[ROM in mental health care: treatment outcomes of both generic and disorder specific instruments in patients with anxiety disorders; a cohort study]. / ROM in de ggz: behandeluitkomsten met specifieke en generieke instrumenten bij patiënten met angststoornissen; een cohortonderzoek.

BACKGROUND: In routine outcome monitoring (rom) generic instruments are often used to measure outcomes. This could hamper the clinical use of these instruments and lead to a possible underestimation of treatment outcomes.
AIM: To examine whether there are differences in the degree of progress between outcomes of disorder specific instruments measuring anxiety symptoms and the Symptomatic Distress subscale of the Outcome Questionnaire-45 (oq-45-sd).
METHOD: Data from 604 patients with an anxiety disorder were analyzed. The mean change scores, percentages of reliable change and effect sizes on the oq-45-sd were compared to the outcomes of seven commonly used instruments that specifically measure the symptoms of anxiety disorders.
RESULTS: The effect sizes on the oq-45-sd and the disorder specific instruments were 0.80 or higher. The correlation between the change scores was moderate, as was the correspondence between the degree to which patients improved reliably. In one third to half of the cases changes on the oq-45-sd and on the disorder specific instruments were not in agreement.
CONCLUSION: The treatment outcomes of the oq-45-sd are approximately as positive as those of the disorder specific instruments. However, discrepancies existed in the extent to which patients had improved. In accordance with the advice of the International Consortium for Health Outcomes Measurement, the use of both kinds of instruments is advised when evaluating the progress of the treatment.

Treatment Outcome, Duration, and Costs: A Comparison of Performance Indicators Using Data from Eight Mental Health Care Providers in The Netherlands.

Assessing performance of mental health services (MHS) providers merely by their outcomes is insufficient. Process factors, such as treatment cost or duration, should also be considered in a meaningful and thorough analysis of quality of care. The present study aims to examine various performance indicators based on treatment outcome and two process factors: duration and cost of treatment. Data of patients with depression or anxiety from eight Dutch MHS providers were used. Treatment outcome was operationalized as case mix corrected pre-to-posttreatment change scores and as reliable change (improved) and clinical significant change (recovered). Duration and cost were corrected for case mix differences as well. Three performance indicators were calculated and compared: outcome as such, duration per outcome, and cost per outcome. The results showed that performance indicators, which also take process variability into account, reveal larger differences between MHS providers than mere outcome. We recommend to use the three performance indicators in a complementary way. Average pre-to-posttreatment change allows for a simple and straightforward ranking of MHS providers. Duration per outcome informs patients on how MHS providers compare in how quickly symptomatic relief is achieved. Cost per outcome informs MHS providers on how they compare regarding the efficiency of their care. The substantial variation among MHS providers in outcome, treatment duration and cost calls for further exploration of its causes, dissemination of best practices, and continuous quality improvement.

[ROM for the elderly: a prospective cohort study of the outcomes on the HoNOS 65+ in various diagnostic groups]. / ROM bij ouderen: een prospectief cohortonderzoek naar de uitkomsten op de HoNOS 65+ bij verschillende diagnosegroepen.

BACKGROUND: Routine outcome monitoring (rom) provides us with opportunities to study treatment outcome in daily clinical practice and to learn from the results.
AIM: To assess the changes that occur in the psychological and social functioning of patients in geriatric psychiatry who are suffering from substance dependence, mood disorder, anxiety disorder, psychotic disorder, or personality disorder.
METHOD: We analysed data relating to 1,810 patients (aged 60-101) from nine mental health care organisations that together form SynQuest cv. The total scores and item scores on the Health of the Nation Outcome Scales for older people (Honos 65+) at the beginning and end of treatment were also analysed and were linked to the diagnosis.
RESULTS: Patients improved significantly (es=0.8). The degree of improvement depended on the patient's principal diagnosis; patients with a mood or anxiety disorder improved the most (es=1.0 and 0.8). The degree of improvement varied per Honos 65+ item. In particular, patients with 'depressive problems' and 'other mental and behavioral problems' showed considerable improvement.
CONCLUSION: Many older patients benefited from the treatment they received in gerontopsychiatry departments. This helps to give elderly patients with psychiatric disorders hope for the future. The scores on the individual items of the Honos 65+ can help clinicians to tailor treatment to the patient's specific problems and to monitor and evaluate treatment outcome in conjunction with the patient.

[Using resource groups in assertive community treatment; literature review and recommendation]. / De inzet van resourcegroepen voor gedeelde besluitvorming bij assertive community treatment; literatuuroverzicht en aanbevelingen.

BACKGROUND: In psychiatry there is an increasing interest in giving patients and their relatives control over the goals of treatment and the way in which treatment is carried out. A structural method of organising this within assertive community treatment (ACT) is to let patients and their relatives participate in what is known as a resource group (RG).
AIM: To provide a systematic view of the advantages of giving patients control over their treatment and the way in which it is carried out via ACT, particularly if this control is organised in the form of an RG.
METHOD: We reviewed the relevant literature on the basis of search instructions in the databases of PubMed and Cochrane Library. We found nine trials that had a randomised controlled design (RCT). Only one of these RCTs involved the use of an RG in ACT.
RESULTS: The approaches used in ACT, whereby patients with schizophrenia had control over their treatment, led to significant improvements that were considerably greater than those achieved in standard care. Improvements were found in symptomatology, social functioning and in the quality of life. There are indications that treatment satisfaction and social functioning improve still further if patients' control over their treatment is organised in an RG.
CONCLUSION: Research demonstrates that positive results are achieved with ACT whereby patients have control over their treatment and the way in which it is carried out. However, further research is needed to determine whether this addition to ACT in the form of an RG is superior to other approaches used previously in ACT, particularly if it concerns the inclusion of an RG.

['I'll serve my time ' II. A replication study of recidivism in patients with a one-year hospital order]. / 'Ik zit mijn tijd wel uit ' II. Een replicatieonderzoek naar recidiven bij patiënten met een strafrechtelijke machtiging.

BACKGROUND: In the Netherlands a one-year hospital order is often imposed on forensic patients with a psychotic disorder. The purpose of the order is to reduce the patient's violence behaviour by forcing him/her to receive medical treatment for a year. A pilot study showed that the recidivism rate for this group, following discharge, was relatively high. Patients who re-offended had relatively high HCR-20 scores and were more often involved in incidents during treatment than patients who had not re-offended. AIM: To replicate the findings of the pilot study and to compare the recidivism rate of this group to the recidivism rate of patients who had been given a detention order for a longer time with possibilties for prolongation ('tbs'). METHOD: The study involved 95 patients with a psychotic disorder who had been treated in an FPA (Forensic Psychiatric Clinic) by reason of a one-year hospital order or a detention order for an unspecified time. Hospital records were consulted in order to complete the HKT-30 and the PCL-R and to check how many incidents had occurred during each patient's treatment. The HKT-30 is a dutch version of the HCR-20. The results were counted at a later date by persons not informed about the outcome. After the hospital records had been checked, the recidivism figures were obtained from the Information Service of the Ministry of Justice. RESULTS: Of the patients subject to the one-year hospital order 43.5% reoffended following discharge. Recidivism by patients who had been given the longer-term detention order was significantly lower, namely 23.1%. The seriousness of the offences committed following discharge differed significantly from the offence for which they were originally charged/convicted. The HKT-30 and factor 2 of the PCL-R predicted the possibility of recidivism, but the number of violent incidents that occurred on the ward did not. CONCLUSION: Our findings indicate that the recidivism among patients subject to a one-year hospital order is relatively high compared to the rate among patients who had received a longer-term detention order. The most likely explanation for this difference is that the hospital order was imposed for a shorter period.

[Background and possible use of ROM in mental health care]. / Achtergronden en gebruiksmogelijkheden van ROM in de ggz.

BACKGROUND: Routine outcome measurement or monitoring ROM has attracted worldwide attention largely as a result of developments in the field of quality care and scientific research. AIM: To provide insight into the significance of ROM for Dutch mental health care. METHOD: We consulted scientific literature on the following subjects: research and its applicability for clinical practice, quality improvement, ROM instruments and their implementation. RESULTS: ROM means that the outcomes of treatment and care are measured routinely as part of the plan-do-check-act cycle aimed at quality improvement. Measurement instruments are selected on clinical, scientific and practical grounds. ROM can be used in four main ways: for the treatment of individual patients, for the testing of policy, for benchmarking and for research. With regards to the implementation of rom, a combined top-down, bottom-up approach is preferable to an entirely top-down or bottom-up approach. CONCLUSION: ROM can help to improve the quality of mental health care because it involves the standardized use of outcome measures and comprehensive databases.

[ROM in adult psychiatry: an evaluation of measurement instruments]. / ROM in de volwassenenpsychiatrie: een evaluatie van meetinstrumenten.

BACKGROUND: An evaluation of the most commonly used ROM measures in Dutch psychiatry is lacking, both for severe mental illnesses and for common psychiatric disorders. AIM: To provide an overview of the characteristics and quality of outcome measures. METHOD: A literature study yielded six outcome measures. The psychometrical, clinical and practical aspects of these scales are described. RESULTS: The measures are suitable and are of adequate quality. DISCUSSION: It remains to be seen if any of the outcome measures are suitable for both serious and less serious mental illnesses. The use of a combination of a self-rating scale and an observerrating scale that measure symptoms and domains of functioning may be the most promising choice.

[The use of HoNOS in the treatment of patients]. / Gebruik van de HoNOS bij de behandeling van patiënten.

BACKGROUND: In order to use outcome scores for making decisions about treatment, practitioners need to know the course of scores of several groups of patients. AIM: To test the applicability of methods for computing cut-off scores and individual changes. METHOD: Using Health of the Nation Outcome Scales (HoNOS), we analysed repeated assessments of 699 adults and 414 elderly patients in different treatment settings. RESULTS: Mean HoNOS scores and cut-off scores differentiated between patient groups reasonably well. Scores and threshold values for elderly patients were relatively high. The reliable change index showed few individual changes even for groups where change was expected. The effect size and the standard error of measurement were found to be more sensitive to change. CONCLUSION: More research is needed before the findings can be generalised.

['I'll serve my time...' A pilot study on recidivism in forensic psychiatric patients forcibly hospitalized and treated for one year and on factors that affect recidivism]. / 'Ik zit mijn tijd wel uit...' Forensisch psychiatrische pilotstudie naar recidive bij patiënten met een strafrechtelijke plaatsing strafrechtelijke plaatsing.

BACKGROUND: So far little is known about psychiatric patients who, on committing a crime, are ordered to undergo one year of inpatient treatment due to a hospital order. Such patients seem to be more difficult to treat and cause more incidents on the ward than forensic patients for whom duration of treatment is not set in advance. This may have something to do with the time-limited nature of the hospital order and may also predict the risk of recidivism following discharge. AIM: To assess to what extent patients with a one-year hospital order relapse upon discharge and to discover the factors that influence the risk of recidivism. METHOD: Retrospective study based on a Dutch sample of 30 forensic psychiatric patients who had received a one-year hospital order and had completed their treatment in a forensic psychiatric hospital between 2002 and 2005. RESULTS: Within four years of their discharge 50% of the research group had relapsed into relatively serious crime, some of them fairly soon after discharge. The recidivism occurred even if the patients continued their treatment upon discharge. This treatment was sometimes provided by the regular psychiatric care services. Recidivists had been sentenced more often in the five years preceding the crime committed upon discharge, had received more psychiatric diagnoses, had obtained higher scores on risk-assessment instruments and had been involved in more incidents during treatment. CONCLUSION: Patients who have received a one-year hospital order often relapse into serious crime, relatively soon after their discharge. One wonders whether the hospital order of one year actually achieves its purpose and whether the mental health services are adequately equipped to supervise these patients after they have completed their compulsory course of hospital treatment.

Parental communication deviance: its stability and the effect of family treatment in recent-onset schizophrenia.

The influence of a behavioural family treatment on parental communication deviance (CD) was investigated in a longitudinal treatment study. Subjects were the parents of young patients with recent-onset schizophrenia or related disorders. Parents and patients were randomly assigned to one of two treatment conditions: individual out-patient treatment or a combination of individual out-patient and family treatment. Parental CD was assessed with the Thematic Apperception Test (TAT) both at the start of the out-patient treatment and after completion of treatment 1 year later. Most families had high levels of CD, a finding which is in agreement with previous CD studies. These high CD levels remained stable over the 12-month period. Family treatment was not effective in influencing the level of CD. The findings suggest that high CD is a stable trait-marker of parents, and they support the notion that high levels of CD may precede the onset of serious psychotic disorders. Studies with more chronic patients are needed to replicate the findings.

Patient attributes and expressed emotion as risk factors for psychotic relapse.

In the context of a prospective, controlled treatment study, contrasting family interventions with individual treatment, the role of expressed emotion (EE) as a predictor of relapse was examined in patients with recent-onset schizophrenia and related disorders (n = 97). EE was compared with 13 predictor variables. The variables, taken from EE and family intervention studies, related to demography, premorbid functioning, present and past illness history, and comorbid substance abuse. Psychotic relapse was operationalized with a conservatively measured relapse criterion, composed of monthly ratings based on the Brief Psychiatric Rating Scale and on clinical judgment during the 12 months of outpatient treatment. Of the 14 predictor variables entered in stepwise survival analyses, 6 variables had probable predictive power on the conservative relapse criterion. These variables were entered in a Cox regression model. EE turned out to be the major predictor of relapse in the overall sample (hazard ratio [HR] 4.90; confidence interval [CI] 1.05-22.92). This finding remained when only patients with a first psychotic episode (p = 0.02) and patients in the individual treatment condition (p = 0.001) were examined. Cannabis abuse was the major predictor of relapse in patients with high-EE families (HR 4.27; CI 1.12-16.29).

The relationships between expressed emotion, affective style and communication deviance in recent-onset schizophrenia.

The relationships between expressed emotion (EE), affective style (AS) and communication deviance (CD) were studied during hospitalization and after discharge. EE was measured with both the Camberwell Family Interview (CFI) and the Five-Minutes Speech Sample (FMSS). The study subjects were patients with recent-onset schizophrenia and related disorders, who were consecutively admitted to an in-patient unit for adolescents, and their parents. The results revealed that CFI/EE was significantly correlated with AS criticism scores during hospitalization, but did not predict AS scores after discharge. FMSS/EE correlated significantly with AS criticism when both measures were administered after discharge. During hospitalization, FMSS/EE was not significantly correlated with AS. No consistent relationship was found between CD and both affective factors (EE and AS). It is concluded that EE and AS overlap with regard to level of criticism when both measures are administered over a short period of time and independent of the time of assessment. In addition, the results indicate that affective and communication factors identify independent family attributes.

Symptoms, cognitive and social functioning in recent-onset schizophrenia: a longitudinal study.

The relationships among symptoms, cognitive functioning and social functioning were investigated in patients with schizophrenia over a period of 15 months. Patients with a mood disorder, a normal control group and a sample of parents of the schizophrenic patients also completed the cognitive tests. In the schizophrenia sample, only disorganisation was correlated with cognitive performance, which was interpreted as further evidence that disorganisation is a separate symptom dimension of schizophrenia. Against expectations, with two of three measurements no significant correlations were found between negative symptoms and cognitive performance. With these two measurements, however, a curvilinear association between negative symptoms and cognitive performance was observed, suggesting that negative symptoms are not a unitary concept. Finally, tentative evidence could be obtained for speed of information processing and selective attention as markers for vulnerability, although the latter is not specific for schizophrenia.

Dimensions and subtypes of recent-onset schizophrenia. A longitudinal analysis.

A sample of young patients with schizophrenia was studied in a longitudinal design to investigate the stability of an earlier reported four-dimensional symptom model (positive symptoms, negative symptoms, disorganization, and depression). Symptoms were measured in an acute phase soon after hospitalization, in a remitted stage 3 months later, and in a "mixed" phase 1 year after the second assessment. A different factor structure was found at each measurement, but a stable four-dimensional structure could be defined that closely resembled the factor structure of the first assessment. The symptom dimensions were uncorrelated, except disorganization and depression. Whether meaningful subtypes could be defined using statistical criteria also was investigated. With cluster analysis, four subtypes were defined that could be characterized as follows: rapid treatment responders, slower responders, and two relapse groups. Although some indication of the validity of these subtypes was found, it is concluded that there is a high risk of creating artificial boundaries with this approach.

Relapse criteria in schizophrenic disorders: different perspectives.

Relapse and exacerbation of psychotic symptoms were investigated in a prospective study of 88 patients with recent-onset schizophrenia and related disorders. Relapse definitions were derived from expressed emotion and family intervention studies and based on the Brief Psychiatric Rating Scale (BPRS), the Present State Examination, and clinical judgment. Results indicate that research and clinical criteria represent different perspectives on relapse. Clinical criteria provide a validity check that can verify BPRS-rated changes in partially remitted patients.

A dimensional and categorical approach to the symptomatology of recent-onset schizophrenia.

Sixty-five patients with recent-onset schizophrenia were assessed with two widely used symptom scales, the Brief Psychiatric Rating Scale-Expanded (BPRS-E) and the Psychiatric Assessment Scale (Manchester scale). Principal components analysis of the BPRS-E scores yielded a four-dimensional structure: positive symptoms, negative symptoms, disorganization, and depression. With the Psychiatric Assessment Scale, three dimensions were found: the positive symptoms (delusions, hallucinations) and disorganization (incoherence) appeared in one dimension. A categorical analysis resulted in predominantly positive, negative, and disorganized clusters, but more than half of the sample could not be allocated to any of these groups.

Symptom dimensions and cognitive and social functioning in recent-onset schizophrenia.

The relationships among symptoms, cognitive functioning and social functioning were investigated in 60 patients with recent-onset schizophrenia. Positive symptoms were unrelated to cognitive measures. Disorganization and depressive symptoms were correlated significantly with Card Sorting performance. Furthermore, only negative symptoms were correlated significantly with social functioning. These results replicate earlier studies with chronic and mixed samples, and support the validity of disorganization as a separate symptom dimension. In contrast to most previous studies, no significant correlations were found between negative symptoms and cognitive measures. However, some evidence was found for a non-linear association between negative symptoms had several cognitive measures. The variation explained by a curvilinear model was not high, but for some cognitive measures this model was clearly superior to a linear model. If replicated, this finding supports the position that cross-sectionally measured negative symptoms cannot be viewed as a unitary concept.