary to stimulate the implementation of ACT in the Netherlands. Declaration of interest: This survey was carried out for the benefit of the second National Assertive Community Treatment conference in Rotterdam, The Netherlands. There were no grants involved.

Effects of community-care networks on psychiatric emergency contacts, hospitalisation and involuntary admission (Article)

2007-07-01T00:00:00Z

Background: Community-care networks are a partnership between the local police force, housing corporations, general social services, specialised home care and mental healthcare services. The networks were set up to improve the healthcare for patients with (chronic) psychiatric problems through local cooperation between different agencies operating in underprivileged areas. Objective: To evaluate the effects of community-care networks on psychiatric emergency contacts, hospitalisation and involuntary admission. Design: An ecological intervention design was used, comparing neighbourhoods with and without a community-care network. Mean numbers and standardised ratios of psychiatric emergency contacts, hospitalisation rates and involuntary admissions were assessed over a 10-year period, covering the early stages and the years in which community-care networks were fully operational. Setting: Underprivileged neighbourhoods in the city of Rotterdam, The Netherlands. Patients: Inhabitants aged 20-64 years living in these neighbourhoods. Results: Standardised ratios for contact with psychiatric emergency services were higher in the neighbourhoods where community-care networks were set up (standardised ratios = 137, 95% CI 121 to 145 in the network neighbourhoods vs standardised ratios = 107, 95% CI 96 to 119 in the control neighbourhoods). Number of admissions and standardised ratios for involuntary admissions were lower in the community-care network neighbourhoods than in the control neighbourhoods (standardised ratios = 123, 95% CI 95 to 157 vs standardised ratios = 152, 95% CI 120 to 191). Conclusions: Community-care networks have a significant impact on the use of mental healthcare services. These networks may be an important tool in the prevention of involuntary admissions.

Psycho-immunology and HIV infection : biopsychosocial determinants of distress, immunological parameters, and disease progression in homosexual men infected with human immunodeficiency virus-1 (Doctoral Thesis)

1994-09-28T00:00:00Z

Subjects who have tested positive for the presence of antibodies against Human Immunodeficiency Virus Type I (further abbreviated as HIV), have to live with a lifethreatening infection. At present, no definite medical cure is available that prevents progression of HIV infection. Therefore, knowledge of being infected with this virus puts a heavy burden on one's coping capabilities. Although some subjects find a way to live with their HIV infection, others have great difficulties in adjusting to it and may suffer from psychological distress. Whether or not HIV-infected subjects develop psychological distress is determined by several factors. These include for instance the experience of other stressful life events, the type of coping style that is used, and the quality of the social network. However, little is known about the relative importance of each of these variables and the way they interact in predicting distress levels. HIV -infected individuals may benefit from psychosocial interventions that aim at increasing social support and improving coping strategies. Although several types of psychosocial intervention may be effective, the relative effectiveness of different psychotherapeutic intervention strategies is unknown. We investigated factors that determine the level of distress and the effectiveness of two different psychosocial interventions in decreasing distress levels in asymptomatic and early symptomatic HIV-infected homosexual men. These studies are described in Part L In Part IT studies pertaining to the associations between psychosocial factors and progression of HIV infection are described. The length of the period until the development of Acquired Immunodeficiency Syndrome (AIDS) varies considerably among individuals and it is hypothesized that some of the variation is due to psychosocial factors. These factors may include stressful life events, psychological distress, coping styles and social support. In the event that psychosocial factors have an influence, psychosocial interventions may slow down the rate of progression, and enhance the effectiveness of medical treatments. Studying the effect of psychosocial factors on disease progression is therefore of clinical relevance. It is of theoretical relevance because insights are gained into psychoneuroimmunological relationships in a virologically and immunologically mediated disease.