The effects of a computerized clinical decision aid on clinical decision-making in psychosis care

OBJECTIVE

Clinicians in mental healthcare have few objective tools to identify and analyze their patient's care needs. Clinical decision aids are tools that support this process. This study examines whether 1) clinicians working with a clinical decision aid (TREAT) discuss more of their patient's care needs compared to usual treatment, and 2) agree on more evidence-based treatment decisions.

METHODS

Clinicians participated in consultations (n = 166) with patients diagnosed with psychotic disorders from four Dutch mental healthcare institutions (research registration number 201700763). Primary outcomes were measured with the modified Clinical Decision-making in Routine Care questionnaire and combined with psychiatric, physical and social wellbeing related care needs. A multilevel analysis compared discussed care needs and evidence-based treatment decisions between treatment as usual (TAU) before, TAU after and the TREAT condition.

RESULTS

First, a significant increase in discussed care needs for TREAT compared to both TAU conditions (β = 20.2, SE = 5.2, p = 0.00 and β = 15.8, SE = 5.4, p = 0.01) was found. Next, a significant increase in evidence-based treatments decisions for care needs was observed for TREAT compared to both TAU conditions (β = 16.7, SE = 4.8, p = 0.00 and β = 16.0, SE = 5.1, p = 0.01).

CONCLUSION

TREAT improved the discussion about physical health issues and social wellbeing related topics. It also increased evidence-based treatment decisions for care needs which are sometimes overlooked and difficult to treat. Our findings suggest that TREAT makes sense of routine outcome monitoring data and improves guideline-informed care.

The Relationship Between Grey Matter Volume and Clinical and Functional Outcomes in People at Clinical High Risk for Psychosis

Objective

To examine the association between baseline alterations in grey matter volume (GMV) and clinical and functional outcomes in people at clinical high risk (CHR) for psychosis.

Methods

265 CHR individuals and 92 healthy controls were recruited as part of a prospective multi-center study. After a baseline assessment using magnetic resonance imaging (MRI), participants were followed for at least two years to determine clinical and functional outcomes, including transition to psychosis (according to the Comprehensive Assessment of an At Risk Mental State, CAARMS), level of functioning (according to the Global Assessment of Functioning), and symptomatic remission (according to the CAARMS). GMV was measured in selected cortical and subcortical regions of interest (ROI) based on previous studies (ie orbitofrontal gyrus, cingulate gyrus, gyrus rectus, inferior temporal gyrus, parahippocampal gyrus, striatum, and hippocampus). Using voxel-based morphometry, we analysed the relationship between GMV and clinical and functional outcomes.

Results

Within the CHR sample, a poor functional outcome (GAF < 65) was associated with relatively lower GMV in the right striatum at baseline (P < .047 after Family Wise Error correction). There were no significant associations between baseline GMV and either subsequent remission or transition to psychosis.

Conclusions

In CHR individuals, lower striatal GMV was associated with a poor level of overall functioning at follow-up. This finding was not related to effects of antipsychotic or antidepressant medication. The failure to replicate previous associations between GMV and later psychosis onset, despite studying a relatively large sample, is consistent with the findings of recent large-scale multi-center studies.

The development and evaluation of a computerized decision aid for the treatment of psychotic disorders

BACKGROUND

Routinely monitoring of symptoms and medical needs can improve the diagnostics and treatment of medical problems, including psychiatric. However, several studies show that few clinicians use Routine Outcome Monitoring (ROM) in their daily work. We describe the development and first evaluation of a ROM based computerized clinical decision aid, Treatment-E-Assist (TREAT) for the treatment of psychotic disorders. The goal is to generate personalized treatment recommendations, based on international guidelines combined with outcomes of mental and physical health acquired through ROM. We present a pilot study aimed to assess the feasibility of this computerized clinical decision aid in daily clinical practice by evaluating clinicians' experiences with the system.

METHODS

Clinical decision algorithms were developed based on international schizophrenia treatment guidelines and the input of multidisciplinary expert panels from multiple psychiatric institutes. Yearly obtained diagnostic (ROM) information of patients was presented to treating clinicians combined with treatment suggestions generated by the algorithms of TREAT. In this pilot study 6 clinicians and 16 patients of Lentis Psychiatric Institute used the application. Clinicians were interviewed and asked to fill out self-report questionnaires evaluating their opinions about ROM and the effectiveness of TREAT.

RESULTS

Six clinicians and 16 patients with psychotic disorders participated in the pilot study. The clinicians were psychiatrists, physicians and nurse-practitioners which all worked at least 8 years in mental health care of which at least 3 years treating patients with psychotic illnesses. All Clinicians found TREAT easy to use and would like to continue using the application. They reported that TREAT offered support in using diagnostic ROM information when drafting the treatment plans, by creating more awareness of current treatment options.

CONCLUSION

This article presents a pilot study on the implementation of a computerized clinical decision aid linking routine outcome monitoring to clinical guidelines in order to generate personalized treatment advice. TREAT was found to be feasible for daily clinical practice and effective based on this first evaluation by clinicians. However, adjustments have to be made to the system and algorithms of the application. The ultimate goal is to provide appropriate evidence based care for patients with severe mental illnesses.

[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.

Are cognitive impairments associated with sensitivity to stress in schizophrenia? An experience sampling study

OBJECTIVE

Patients with a diagnosis of schizophrenia display cognitive impairments and abnormal sensitivity to stress. However, little is known about the relationship between these two endophenotypes.

METHOD

Neuropsychological tests were administered to 42 patients with schizophrenia or other psychosis to assess cognitive functioning, and the experience sampling method (a structured diary technique assessing current context and mood in daily life) was used to assess 1) appraised subjective stress related to daily events and activities and 2) emotional reaction to these daily life stressors.

RESULTS

Multilevel random regression analyses showed that in some instances, cognitive functioning did not alter emotional reaction to stress. In other instances, an inverse relationship was found, indicating that a better performance on neuropsychological tests was related to greater emotional reaction to stress.

CONCLUSIONS

The results indicate that emotional reaction to stress in the daily lives of patients with schizophrenia may not be a consequence of cognitive impairments and that the two mechanisms may act through different pathways. Such pathways may be related to the extremes of clinical outcome that have been observed in schizophrenia: an episodic, reactive, good outcome and a more chronic form characterized by high levels of negative symptoms and cognitive impairments.

Emotional reactivity to daily life stress in psychosis

BACKGROUND

The vulnerability-stress model of psychotic disorders describes, in essence, an interaction between personal vulnerability and environmental stressors. The present study investigated this interaction and studied emotional reactivity to daily life stress as a vulnerability marker for psychotic illness.

METHODS

Patients with psychotic illness (n = 42), their first-degree relatives (n = 47), and control subjects (n = 49) were studied with the Experience Sampling Method (a structured diary technique assessing thoughts, current context, and mood in daily life) to assess (1) appraised subjective stress of daily events and smaller disturbances in daily life and (2) emotional reactivity conceptualized as changes in both negative affect and positive affect.

RESULTS

Multilevel regression analyses showed that an increase in subjective stress was associated with an increase in negative affect and a decrease in positive affect in all groups. However, the groups differed quantitatively in their pattern of reactions to stress. Patients with psychotic illness reacted with more intense emotions to subjective appraisals of stress in daily life than control subjects. The decrease in positive affect in the relatives was similar to that of the patients, while the increase in negative affect in this group was intermediary to that of patients and control subjects.

CONCLUSIONS

Higher levels of familial risk for psychosis were associated with higher levels of emotional reactivity to daily life stress in a dose-response fashion. Subtle alterations in the way persons interact with their environment may constitute part of the vulnerability for psychotic illness.

The context of delusional experiences in the daily life of patients with schizophrenia

BACKGROUND

Global characteristics and psychosocial risk factors related to delusions have been identified. The present study extends these findings to the level of everyday functioning, identifying characteristics of delusional moments (DMs) and contextual risk and protective factors for delusional exacerbations in daily life.

METHODS

Data were collected using the Experience Sampling Method (ESM), a time-sampling technique. Forty-eight chronic patients diagnosed with schizophrenia rated the intensity of pathological symptoms and mood states and described their thoughts and the environmental context during consecutive moments in daily life. Delusions were defined on the basis of self-rated suspicion, preoccupation, feeling controlled, and coded thought pathology. Daily context included current activity, persons present and location. Characteristics of DMs and non-delusional moments (nDMs) were compared, and a multilevel logistic regression model was used to identify contexts that might trigger or prevent DMs.

RESULTS

On average, patients experienced delusions less than one-third of the time. DMs were characterized by higher negative affect and lower positive affect. The presence of family or acquaintances decreased the risk of subsequently experiencing a DM, whereas withdrawal from activities increased this risk.

CONCLUSIONS

Data support the validity of ESM for investigating delusions in schizophrenia. Daily life contexts appear to alter the probability that delusions will occur. Knowledge about such contexts may therefore be useful in helping patients develop better coping strategies and in creating therapeutic interventions that can lessen emotional distress.

Schizophrenia patients are more emotionally active than is assumed based on their behavior

Flat affect is a core symptom of schizophrenia. To date, researchers have focused primarily on emotional expression. Only recently has the emotional experience of patients with schizophrenia been studied in laboratory settings. The goal of this study is to assess emotional experience in the complex world of daily life. A structured time-sampling technique, the Experience Sampling Method, was used to collect data. Schizophrenia subjects (n = 58) were compared to 65 nonpatient controls. Patients were divided into blunted and nonblunted subgroups on the basis of Brief Psychiatric Rating Scale (BPRS) behavioral ratings of flat affect. Schizophrenia subjects experienced more intense and more variable negative emotions than controls. For the positive emotions, we found less intensity and less variability in the schizophrenia subjects. No difference in patterns of affect was found between the blunted and the nonblunted schizophrenia subgroups. Our findings suggest that patients with schizophrenia are more emotionally active than has been assumed based on behavioral observations.

Time, context, and subjective experiences in schizophrenia

Systematic investigations into the experience of schizophrenic patients as they react and adapt to social environments are rare. Yet such information is extremely useful for understanding the psychopathology of schizophrenia, the planning of treatments, as well as for creating optimal treatment and living environments. In this study, dynamic fluctuations of mental state, social context, and experience in the daily life of schizophrenic patients were measured. Data were collected using the Experience Sampling Method on nine schizophrenic subjects and seven nonpsychiatric controls. Schizophrenic patients spent more time alone than normal--a difference that was largely created by the subsample of outpatients; hospitalized patients were less alone. As a group, the patients felt best when they were with one to three persons. The most troublesome condition reported was being alone or being in the company of more than three people. Three cases are presented to illustrate the individual variability of subjects' experience.

The daily life of ambulatory chronic mental patients

The purpose of this research is to describe in greater detail than is typically done the daily life experiences of 11 ambulatory chronic mental patients and 11 nonpsychiatric controls. The subjects, although diagnostically heterogeneous, were representative of Dutch chronic mental patients. The Experience-Sampling Method was used to signal subjects randomly 10 times a day for 6 consecutive days to fill out self-rating forms assessing mental state and contextual information at the moment of the signal. Compliance was good. In time-allocation comparisons with nonpsychiatric subjects the patients were found to live relatively "normal" lives. As expected, their psychopathology was influenced by social environments such as being alone, at home, or in society at large. Contrary to other studies that stress the social isolation of such individuals, the chronic subjects reported feeling better away from home and among people than normal subjects. When alone, chronic patients reported daydreaming more and noted a tendency to drift away from thoughts about current activities. Mental state fluctuations and daily interactions, characteristic of this group, are examined in relation to theories of vulnerability and coping style of chronic mental patients, with an eye to individualized treatment applications.