Exploring the use of Routine Outcome Monitoring in the treatment of patients with a psychotic disorder

BACKGROUND

Routine Outcome Monitoring (ROM) has become part of the treatment process in mental health care. However, studies have indicated that few clinicians in psychiatry use the outcome of ROM in their daily work. The aim of this study was to explore the degree of ROM use in clinical practice as well as the explanatory factors of this use.

METHODS

In the Northern Netherlands, a ROM-protocol (ROM-Phamous) for patients with a psychotic disorder has been implemented. To establish the degree of ROM-Phamous use in clinical practice, the ROM results of patients (n=204) were compared to the treatment goals formulated in their treatment plans. To investigate factors that might influence ROM use, clinicians (n=32) were asked to fill out a questionnaire about ROM-Phamous.

RESULTS

Care domains that were problematic according to the ROM-Phamous results were mentioned in the treatment plan in 28% of cases on average (range 5-45%). The use of ROM-Phamous in the treatment process varies considerably among clinicians. Most of the clinicians find ROM-Phamous both useful and important for good clinical practice. In contrast, the perceived ease-of-use is low and most clinicians report insufficient time to use ROM-Phamous.

CONCLUSIONS

More frequent ROM use should be facilitated in clinicians. This could be achieved by improving the fit with clinical routines and the ease-of-use of ROM systems. It is important for all stakeholders to invest in integrating ROM in clinical practice. Eventually, this might improve the diagnostics and treatment of patients in mental health care.

Symptomatic remission in psychosis and real-life functioning

BACKGROUND

In 2005 Andreasen proposed criteria for remission in schizophrenia. It is unclear whether these criteria reflect symptom reduction and improved social functioning in daily life.

AIMS

To investigate whether criteria for symptomatic remission reflect symptom reduction and improved functioning in real life, comparing patients meeting remission criteria, patients not meeting these criteria and healthy controls.

METHOD

The Experience Sampling Method (ESM), a structured diary technique, was used to explore real-life symptoms and functioning in 177 patients with (remitted and non-remitted) schizophrenia spectrum disorders and 148 controls.

RESULTS

Of 177 patients, 70 met criteria for symptomatic remission. These patients reported significantly fewer positive and negative symptoms and better mood states compared with patients not in remission. Furthermore, patients in remission spent more time in goal-directed activities and had less preference for being alone when they were with others. However, the patient groups did not differ on time spent in social company and doing nothing, and both the remission and non-remission groups had lower scores on functional outcome measures compared with the control group.

CONCLUSIONS

The study provides an ecological validation for the symptomatic remission criteria, showing that patients who met the criteria reported fewer positive symptoms, better mood states and partial recovery of reward experience compared with those not in remission. However, remission status was not related to functional recovery, suggesting that the current focus on symptomatic remission may reflect an overly restricted goal.

Experience sampling research in individuals with mental illness: reflections and guidance

OBJECTIVE

The experience sampling method (ESM) represents a valuable way of assessing clinical phenomena in real world settings and across time. Despite its theoretical advantages, using this methodology in psychiatric populations is challenging. This paper acts as a guide to researchers wishing to employ this approach when investigating mental illness.

METHOD

The contents represent the opinions of researchers around the United Kingdom and the Netherlands who are experienced at using the ESM.

RESULTS

In ESM studies, participants are required to fill in questions about their current thoughts, feelings and experiences when prompted by an electronic device (e.g. a wristwatch, PDA). Entries are typically made at fixed or random intervals over 6 days. This article outlines how to design and validate an ESM diary. We then discuss which sampling procedure to use and how to increase compliance through effective briefing and telephone sessions. Debriefing, data management and analytical issues are considered, before suggestions for future clinical uses of the ESM are made.

CONCLUSION

The last decade has seen an increase in the number of studies employing the ESM in clinical research. Further research is needed to examine the optimal equipment and procedure for different clinical groups.

The dynamics of symptomatic and non-symptomatic coping with psychotic symptoms in the flow of daily life

OBJECTIVE

Previous research has suggested that going along with psychotic symptoms (symptomatic coping) is less effective than other coping strategies with psychotic symptoms. This pilot study aims to validate such findings using a momentary assessment strategy of coping with stress in daily life.

METHOD

Patients with psychosis (n = 35) were studied with the Experience Sampling Method (ESM; a structured diary technique) to assess coping with stress in daily life. This was analysed in relation to coping with psychotic symptoms using a previously validated interview (Maastricht Assessment of Coping Strategies).

RESULTS

Symptomatic and non-symptomatic coping were negatively associated with each other. Symptomatic coping was negatively associated with the level of coping in daily life, whereas a positive association was apparent for non-symptomatic coping. Non-symptomatic coping, but not symptomatic coping, predicted appraisals of distress associated with psychotic symptoms.

CONCLUSION

Effective coping may be associated with the tendency to develop conscious appraisals of distress associated with psychotic symptoms.

[Can the "Camberwell Assessment of Need" predict changes in care consumption?]

BACKGROUND

Because of the shift in the Dutch psychiatric care system towards care based on actual need, we should have some kind of instrument for assessing the future need for care. The Camberwell Assessment of Need (CAN) is such an instrument. It is particularly useful when there is a clear link between the need for care and the consumption of care.

AIM

To study whether the can is a predictor of (changes in) care consumption.

METHOD

The Maastricht Cumulative Needs for Care Monitor (CNCM) involves an interview with all patients with psychotic disorders who are in care in the Maastricht region. The interview takes place at intake and thereafter annually. The main instrument of the CNCM is the CAN, but other instruments are also included. CNCM data are matched with care consumption data extracted from the Psychiatric Case Register South Limburg, including both care consumption in the year before and in the year after the CNCM assessment.

RESULTS

Patients with intermediate or higher levels of need for care were found to use more inpatient care than patients with lower levels of need for care. In addition, the results showed that a high level of need for care was a predictor of shifts from low inpatient care consumption to high inpatient care consumption, although statistically imprecise by conventional alpha.

CONCLUSION

The CAN may well be a valuable instrument for assessing future inpatient care consumption.

Sex differences in emotional reactivity to daily life stress in psychosis

BACKGROUND

The expression of schizophrenia has been reported to differ between the sexes. The current study investigates whether these sex differences in clinical expression are reflected in one underlying mechanism that may be causally related to psychosis, namely increases in stress sensitivity in daily life.

METHOD

Forty-two participants (22 men, 20 women) with Research Diagnostic Criteria-defined psychotic disorder in a state of clinical remission were studied with the Experience Sampling Method (a structured diary technique assessing current context and mood in daily life) to assess (1) appraised subjective stress related to daily events and activities and (2) emotional reactivity conceptualized as changes in both negative affect and positive affect in relation to the subjective stress. Data were collected from January 1997 to May 1999.

RESULTS

Multilevel regression analyses revealed that women reported a significantly (p < .05) increased emotional reactivity to daily life stress compared with men, reflected in both an increase in negative affect and a decrease in positive affect.

CONCLUSION

These results suggest that gender differences may not be limited to the characteristics of psychosis but may also be reflected in underlying etiologic mechanisms. Furthermore, these results might strengthen the hypothesis that women are more susceptible than men to a schizoaffective expression of schizophrenia.

Do life events have their effect on psychosis by influencing the emotional reactivity to daily life stress?

BACKGROUND

Life events (LE) have consistently been found to influence course and outcome of psychotic disorders. However, the mechanism through which they operate is not known. The present study investigated whether LE have their effect by impacting on the emotional sensitivity for daily hassles.

METHOD

Patients with clinically remitted psychotic illness (N=42) were studied with the Experience Sampling Method (a structured diary technique assessing current context and mood in daily life) to assess: (1) appraised subjective stress related to daily events and activities; and (2) emotional reactivity conceptualized as changes in both negative affect (NA) and positive affect (PA). LE were assessed with the Brown & Harris Life Event and Difficulties Schedule.

RESULTS

Multilevel regression analyses showed that previous exposure to LE influenced the appraised stressfulness of neither daily events nor the activities in which the subjects were involved. However, a history of LE did modify the emotional reaction to daily life stress, both in models predicting NA and in models predicting PA.

CONCLUSIONS

By their cumulative effect on emotional reactivity to daily activities and events, LE may render individuals more vulnerable to the onset or persistence of psychotic experiences.