Five-year follow-up of the iBerry Study: screening in early adolescence to identify those at risk of psychopathology in emerging adulthood

The iBerry Study, a Dutch population-based high-risk cohort (n = 1022) examines the transition from subclinical symptoms to psychiatric disorders in adolescents. Here, we present the first follow-up measurement, approximately 3 years after baseline assessment and 5 years after the screening based on self-reported emotional and behavioral problems (SDQ-Y). We give an update on the data collection, details on the (non)response, and the results on psychopathology outcomes. The first follow-up (2019-2022) had a response rate of 79% (n = 807). Our results at baseline (mean age 15.0 years) have shown the effectiveness of using the SDQ-Y to select a cohort oversampled for the risk of psychopathology. At first follow-up (mean age 18.1 years), the previously administered SDQ-Y remains predictive for selecting adolescents at risk. At follow-up, 47% of the high-risk adolescents showed significant mental health problems based on self- and parent reports and 46% of the high-risk adolescents met the criteria for multiple DSM-5 diagnoses. Compared to low-risk adolescents, high-risk adolescents had a sevenfold higher odds of significant emotional and behavioral problems at follow-up. Comprehensive assessment on psychopathology, substance abuse, psychotic symptoms, suicidality, nonsuicidal self-injury, addiction to social media and/or video gaming, and delinquency, as well as social development, and the utilization of healthcare and social services were conducted. This wave, as well as the ones to follow, track these adolescents into their young adulthood to identify risk factors, elucidate causal mechanisms, and discern pathways leading to both common and severe mental disorders. Results from the iBerry Study will provide leads for preventive interventions.

Alcohol use disorder and muscle weakness: Original study of the effect of vitamin D supplementation in ambulatory participants with alcohol use disorder

INTRODUCTION

Chronic alcohol-related myopathy presents with proximal muscle weakness. We studied the effect of vitamin D supplementation on muscle weakness in adults with alcohol use disorder.

METHOD

Randomized controlled trial. Participants were community-dwelling adults with alcohol use disorder. Participants allocated to VIDIO, vitamin D intensive outreach, received bimonthly oral doses of 50,000‒100,000 IU cholecalciferol for 12 months. Participants allocated to CAU, care as usual, received prescriptions of once-a-day tablets containing 800 IU cholecalciferol and 500 mg calcium carbonate. Data included demographic variables, laboratory tests, alcohol use, and rating scales of help-seeking and support. Main outcomes were the participants' quadriceps maximum voluntary contractions (qMVC) and serum-25(OH)vitamin D concentrations, 25(OH)D.

RESULTS

In 66 participants, sex ratio 50/16, mean age 51 year, alcohol use was median 52 [IQR 24‒95] drinks per week. Baseline qMVC values were 77% (SD 29%) of reference values. Laboratory tests were available in 44/66 participants: baseline 25(OH)D concentrations were 39.4 (SD 23.7) nmol/L. Thirty-one participants with 25(OH)D concentrations <50 nmol/L received either VIDIO or CAU and improved in qMVC, respectively with mean 51 (P<0.05) and 62 Newton (no P-value because of loss of follow-up) after one year of treatment. Vitamin D status increased with mean +56.1 and +37.4 nmol/L, respectively in VIDIO and CAU.

CONCLUSION

The qMVC values improved during vitamin supplementation in adults with vitamin D deficiency and alcohol use disorder. Despite higher 25(OH)D concentrations in VIDIO, in terms of muscle health no advise could be given in favor of one vitamin strategy over the other.

TRIAL REGISTRATION

Netherlands Trial Register (NTR) identifier: NTR4114.

Workplace trauma and professional quality of Life in clinical and forensic psychiatry: the CRITIC study

Background

Frontline staff in psychiatry need to perform at a very high professional level in order to ensure patient and community safety. At the same time they are exposed to high levels of stress and workplace trauma. This may have severe consequences for their professional quality of life. In addition, health care workers in general have higher incidence levels of childhood adversity than the general population. The CRITIC (CRITical Incidents and aggression in Caregivers) Study aims to improve increased understanding of the interaction between personal life history (childhood adversity and benevolence), individual capabilities, exposure to trauma and violence at work and Professional Quality of Life (ProQOL).

Method

The Critic Study is a cross-sectional survey of these aspects in frontline, treatment and administrative staff in clinical and forensic psychiatry. We aim to include 360 participants. Participants will be asked to complete questionnaires on childhood adversity and childhood benevolence (assessing personal life history), professional quality of life, current trauma and violence exposure, current mental health (depression, anxiety and stress), coping, social support, work engagement and resilience. In this study we will examine the moderating role of adverse and benevolent childhood experiences in the association between workplace trauma exposure and professional quality of life. Finally, a theoretical model on the relationships between trauma, stress and coping in the context of professional functioning will be tested using structural equation modelling.

Discussion

The CRITIC study examines which factors influence the complex relationship between childhood adversity and benevolence, and ProQOL in healthcare workers. It also aims to provide insight into the complex relationship between personal life history, individual characteristics, exposure to trauma and violence at work and ProQOL. The results can be used for designing interventions to increase resilience to trauma and to improve professional quality of life among health care professionals.

Trial registration

The CRITIC study has been approved by the Medical Ethical Committee of the Erasmus Medical Centre, under trial registration number NL73417.078.20.

Experiencing discrimination mediates the relationship between victimization and social withdrawal in patients suffering from a severe mental illness: A cross-sectional study

Psychiatric patients are often victims of crime and discrimination and are often socially withdrawn. This has negative consequences for their health and recovery. We examined whether such discrimination mediates the association between victimization and social withdrawal, and whether these associations differ between men and women. We also determined the prevalence of social withdrawal and the discrimination experienced by patients suffering from a severe mental illness. This study is embedded in the Victimization in Psychiatric Patients study. Information on discrimination, social withdrawal and victimization was obtained using structured self-report questionnaires (N = 949). We reported the 12-month prevalence of these phenomena and used path analysis to estimate the direct path between personal and property victimization and social withdrawal, and the indirect path through the discrimination experienced. The impact of gender was assessed by testing interaction terms. Social withdrawal was reported by 20.6% (95%CI 18.1-23.2) of participants, and being discriminated against in the past 12 months by 75.3% (95%CI: 72.6-78.0%). While crime victimization had no direct effects on social withdrawal, personal crime victimization (B = 0.47; 95%CI 0.25-0.72; p < 0.001) and property crime victimization (B = 0.65; 95%CI 0.42-0.93; p < 0.001) had significant indirect effects on social withdrawal, which were mediated by the discrimination experienced. In men we found a direct negative effect of property crime on social withdrawal (B = -0.68; 95%CI: -1.21to -0.11, p = 0.014). We conclude that personal and property victimization, for both men and women, was associated with higher levels of social withdrawal, and this was fully mediated by the discrimination experienced.

[Differences in the prevalence of acute involuntary admissions between Apeldoorn, Rotterdam and Amsterdam]

BACKGROUND

There are regional differences in the Netherlands in the numbers of emergency compulsory admissions (Inbewaringstelling: IBS). We looked at three 24/7 facilities to investigate the relationships between patient and consultation characteristics on the one hand, and numbers of emergency compulsory admissions on the other, against the background of the level of urbanisation.

METHOD

We compared emergency consultations in 18-64 year olds in Apeldoorn, Amsterdam and Rotterdam between 2012 and 2016 in terms of socio-demographic, procedural and clinical characteristics, and in terms of outcome. We used the Severity of Psychiatric Illness Scale (SPI) to determine disorder severity.

RESULTS

Apeldoorn had as many consultations per 100,000 inhabitants as the highly urbanised city of Rotterdam. GPs there referred 68% of patients, compared with 25% in Amsterdam and 50% in Rotterdam. In Apeldoorn, 17% of the patients were psychotic, compared with 35% in the other regions. In addition, 66% of the patients there had a low SPI score, compared with 40% in the large cities. Amsterdam and Rotterdam had 3.5 times higher risk of emergency compulsory admissions as Apeldoorn. After adjustment for socio-demographic, procedural and clinical characteristics, this difference with Apeldoorn was 1.5 for Amsterdam and 2.6 for Rotterdam. SPI score and psychotic disorder were found to be the most important predictors of IBS admission.

CONCLUSION

Differences in consultation numbers, referral patterns and the location of consultations indicate that there are regional differences in the position of the 24/7 facility in the mental health care system. The numbers of emergency compulsory emissions were related in part to the level of urbanisation and the associated epidemiological differences but probably also to differences in the position of the crisis facility in the mental health care system. Differences in admission numbers were primarily linked to differences in diagnostic characteristics and disorder severity and, to a lesser extent, to referral patterns and socio-demographic characteristics. However, these variables did not explain all the observed inter-regional differences.

Determinants of Quality of Life and Treatment Satisfaction During Long-Term Involuntary In-patient Treatment of Dual-Diagnosis Patients

INTRODUCTION

Treatment resistance and disengagement from mental health services are major obstacles in the treatment of dual diagnosis patients with Severe Mental Illness. The patients in this study were admitted to a long-term involuntary treatment facility.

AIM OF THE STUDY

To study which patient experiences and perceptions are related to the outcome measures Subjective Quality of Life (SQOL) and Treatment Satisfaction (TS) during the long-term involuntary treatment.

METHODS

Patients were invited for an interview by an independent researcher, which included self-report questionnaires. The structured interviews included self-assessing Helping Alliance, Insight, Attitude toward involuntary admission, Perceived coercion and Perceived benefit were studied as determinants of SQOL and TS. The relationship between the determinants and the outcomes were analyzed by linear regression analysis.

RESULTS

Patient reported outcomes from dual diagnosis patients in a long-term treatment facility, showed that most of the patients, in spite of the involuntary character of the treatment, were satisfied with the treatment. With respect to the determinants of SQOL and TS the perceptions that "My opinion is taken into account" and "Perceived benefits of the treatment" are strong predictors of both the outcomes.

CONCLUSIONS

The current study shows that the most important aspects for treatment satisfaction and quality of life of dual-diagnosis patients admitted involuntary to long-term treatment, are being listened to (being taken seriously) and experiencing improvements during treatment. These qualities reflect the goals of Shared Decision Making and Perceived Procedural Justice in treatment. The study also corroborates earlier findings that even when treated involuntarily, patients might not hold particular negative views regarding their treatment.

Histological study on the influence of puberty suppression and hormonal treatment on developing germ cells in transgender women

STUDY QUESTION

Can transgender women cryopreserve germ cells obtained from their orchiectomy specimen for fertility preservation, after having used puberty suppression and/or hormonal treatment?

SUMMARY ANSWER

In the vast majority of transgender women, there were still immature germ cells present in the orchiectomy specimen, and in 4.7% of transgender women—who all initiated medical treatment in Tanner stage 4 or higher—mature spermatozoa were found, which would enable cryopreservation of spermatozoa or testicular tissue after having used puberty suppression and/or hormonal treatment.

WHAT IS KNOWN ALREADY

Gender affirming treatment (i.e. puberty suppression, hormonal treatment, and subsequent orchiectomy) impairs reproductive function in transgender women. Although semen cryopreservation is generally offered during the transition process, this option is not feasible for all transgender women (e.g. due to incomplete spermatogenesis when initiating treatment in early puberty, in case of inability to masturbate, or when temporary cessation of hormonal treatment is too disruptive). Harvesting mature spermatozoa, or testicular tissue harboring immature germ cells, from orchiectomy specimens obtained during genital gender-affirming surgery (gGAS) might give this group a chance of having biological children later in life. Previous studies on spermatogenesis in orchiectomy specimens showed conflicting results, ranging from complete absence of germ cells to full spermatogenesis, and did not involve transgender women who initiated medical treatment in early- or late puberty.

STUDY DESIGN, SIZE, DURATION

Histological and immunohistochemical analyses were performed on orchiectomy specimens from 214 transgender women who underwent gGAS between 2006 and 2018. Six subgroups were identified, depending on pubertal stage at initiation of medical treatment (Tanner stage 2-3, Tanner stage 4-5, adult), and whether hormonal treatment was continued or temporarily stopped prior to gGAS in each of these groups.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All transgender women used a combination of estrogens and testosterone suppressing therapy. Orchiectomy specimen sections were stained with Mayer’s hematoxylin and eosin and histologically analyzed to assess the Johnsen score and the ratio of most advanced germ cell types in at least 50 seminiferous tubular cross-sections. Subsequently, immunohistochemistry was used to validate these findings using spermatogonia, spermatocytes or spermatids markers (MAGE-A3/A4, γH2AX, Acrosin, respectively). Possibilities for fertility preservation were defined as: preservation of spermatozoa, preservation of spermatogonial stem cells or no possibilities (in case no germ cells were found). Outcomes were compared between subgroups and logistic regression analyses were used to assess the association between the duration of hormonal treatment and the possibilities for fertility preservation.

MAIN RESULTS AND THE ROLE OF CHANCE

Mature spermatozoa were encountered in 4.7% of orchiectomy specimens, all from transgender women who had initiated medical treatment in Tanner stage 4 or higher. In 88.3% of the study sample orchiectomy specimens only contained immature germ cells (round spermatids, spermatocytes or spermatogonia, as most advanced germ cell type). In 7.0%, a complete absence of germ cells was observed, all these samples were from transgender women who had initiated medical treatment in adulthood. Cessation of hormonal treatment prior to gGAS did not affect the presence of germ cells or their maturation stage, nor was there an effect of the duration of hormonal treatment prior to gGAS.

LIMITATIONS, REASONS FOR CAUTION

Since data on serum hormone levels on the day of gGAS were not available, we were unable to verify if the transgender women who were asked to temporarily stop hormonal treatment 4 weeks prior to surgery actually did so, and if people with full spermatogenesis were compliant to treatment.

WIDER IMPLICATIONS OF THE FINDINGS

There may still be options for fertility preservation in orchiectomy specimens obtained during gGAS since a small percentage of transgender women had full spermatogenesis, which could enable cryopreservation of mature spermatozoa via a testicular sperm extraction procedure. Furthermore, the vast majority still had immature germ cells, which could enable cryopreservation of testicular tissue harboring spermatogonial stem cells. If maturation techniques like in vitro spermatogenesis become available in the future, harvesting germ cells from orchiectomy specimens might be a promising option for those who are otherwise unable to have biological children.

STUDY FUNDING/COMPETING INTEREST

None.

TRIAL REGISTRATION NUMBER

N/A.

Dutch Mental Health Patients' and Significant Others' Perspectives on Compulsory Treatment at Home: One Size Does Not Fit All

On January 1, 2020, the Compulsory Mental Health Care Act took effect in the Netherlands. It contains provisions for compulsory community treatment (CCT) and compulsory treatment at home (CTH). In this study, we collected the opinions of patients and their significant others on CTH and on their preferences regarding compulsory care in their homes. Patients and their significant others were involved in the experience-based co-design of a purpose-built online questionnaire. This questionnaire was completed by 624 patients and 531 significant others. Sixty-one percent of the patients and 62% of the significant others did not want compulsory treatment to take place at home but in hospital or elsewhere. Patients' and significant others' opinion showed few differences, except with regard to the involvement of the significant others in CTH. As the respective views of patients and significant others were mixed, we recommend that crisis plans and compulsory treatment plans should be individually tailored to the needs and wishes of patients and their significant others regarding CTH.

[High and intensive care as a next step in the reduction of coercion]

BACKGROUND

The high and intensive care (HIC) model provides a framework for acute admission wards and is being implemented since 2013 by all mental healthcare institutions in the Netherlands.

AIM

To investigate how the HIC model has been implemented between 2014 and 2018 and how the implementation of the HIC model is associated to coercive measures.

METHOD

Between 2014 and 2018, 79 audits were organized in two phases within 25 institutions to measure the degree of implementation of HIC using a model fidelity scale, the HIC monitor. HIC monitor scores were compared to data on coercion to determine the relationship between implementation of the HIC model and coercive measures.

RESULTS

Scores on the HIC monitor increased over time, especially in terms of vision, hospitality and facilities. However, a third of wards scored lower on the HIC monitor in the second audit compared to the first audit. Institutions that score higher use less seclusion and use less forced medication.

CONCLUSION

Progress in the implementation of the HIC model is visible and institutions that are further in the implementation of the HIC model apply less coercion. Securing implementation proves difficult. Attention should be paid to the national staff shortage and systematic evaluation of coercion.

[Assertive Treatment as a regular function within mental health]

BACKGROUND

The setting for providing assertive treatment (AT) has changed during the last 30 years in The Netherlands from assertive community treatment (ACT) and flexible assertive community treatment (FACT) to municipalities. The provision of AT varies between municipalities.

AIM

Describing the concept of AT, the nature and size of the target group, and the reasons why people with severe mental illness (SMI) do not seek treatment and the place of AT in mental health care.

METHOD

We used literature en available quantitative data.

RESULTS

AT regularly provided by mental health care is required in patients with SMI and social problems who do not seek treatment. When mental health care and social care collaborate on the level of the patient, treatment and handling of social problems can strengthen each other. This collaboration prevents discontinuity of care and breaking a trusting relationship because patients do not need to be transferred from social service to mental health care or vice versa. AT is on the continuum of voluntarily to compulsory care.AT provided by mental health care (usually provided by FACT-teams) is indicated for SMI patients with social problems and who do not seek treatment. The size of the target group is around 5000 - 20.000 patients in The Netherlands. Reasons not to seek help for people with SMI include within person factor, mental health related factors, or factors related to the interaction of SMI patients and mental health. We advocate for AT to become a regular part of mental health care, and for mental health care and social domain professionals to collaborate on case level. Acting this way, mental health treatment and addressing social problems can reinforce each other and discontinuity of care and breaking a trusting relationship can be prevented. AT is on the continuum of voluntary to involuntary treatment. That is why we suggest AT to be a better term than assertive outreach.

CONCLUSION

It is a given fact that not all patients with SMI and social problems seek treatment. By making AT a regular part of mental health services, we prevent discontinuity of care and we fill the gap between voluntarily and compulsory care.

Adult Attachment and Personal, Social, and Symptomatic Recovery From Psychosis: Systematic Review and Meta-Analysis

Despite growing evidence for the role of attachment in psychosis, no quantitative review has yet been published on the relationship in this population between insecure attachment and recovery in a broad sense. We therefore used meta-analytic techniques to systematically appraise studies on the relationship between attachment and symptomatic, social and personal recovery in clients with a psychotic disorder. Using the keywords attachment, psychosis, recovery and related terms, we searched six databases: Embase, Medline Epub (OVID), Psycinfo (OVID), Cochrane Central (trials), Web of Science, and Google Scholar. This yielded 28 studies assessing the associations between adult attachment and recovery outcome in populations with a psychotic disorder. The findings indicated that insecure anxious and avoidant attachment are both associated with less symptomatic recovery (positive and general symptoms), and worse social and personal recovery outcomes in individuals diagnosed with a psychotic disorder. The associations were stronger for social and personal recovery than for symptomatic recovery. Attachment style is a clinically relevant construct in relation to the development and course of psychosis and recovery from it. Greater attention to the relationship between attachment and the broad scope of recovery (symptomatic, social, and personal) will improve our understanding of the illness and efficacy of treatment for this population.

Personal Recovery in People With a Psychotic Disorder: A Systematic Review and Meta-Analysis of Associated Factors

Background: Personal recovery (PR) is a subjective, multidimensional concept, and quantitative research using PR as an outcome is rapidly increasing. This systematic review is intended to support the design of interventions that contribute to PR in psychotic disorders, by providing an overview of associated factors and their weighted importance to PR: clinical factors, social factors, and socio-demographic characteristics are included, and factors related to the concept of PR (organized into CHIME dimensions). Methods: A systematic literature search was conducted from inception to March 2020. Quantitative studies that had used a validated questionnaire assessing the concept of PR were included. Mean effect sizes for the relationship between PR-scale total scores and related factors were calculated using meta-analyses. Sources of heterogeneity were examined using meta-regression tests. Results: Forty-six studies, that used (a total of) eight PR measures, showed that in clinical factors, affective symptoms had a medium negative association with PR-scale total scores (r = -0.44, 95%CI -0.50 to -0.37), while positive, negative and general symptoms had small negative correlations. No association was found with neuro-cognition. Social factors (support, work and housing, and functioning) showed small positive correlations. Gender and age differences had barely been researched. Large associations were found for PR-scale total scores with the CHIME dimensions hope (r = 0.56, 95%CI 0.48-0.63), meaning in life (r = 0.48, 95%CI 0.38-0.58) and empowerment (r = 0.53, 95%CI 0.42-0.63); while medium associations were found with connectedness (r = 0.34, 95%CI 0.43-0.65) and identity (r = 0.43, 95%CI 0.35-0.50). Levels of heterogeneity were high, sources included: the variety of PR measures, variations in sample characteristics, publication bias, variations in outcome measures, and cultural differences. Discussion: Most interventions in mental healthcare aim to reduce symptoms and improve functioning. With regard to stimulating PR, these interventions may benefit from also focusing on enhancing hope, empowerment, and meaning in life. The strength of these findings is limited by the challenges of comparing separate CHIME dimensions with questionnaires assessing the concept of PR, and by the high levels of heterogeneity observed. Future research should focus on the interaction between elements of PR and clinical and social factors over time.

Diagnose, indicate, and treat severe mental illness (DITSMI) as appropriate care: A three-year follow-up study in long-term residential psychiatric patients on the effects of re-diagnosis on medication prescription, patient functioning, and hospital bed utilization

Background.

While polypharmacy is common in long-term residential psychiatric patients, prescription combinations may, from an evidence-based perspective, be irrational. Potentially, many psychiatric patients are treated on the basis of a poor diagnosis. We therefore evaluated the DITSMI model (i.e., Diagnose, Indicate, and Treat Severe Mental Illness), an intervention that involves diagnosis (or re-diagnosis) and appropriate treatment for severely mentally ill long-term residential psychiatric patients. Our main objective was to determine whether DITSMI affected changes over time regarding diagnoses, pharmacological treatment, psychosocial functioning, and bed utilization.

Methods.

DITSMI was implemented in a consecutive patient sample of 94 long-term residential psychiatric patients during a longitudinal cohort study without a control group. The cohort was followed for three calendar years. Data were extracted from electronic medical charts. As well as diagnoses, medication use and current mental status, we assessed psychosocial functioning using the Health of the Nations Outcome Scale (HoNOS). Bed utilization was assessed according to length of stay (LOS). Change was analyzed by comparing proportions of these data and testing them with chi-square calculations. We compared the numbers of diagnoses and medication changes, the proportions of HoNOS scores below cut-off, and the proportions of LOS before and after provision of the protocol.

Results.

Implementation of the DITSMI model was followed by different diagnoses in 49% of patients, different medication in 67%, some improvement in psychosocial functioning, and a 40% decrease in bed utilization.

Conclusions.

Our results suggest that DITSMI can be recommended as an appropriate care for all long-term residential psychiatric patients.

Compulsory treatment in patients' homes in the Netherlands: what do mental health professionals think of this?

BACKGROUND

Compulsory treatment in patients' homes (CTH) will be introduced in the new Dutch mental health legislation. The aim of this study is to identify the opinions of mental health workers in the Netherlands on compulsory community treatment (CCT), and particularly on compulsory treatment in the patients' home.

METHODS

This is a mixed methods study, comprising a semi-structured interview and a survey. Forty mental health workers took part in the semi-structured interview about CCT and 20 of them, working in outpatient services, also completed a questionnaire about CTH. Descriptive analyses were performed of indicated (dis) advantages and problems of CCT and of mean scores on the CTH questionnaire.

RESULTS

Overall, the mental health workers seemed to have positive opinions on CCT. With respect to CTH, all mean scores were in the middle of the range, possibly indicating that clinicians were uncertain regarding safety issues and potential practical problems accompanying the use of CTH.

CONCLUSIONS

The majority of the participating mental health workers in this study had a positive attitude towards CCT, but they seemed relative uncertain about potential possibilities and problems of working with CTH.

[Flexible assertive community treatment (FACT) as part of a community (health) network]

Community-based care for people with severe mental illness increasingly requires far-reaching cooperation between different domains. This cooperation must always be unique and local, and at the same time provide an answer to generic and nationally set goals.<br/> AIM: Offering new insights on collaboration within and between domains.<br/> METHOD: Reflection on developments in the social domain and specialist mental healthcare using relevant literature and recent (inter)national experiences.<br/> RESULTS: It seems possible to provide better integral care by allowing FACT-teams to network together with Social Support partners (e.g. by sharing financial and/or human resources). In this process, networks of care for people with serious mental illness (SMI), develop over various phases and realize new partnerships. The model fidelity scale for FACT-teams was adjusted to facilitate that process. CONCLUSIONS The new FACT model fidelity scale is ready to allow FACT-teams to explore flexible local solutions for partnerships to realize the much-needed multi-domain integrated community care for people with SMI.

[Regional differences in compulsory treatment in mental health care in the Netherlands during 2013-2017]

Compulsory treatment in mental health care has continuously increased for years. Registration of court ordered compulsory psychiatric care is based upon counts of legal authorisations. These counts do not refer to number of individual persons involved.<br/> AIM: To report the number age-specific prevalence of coercion in psychiatric care, number of persons involved, age distribution and regional differences.<br/> METHOD: Analysis of the number of requests for compulsory care and population size according to the age groups for the years 2013-2017. We used direct age standardisation at the level of jurisdiction regions.<br/> RESULTS: The annual number of unique persons for whom compulsory care was requested was 28% less than the number of requested court orders. The annual increase in compulsory care was 3%. Per specific treatment order the increase during 2013-2017 was 12% for emergency compulsory admissions, 8% for hospital admissions, 10% for extended hospital admissions and 43% for community treatment order.<br/> CONCLUSION: The number of persons for whom compulsory mental care is requested increased on average by 3% each year. Greatest increase was observed for age groups 25-44 years and 80 years and older. After age-standardisation substantial differences remain between jurisdiction regions.

[Mental health in Eastern Lille: a future of network-psychiatry?]

For some time now, East Lille has been working with a relatively modern mental health care system that remarkably resembles Dutch health care with the same values and norms that we want to implement in the Netherlands as well.<br/> AIM: Gaining inspiration to further investigate regional cooperation and 'network care' in Dutch psychiatry.<br/> METHOD: A delegation from the board of f-act-Netherlands and ccaf paid a working visit to Lille.<br/> RESULTS: The basis of the East Lille working method is a charter of shared values developed with all parties, clients, relatives, employees and external professionals, which is signed by every professional. In case of doubt, a change of context or the introduction of new working methods, these values are used first. CONCLUSIONS High quality mental health care develops in dialogue, in which working methods, service delivery models and interventions are linked to each other by means of network care. Through reflection, moral deliberation and appreciative auditing, care is progressively improved. These procedures guarantee a modern process of quality improvement.

Clinical effects and treatment outcomes of long-term compulsory in-patient treatment of treatment-resistant patients with severe mental illness and substance-use disorder

BACKGROUND

The treatment of homeless dual-diagnosis patients (i.e., those with severe mental illness and substance-use disorder) is difficult and often fails. For patients in the Netherlands who had not responded to earlier voluntary and compulsory treatment, a new treatment facility - Sustainable Residence (SuRe) - was developed to offer long-term compulsory in-patient treatment.

AIM OF THE STUDY

To study patterns of changes in clinical and functional outcomes during treatment at SuRe and how these relate to eventual treatment outcome.

METHODS

On the basis of the intensity of care needed after four years, three groups of patients were distinguished (total n = 165): those discharged to a less restrictive and less supportive setting (n = 70, 42%), those still hospitalized at SuRe at the end of the four-year study period (n = 69, 42%) and those referred to a more appropriate setting (n = 26, 16%). Random coefficient analysis was used to examine differences between groups regarding changes in clinical and functional outcomes during treatment. During treatment, outcomes were monitored using Routine Outcome Assessment.

RESULTS

All three groups made small but significant improvements on global psychosocial functioning, distress and therapeutic alliance (effect sizes (ES) 0.11 to 0.16 per year). Patients who were discharged to a less restrictive setting showed small to moderate improvement in risk to self and others, psychiatric symptoms, and skills for daily living (ES 0.19-0.33 per year and 0.42-0.73 for their mean 2.2-year treatment period). Patients remaining at SuRe showed a small increase in risk to self (ES 0.20 per year; 0.80 for their treatment period of four years or more). Oppositional behaviour was consistently greater in referred patients than in the other groups (ES 0.74-0.75).

CONCLUSION

Long-term compulsory treatment appeared to have helped improve clinical and functional outcomes in a substantial proportion (42%) of previously severely dysfunctional, treatment-resistant dual-diagnosis patients, who could then be discharged to a less restrictive and less supportive environment. However, risk-to-self increased in a similar proportion. A smaller number of patients (16%) showed marked oppositional behaviour and needed a higher level of care and protection in another facility.

[Modifications in therapy for patients with severe mental illness and intellectual disability: a qualitative study]

In ambulant psychiatric care, intellectual disability (id) is often not recognised. Therefore, a Screener for Intelligence and Learning disabilities (scil) was recently introduced to assist recognition. However, because, current therapy is not adjusted for id-related problems, its effectiveness remains unknown.<br/> AIM: To gain insight into adequate adaptation of interventions by professionals for patients with severe mental illness (smi) and id, to improve the quality of care without the need to develop a completely new program of therapy.<br/> METHOD: A qualitative design (n=15) including 8 interviews and one focus group, among psychiatric practitioners and id experts.<br/> RESULTS: Five main themes were identified to adjust therapy: treatment, communication, inclusion of the network, estimation of support needs and self-management. CONCLUSIONS To align therapy with the requirements of patients with smi and id, a patient-oriented approach to care is necessary. Simple but effective modifications, summarised in a toolkit, appear to contribute to this. To offer appropriate care to patients with smi and id, attention is needed for both a support-oriented and a recovery-oriented approach.

Testing the Integral Model of treatment motivation in outpatients with severe mental illness

The current study tested the Integral Model of treatment motivation (IM) in a sample of 294 outpatients with severe mental illness, using structural equation modelling. The obtained structural model was not consistent with original theory, nor was the model invariant across time and patient groups (psychotic disorders and personality disorders). The patient’s perceived suitability of treatment, perceived costs of treatment and outcome expectancy were most strongly associated with motivation and treatment engagement. The model explained between 22 and 86% of variance in clinical outcomes, depending on the timing of the assessment. Currently, the IM does not constitute a robust framework for patterns through which patients become motivated to engage in treatment, but does explain substantial amounts of variance in clinical outcomes. The future potential of IM as a basis for interventions in the mental health care is discussed, including suggestions for subsequent research and potential alterations of the IM to improve its utility for application in clinical practice.

[Model fidelity of flexible assertive community treatment (F-ACT) teams: five years of audit results]

The Flexible act (f-act) has been introduced in the Netherlands since 2004, alongside the Assertive Community Treatment (act) model. An estimate of 400 (f-)act teams concurrently provide care to approximately 70.000 people with serious mental illness. The ccaf has been assessing the model fidelity of act and f-act teams since 2009 to promote the quality and transparency of healthcare for clients with serious mental illness. OBJECTIVE To describe the state of implementation of f-act and associated trends in the Netherlands.<br /> METHOD: Analysis of the ccaf database, which holds the data of audits conducted between 2009 and 2014.<br /> RESULTS: The audits conducted by ccaf between 2009 and 2014 indicated an adequate implementation of f-act. The team foundations were well organized, featuring a multidisciplinary team structure, management of medication, practical support and investment in healthcare continuity, including during an admission. However, the results regarding participation and recovery were unsatisfactory. Furthermore, the results depicted a decline in the scores concerning a number of areas, including outreach and support of participation and recovery. CONCLUSIONS Although the data indicates an on average satisfactory implementation of f-act in the Netherlands, there are signs that the implementation of f-act is under pressure with relatively fewer home visits, a rising caseload and a reduced investment in recovery and participation. The findings are in accordance with the signs and arguments to adjust the emphasis on reducing hospital admissions, prioritizing the consolidation of outpatient care instead.

[Efficacy of integrated dual disorder treatment for dual disorder patients: a systematic literature review]

BACKGROUND

Dual diagnosis (substance use disorder combined with a comorbid mental illness) is a common problem. One of the methods to treat this is integrated dual diagnosis treatment (IDDT). IDDT consists of the simultaneous, integrated application of different treatment components. Their efficacy, however, has only been studied separately. As a result, the effectiveness of the IDDT program as a whole remains unclear.

AIM

To evaluate the scientific evidence relevant to the effectiveness of IDDT in dual diagnosis patients.

METHOD

A systematic literature review using MEDLINE, Embase and PsycINFO (Prisma guideline).

RESULTS

Six studies were found: a randomised controlled study (RCT), two non-randomised controlled studies, and three uncontrolled pre-post studies . There was a notably large diversity in outcome measures. The results differed significantly, including some studies concluding a significant (additional) effect, while others concluded that there was no indication of a significant effect of IDDT.

CONCLUSION

In clinical practice, IDDT is recommended and chosen frequently as the treatment for patients with dual diagnosis. However, it is remarkable how limited and unthorough the research is pertaining to the effects of the full IDDT program on dual diagnosis.

[Intensive home treatment: a first observational evaluation]

Yulius intensive home treatment (iht) offers six weeks of home-care to psychiatric patients in crisis who would normally be hospitalised.<br/> AIM: To study patient characteristics and the content and outcomes of iht.<br/> METHOD: We followed the handling of 75 consecutive applications for iht. Details were recorded before and after admission to the treatment.<br/> RESULTS: Fifteen patients were referred in order to shorten the period of hospitalisation, and 60 were referred in order to prevent hospitalisation; 59 of the 75 persons admitted for the treatment received iht, and 41 patients finished the six-week module and provided follow-up data. Psychiatric symptoms improved significantly, suicidality was reduced, the caregiver's burden became much lighter and the evaluation by both patient and caregiver was very positive. iht was sufficient to prevent the need for hospitalisation of 75% of the patients referred for reduced hospitalisation, and it was also adequate to prevent the hospitalisation of more than 91% of patients referred for that particular purpose.<br/> CONCLUSION: iht is highly appreciated and is possibly a good alternative to hospitalisation. However, in the future there will have to be randomised, controlled research in order to determine the effectiveness of iht compared to hospitalisation.

[Mental health as a front-line service for bewildered persons]

'Bewildered persons' have often been in the news over the last few years. There has been much discussion about the meaning of the term 'bewildered persons', the number of people involved, the way the problem should be tackled and the role of the mental health services.<br/> AIM: To look critically at the term 'bewildered persons' and to discuss the suspected increase in numbers and the role of mental health services.<br/> METHOD: Review and discussion of the relevant literature relating to 'bewildered persons' which has been published in the last 25 years.<br/> RESULTS: The term 'bewildered persons' is a general label given by the Dutch police to several groups of people. Suicide rates are rising and more and more people are being compulsorily admitted to psychiatric clinics and hospitals. These factors indicate that increasing numbers of people may now be a danger to themselves and to their fellow-citizens. It is not clear whether the increase in numbers is real or simply reflects the extra attention given by the police. These people may in fact be a new group consisting of persons already known to the mental health services. A national team that aims to improve the care of 'bewildered persons' has made several recommendations to stop the increase: prevention and better cooperation between municipalities and mental health facilities. In our view the mental health services should operate at the front-line of the public mental health service, providing low-threshold diagnostics, assertive outreach and treatment for patients who have mental disorders but are unwilling to accept care or treatment. Such a service requires adequate finance, good cooperative agreements and removal of the bureaucratic and financial barriers that prevent patients from seeking care.<br/> CONCLUSION: 'Bewildered persons' is an umbrella term used to denote people who urgently require care and are a public nuisance and who display disturbing behavior. 'Bewildered persons', who now form a part of the group of people targeted by the public health services, have been around for a long time but have been referred to by different names. They require the structured assistance of integrated care, access to social and medical services and timely diagnosis and treatment. People who have somehow slipped through the net of care facilities should not be left to fend for themselves.

[Working methods of ambulatory psychiatric emergency services in the Netherlands]

BACKGROUND

No recent information is available concerning the working methods of the ambulatory psychiatric emergency services in The Netherlands.<br/>

AIM

To obtain insight into the working methods of the ambulatory psychiatric emergency services.<br/>

METHOD

We performed a descriptive research.<br/>

RESULTS

Twenty of the 28 ambulatory psychiatric emergency services participated in our study (more than 71 %). The study revealed that some of the ambulatory psychiatric emergency services used differing procedures. However, all the services had a common target: they dealt with young people, adults and the elderly. In half of the organisations it was the community mental health nurse who initially went alone to visit a prospective patient. There are large differences in the number of face-to-face contacts made by emergency services and in the type of medication provided before the patient was taken by ambulance to a psychiatric hospital.<br/>

CONCLUSION

In our study we describe the working methods used by several of the ambulatory psychiatric emergency services in the Netherlands. However, our investigation produced only limited information because participating institutions were often unable to provide the information we requested and/or they did not record the methods they had used. More attention needs to be given to the best way of dealing with patients who already have an official 'emergency card'; in addition, more information is required about whether the medication used by the emergency services influenced the subsequent course of the treatment that a patient received. In view of the current situation certain important features of the emergency services such as the quality of care they provided remains underexposed.

[The number of compulsory admissions continues to rise: implications for the new Dutch law on obligatory mental health care]

BACKGROUND

Since the introduction of the new Dutch law on compulsory mental health care, the Bopz, there has been a marked increase in the number of compulsory admissions in mental health care in the Netherlands. When the new law underwent its third evaluation in 2002, it was decided that the law no longer reflected current views on the admission policy in mental health care. The draft on a new law on compulsory admissions to mental health care has already been published. One of the goals of the new law is to reduce the number of compulsory hospital admissions and to ensure that patients with mental health problems receive compulsory community care and outpatient care.

AIM

To describe and analyse the use of compulsory admissions and community treatment orders (CTOs), and to make recommendations.

METHOD

We analyse the number of CTOs and court-ordered admissions in the Netherlands between 2003 and 2013 on the basis of figures supplied by the Council for the Judiciary.

RESULTS

In the period 2003-2013 the number of compulsory emergency admissions increased from 43 to 47 per 100,000 inhabitants. During the same period the number of court-ordered admissions rose from 44 per 100,000 inhabitants in 2003 to 89 per 100,000 in 2013. (These figures include CTOs.) We were unable to perform more detailed studies because of the lack of records giving, for instance, the characteristics of patients who have undergone compulsory admission.

CONCLUSION

Emergency compulsory admissions, CTOs and court-ordered admissions to mental health care continued to rise in the period 2003-2013. There is an urgent need for more detailed registration of the type an duration of compulsory admissions to psychiatric care and for more research into the type of treatment that can prevent the use of coercion to mental health care.

[Functional remission of people with serious mental illness (SMI): psychometric properties of a new ROM-instrument]

BACKGROUND

Instruments are used for routine outcome monitoring of patients with severe mental illness in order to measure psychiatric symptoms, care needs and quality of life. By adding an instrument for measuring functional remission a more complete picture can be given of the complaints, the symptoms and general functioning, which can give direction to providing care for patients with severe mental illness.

AIM

To describe the development and testing of a new instrument of functional remission (FR) among people with a psychotic disorder or another serious mental disorder (SMI) as an addition to the symptomatic remission (SR), according to international criteria.

METHOD

The FR-assessment involves assessment by a mental health professional who conducts a semi-structured interview with the patient and his or her family and/or uses patient files relating to the three areas of functioning: daily living and self-care; work, study and housekeeping; and social contacts. These areas are rated on a three-point scale of 0: independent; 1: partially independent; 2: dependent. The assessment covers a period of six months, in accordance with the measurement of symptomatic remission and should be part of regular routine outcome monitoring (ROM) procedures. The FR-instrument was used in 2012 with 840 patients from eight Dutch mental care institutions and included a one-year follow-up among 523 patients (response 62%).

RESULTS

The results showed that the instrument is relatively easily to complete. It was also relevant for clinical practice, although further research is needed because of the raters' low response. Intra- and inter-rater reliability, discriminating and convergent validity, and sensitivity to change were rated sufficient to good.

CONCLUSION

If the FR-instrument becomes part of regular ROM-procedures and is used as a measure of societal participation, it could be a useful addition to current measures of symptomatic remission.

Insight change in psychosis: relationship with neurocognition, social cognition, clinical symptoms and phase of illness

OBJECTIVE

Impaired insight is an important and prevalent symptom of psychosis. It remains unclear whether cognitive disturbances hamper improvements in insight. We investigated the neurocognitive, social cognitive, and clinical correlates of changes in insight.

METHOD

One hundred and fifty-four patients with a psychotic disorder were assessed at baseline (T0 ) and after three years (T3 ) with the Birchwood Insight Scale, the Positive And Negative Syndrome Scale, measures of neurocognition and social cognition. Linear regression analyses were conducted to examine to what extend neurocognition, social cognition, clinical symptoms and phase of illness could uniquely predict insight change. Subsequently, changes in these factors were related to insight change.

RESULTS

Better neurocognitive performance and fewer clinical symptoms at baseline explained insight improvements. The additional effect of clinical symptoms over and above the contribution of neurocognition was significant. Together, these factors explained 10% of the variance. Social cognition and phase of illness could not predict insight change. Changes in clinical symptoms, but not changes in neurocognitive performance were associated with insight change.

CONCLUSION

Neurocognitive abilities may predict, in part, the development of insight in psychosis.

[A monitor for the emergency psychiatric service chain]

BACKGROUND

Many organisations are involved in the delivery of psychiatric emergency care to patients in crisis. We therefore refer to these organisations as the Psychiatric Emergency Chain (PEC). The quality of the PEC determines the quality of the psychiatric emergency care in a region. In order to measure the quality of this type of care a monitor has been developed in collaboration with the main stakeholders in the region Western North Brabant (WNB).

AIM

To develop a monitor to measure the quality of a PEC in a region, identify weak spots in the chain and feed back the results to the chain.

METHOD

By searching the literature, studying the primary process in the chain and by having interviews with stakeholders we compiled a questionnaire for monitoring the pec. The monitor was tested in the WNB region and adjusted on the basis of experiences with the respondents. Then the monitor was generalised and tested in another region (Eindhoven and the Kempen) in order to find out whether this instrument might also be applicable to other pecs in the Netherlands.

RESULTS

The monitor provided the PEC with a common language for evaluating the chain. The monitor was able to pinpoint particular weak spots and collaboration problems such as the response time required to reach the emergency, communication between and within organisations and domain discussions between different stakeholders. Chain partners used the results of the monitor to negotiate better collaborative agreements and to improve their care.

CONCLUSION

The monitor is able to pinpoint problem areas in the PEC and subsequently to generate feedback to its stakeholders. This creates opportunities for improvement in the PEC. Therefore the monitor is a useful instrument for evaluating a local PEC periodically.

[Contribution to quality of care or caught in a digital labyrinth? Experience with electronic records of patients receiving long-term mental health care]

BACKGROUND

In recent years electronic health records (EHRs) have been introduced on a large scale into mental health care. EHRs have a great number of advantages, one of the main ones being readability. However, very little attention seems to have been paid to the potential disadvantages and risks associated with EHRs.

AIM

To point to some of the disadvantages and risks of EHRs, in their present form, particularly in relation to the care of patients with severe mental illness (SMI).

METHOD

On the basis of clinical experience and relevant literature, we discuss some of the disadvantages and risks associated with EHRs in their current form.

RESULTS

In long-term, multidisciplinary and complex treatments of patients with SMI, EHRs in their current form fail to provide the psychiatrist with an adequate overview of the treatment process. This is largely due to the way they are designed: an ever-increasing quantity of information about complex treatment stored in separate files that can only be accessed individually and that contain free text. In mental health care the introduction of new technology, unlike the introduction of new drugs, seems to occur without structured surveillance of the disadvantages and risks involved.

CONCLUSION

EHRs need to be re-designed at the earliest opportunity.

Changes in motivation for treatment in precontemplating dually diagnosed patients receiving assertive community treatment

In a population of dually diagnosed patients receiving assertive community treatment we used the theoretical framework of the transtheoretical model to establish (a) the proportions and characteristics of patients who were not motivated for treatment for psychiatric symptoms and substance use, (b) the proportion of patients who moved towards behavioral change after about 1 year, and examine how this change was related with clinical outcome; and (c) the sequence of change processes. Chi square tests and T tests were used to compare the patient characteristics and outcomes of patients who remained in precontemplation with those who progressed. During follow-up, 47 % of the patients came out of the precontemplation phase for treatment of psychiatric symptoms and 38 % for substance use behavior. Those who remained in precontemplation benefited less from treatment. Of those who did move forward, most appeared to become motivated for psychiatric treatment before becoming motivated to reduce substance use.

[An increase of compulsory admissions in Belgium and the Netherlands: an epidemiological exploration ]

BACKGROUND

Although compulsory admission (CA) is highly relevant to society, epidemiological data for European countries are scarce and of limited reliability and comparability. In several European countries the incidence of CA seems to be increasing.

AIM

To estimate the incidence and evolution of CA in Belgium and the Netherlands by pooling and analysing available epidemiological data.

METHOD

We reviewed the literature systematically, paying particular attention to relevant epidemiological data (in published articles and in grey literature). All data were (re)calculated into yearly incidence rates of CA per 100,000 inhabitants.

RESULTS

The incidence of CA increased by 42% in Belgium (1999-2008) and by 25% in the Netherlands (2002-2009), culminating in incidence rates of 47/100,000/y (Belgium, 2008) and 80/100.000/y (Netherlands, 2009). Between-country differences can be attributed partly to differences in the legal systems. More detailed results, regional differences, and problems with the comparison of epidemiological data on CA are discussed.

CONCLUSIONS

Our data point to a significant increase of the incidence of CA in both Belgium and the Netherlands. To improve the comparability and quality of the data on CA, European countries will need to strive for greater uniformity and standardisation in the way these data are registered.

The effects of assertive community treatment including integrated dual diagnosis treatment on nuisance acts and crimes in dual-diagnosis patients

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.

[Emergency compulsory admission in crisis situations; the Amsterdam Study of Acute Psychiatry]

BACKGROUND

This article presents initial data from the Amsterdam Study of Acute Psychiatry (ASAP) which investigated the factors that play a role in the decision to admit a patient compulsorily to a psychiatric clinic in the Amsterdam area.

AIM

To find out how socio-demographic factors, a patient’s psychiatric history and pathway to care influence a patient’s chance of being served with an emergency compulsory admission order during emergency consultation.

METHODS

We conducted a prospective cohort study of 1970 consecutive patients who consecutively came into contact with the Psychiatric Emergency Service Amsterdam (PESA) in the period September 2004 to September 2006.

RESULTS

A patient who had been admitted compulsorily once in the previous five years ran an increased risk of compulsorily admission (or 3.9). Referral by the police or by the mental health services also implied a high risk of a compulsorily admission (or 2.2 and or 2.6 respectively).

CONCLUSION

A previous compulsorily admission and referral by the police or mental health services were found to be predictors of emergency compulsory admission, irrespective of possible danger to the patient himself and others and irrespective of the patient’s lack of motivation for treatment.

[Effects of treatment duration on the interpretation of ROM data in ACT patients]

BACKGROUND

Patients with severe mental illness (SMI) generally receive long-term treatment. Interrupting treatment or leaving treatment early can lead to problems with the interpretation of routine outcome monitoring (ROM) data.

AIM

To describe the link between early drop-out and treatment duration on the one hand, and patient characteristics and scores on a ROM outcome measure, namely the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS), on the other hand.

METHOD

Annual CANSAS assessments of patients in assertive community treatment (ACT).

RESULTS

2946 CANSAS assessments were performed on 1041 patients who had been treated by an ACT team for an average of 1.4 years since their first ROM assessment. Patients who remained under treatment by an ACT team were more frequently male, born outside the Netherlands and had a psychotic or addiction disorder more frequently than patients who had left the ACT team treatment early. Patients who remained in ACT had, both at the start of treatment and at their last assessment, more unfulfilled needs than patients who had been treated for a shorter period.

CONCLUSION

For the correct interpretation of ROM data for patients with SMI, one needs to have information about patient characteristics and the treatment duration.

Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment

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 -68%, P<0.001) and of patients engaging in aggression (relative risk reduction RRR = -50%, P<0.05) and the time spent in seclusion (RRR = -45%, 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.

Methodological issues in monitoring the use of coercive measures

PURPOSE

In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework.

METHODS

Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used.

RESULTS

Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institute's catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184h may be seen as high in an international perspective.

CONCLUSION

Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters.

[Development of a fidelity scale for function assertive community treatment (FACT)]

BACKGROUND

Assertive community treatment (ACT) is one of the most important models for the care and treatment, in the community, of people with severe mental illness (SMI). ACT is concerned primarily with smi-patients who have the most complex problems and it provides care by means of intensive assertive outreach. Function act (FACT) provides care for the entire group of SMI - patients and combines the principles of case management and ACT. For a long time it has been possible to measure the degree of ACT model reliability using the facts reliability scale. Throughout this time, however, a reliability scale for FACT was not available.

AIM

To develop a reliability scale for fact teams.

METHOD

Using the knowledge of experts and feedback from fact teams it has been possible to develop a reliability scale for fact teams. The scale was tested and subsequently adapted as a result of 10 pilot trials performed by 10 fact teams.

RESULTS

The definitive version of the scale was confirmed in 2008 and is currently used in the field.

CONCLUSION

With the ACT and FACT reliability scales the research field now have two instruments with which teams working with SMI - patients can measure model reliability. The DACTS and FACTS provide opportunities for quality improvement and transparency.

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

BACKGROUND

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

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.

Crisis intervention and acute psychiatry in Amsterdam, 20 years of change: a historical comparison of consultations in 1983 and 2004-2005

AIM

There has been a striking increase in the number of compulsory admission proceedings in the Netherlands since 1992, to such an extent that treatment in Amsterdam's psychiatric clinics is in danger of being dominated by coercive treatment. Our aim was to establish a picture of the changes in emergency psychiatry that have contributed to the increase in the number of acute compulsory admissions.

METHODS

A cohort (N = 460) of psychiatric emergency consultations with the city crisis service in 1983 was compared with a similar cohort (N = 436) in 2004-2005. The study focused on the following variables: patient characteristics, crisis-service procedures and consultation outcomes.

RESULTS

Compared with 1983, there are now more services involved in crisis support in the public domain for psychiatric patients. The number of patients referred by the police has risen from 29% to 63%. In 1983, all consultations took place where the patients were located; at present, 60% take place at the crisis service premises. The number of psychotic patients in the cohort has increased from 52.0% and 63.3 %. There has been an increase in the proportion of compulsory admissions and a sharp decrease in the proportion of voluntary admissions from 61% to 28% of all admissions. Overall, the percentage of consultations leading to a psychiatric admission has fallen from 42% to 27%.

CONCLUSION

The front-line outreach service of 1983 has changed into a specialist psychiatric emergency department with a less pronounced outreach component. Voluntary admissions to psychiatric hospitals have almost disappeared as a feature of the crisis service.

Dye alignment in luminescent solar concentrators: I. Vertical alignment for improved waveguide coupling

Luminescent solar concentrators (LSCs) use dye molecules embedded in a flat-plate waveguide to absorb solar radiation. Ideally, the dyes re-emit the absorbed light into waveguide modes that are coupled to solar cells. But some photons are always lost, re-emitted through the face of the LSC and coupled out of the waveguide. In this work, we improve the fundamental efficiency limit of an LSC by controlling the orientation of dye molecules using a liquid crystalline host. First, we present a theoretical model for the waveguide trapping efficiency as a function of dipole orientation. Next, we demonstrate an increase in the trapping efficiency from 66% for LSCs with no dye alignment to 81% for a LSC with vertical dye alignment. Finally, we show that the enhanced trapping efficiency is preserved for geometric gains up to 30, and demonstrate that an external diffuser can alleviate weak absorption in LSCs with vertically-aligned dyes.

Dye alignment in luminescent solar concentrators: I. Vertical alignment for improved waveguide coupling

Luminescent solar concentrators (LSCs) use dye molecules embedded in a flat-plate waveguide to absorb solar radiation. Ideally, the dyes re-emit the absorbed light into waveguide modes that are coupled to solar cells. But some photons are always lost, re-emitted through the face of the LSC and coupled out of the waveguide. In this work, we improve the fundamental efficiency limit of an LSC by controlling the orientation of dye molecules using a liquid crystalline host. First, we present a theoretical model for the waveguide trapping efficiency as a function of dipole orientation. Next, we demonstrate an increase in the trapping efficiency from 66% for LSCs with no dye alignment to 81% for a LSC with vertical dye alignment. Finally, we show that the enhanced trapping efficiency is preserved for geometric gains up to 30, and demonstrate that an external diffuser can alleviate weak absorption in LSCs with vertically-aligned dyes.

Dye alignment in luminescent solar concentrators: II. Horizontal alignment for energy harvesting in linear polarizers

We describe Linearly Polarized Luminescent Solar Concentrators (LP-LSCs) to replace conventional, purely absorptive, linear polarizers in energy harvesting applications. As a proof of concept, we align 3-(2-Benzothiazolyl)-N,N-diethylumbelliferylamine (Coumarin 6) and 4- dicyanomethyl-6-dimethylaminostiryl-4H-pyran (DCM) dye molecules linearly in the plane of the substrate using a polymerizable liquid crystal host. We show that up to 38% of the photons polarized on the long axis of the dye molecules can be coupled to the edge of the device for an LP-LSC based on Coumarin 6 with an order parameter of 0.52.

Dye alignment in luminescent solar concentrators: II. Horizontal alignment for energy harvesting in linear polarizers

We describe Linearly Polarized Luminescent Solar Concentrators (LP-LSCs) to replace conventional, purely absorptive, linear polarizers in energy harvesting applications. As a proof of concept, we align 3-(2-Benzothiazolyl)-N,N-diethylumbelliferylamine (Coumarin 6) and 4-dicyanomethyl-6-dimethylaminostiryl-4H-pyran (DCM) dye molecules linearly in the plane of the substrate using a polymerizable liquid crystal host. We show that up to 38% of the photons polarized on the long axis of the dye molecules can be coupled to the edge of the device for an LP-LSC based on Coumarin 6 with an order parameter of 0.52.

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

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.

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

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.

Financial incentives to improve adherence to medication in five patients with schizophrenia in the Netherlands

OBJECTIVE

Non-adherence to antipsychotic medication is common and increases the risk of psychotic relapse. A promising intervention may be a strategy wherein financial incentives are offered.

METHODS

In a pilot study in The Netherlands, five patients with schizophrenia were offered financial incentives for a duration of one year to improve adherence to medication. Adherence and hospital days were measured.

RESULTS

The percentage of accepted depot injections increased from an average of 44% in the previous year to 100% in the year when financial incentives were offered. While patients had been hospitalised for an average of 100.2 days in the previous year, only one was re-admitted for 17 days during the year of the intervention.

CONCLUSIONS

The differences in adherence before and after the intervention were large and of clinical significance. However, randomised controlled trials are required to provide conclusive evidence on the effectiveness of offering financial incentives and potential consequences.