Associations between disturbed sleep and attenuated psychotic experiences in people at clinical high risk for psychosis.

BACKGROUND: Pre-diagnostic stages of psychotic illnesses, including 'clinical high risk' (CHR), are marked by sleep disturbances. These sleep disturbances appear to represent a key aspect in the etiology and maintenance of psychotic disorders. We aimed to examine the relationship between self-reported sleep dysfunction and attenuated psychotic symptoms (APS) on a day-to-day basis. METHODS: Seventy-six CHR young people completed the Experience Sampling Methodology (ESM) component of the European Union Gene-Environment Interaction Study, collected through PsyMate® devices, prompting sleep and symptom questionnaires 10 times daily for 6 days. Bayesian multilevel mixed linear regression analyses were performed on time-variant ESM data using the brms package in R. We investigated the day-to-day associations between sleep and psychotic experiences bidirectionally on an item level. Sleep items included sleep onset latency, fragmentation, and quality. Psychosis items assessed a range of perceptual, cognitive, and bizarre thought content common in the CHR population. RESULTS: Two of the seven psychosis variables were unidirectionally predicted by previous night's number of awakenings: every unit increase in number of nightly awakenings predicted a 0.27 and 0.28 unit increase in feeling unreal or paranoid the next day, respectively. No other sleep variables credibly predicted next-day psychotic symptoms or vice-versa. CONCLUSION: In this study, the relationship between sleep disturbance and APS appears specific to the item in question. However, some APS, including perceptual disturbances, had low levels of endorsement amongst this sample. Nonetheless, these results provide evidence for a unidirectional relationship between sleep and some APS in this population.

[Assertive Treatment as a regular function within mental health]. / Van bemoeizorg naar assertieve behandeling als regulier aanbod vanuit de ggz.

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.

Polygenic liability for schizophrenia and childhood adversity influences daily-life emotion dysregulation and psychosis proneness.

OBJECTIVE: To test whether polygenic risk score for schizophrenia (PRS-S) interacts with childhood adversity and daily-life stressors to influence momentary mental state domains (negative affect, positive affect, and subtle psychosis expression) and stress-sensitivity measures. METHODS: The data were retrieved from a general population twin cohort including 593 adolescents and young adults. Childhood adversity was assessed using the Childhood Trauma Questionnaire. Daily-life stressors and momentary mental state domains were measured using ecological momentary assessment. PRS-S was trained on the latest Psychiatric Genetics Consortium schizophrenia meta-analysis. The analyses were conducted using multilevel mixed-effects tobit regression models. RESULTS: Both childhood adversity and daily-life stressors were associated with increased negative affect, decreased positive affect, and increased subtle psychosis expression, while PRS-S was only associated with increased positive affect. No gene-environment correlation was detected. There is novel evidence for interaction effects between PRS-S and childhood adversity to influence momentary mental states [negative affect (b = 0.07, P = 0.013), positive affect (b = -0.05, P = 0.043), and subtle psychosis expression (b = 0.11, P = 0.007)] and stress-sensitivity measures. CONCLUSION: Exposure to childhood adversities, particularly in individuals with high PRS-S, is pleiotropically associated with emotion dysregulation and psychosis proneness.

[Mental health in Eastern Lille: a future of network-psychiatry?] / De ggz in Oost-Lille: inspiratie voor de praktijk van netwerkzorg in de ggz.

BACKGROUND: 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.
AIM: Gaining inspiration to further investigate regional cooperation and 'network care' in Dutch psychiatry.
METHOD: A delegation from the board of f-act-Netherlands and ccaf paid a working visit to Lille.
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.

[Flexible assertive community treatment (FACT) as part of a community (health) network]. / FACT als onderdeel van wijkgerichte zorg in het (zorg)netwerk.

BACKGROUND: 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.
AIM: Offering new insights on collaboration within and between domains.
METHOD: Reflection on developments in the social domain and specialist mental healthcare using relevant literature and recent (inter)national experiences.
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.

[Positive effects of psychoeducation on mental disorders in the Netherlands]. / Positieve effecten van voorlichting over psychiatrische aandoeningen in de algemene bevolking.

BACKGROUND: Mental Health First Aid (mhfa) is a psychoeducation program designed to recognize mental health problems in others, to approach and support them and to refer them to appropriate help.
AIM: To discuss the possible contribution that mhfa can make to the early detection, intervention and destigmatization of mental health problems in the Netherlands.
METHOD: Description of the characteristics, effectiveness and knowledge gaps of mhfa in the Dutch context based on literature and practice.
RESULTS: Positive experiences abroad suggest that mhfa can also contribute to early detection, intervention and destigmatization of mental disorders in the Netherlands. Optimization of the program on the local context is important here.
CONCLUSION: Dutch evaluation- and effect studies are needed to determine whether the positive effects from international research also apply in the Netherlands, whether adults and young people receive early and adequate help thanks to mhfa, and how the stigma surrounding mental disorders can be further reduced.

[Indicating care: quite a challenge]. / Indiceren voor zorg: een hele uitdaging.

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[Decision aid for the treatment of psychotic illness: development of TReatment E-AssisT (TREAT)]. / Beslistool bij de behandeling van psycho-tische aandoeningen: de ontwikkeling van TReatment E-AssisT (TREAT).

BACKGROUND: Use of decision aids in mental health care is increasing and will also be introduced in the Dutch mental healthcare system. We describe the context of this development and discuss how decision aids could facilitate evidence-based psychiatry.
AIM: To describe the development of the decision aid TReatment E-Assist (TREAT) in the Dutch mental healthcare system that aims to optimize treatment of people with a psychotic illness.
METHOD: We describe how the TREAT application works and discuss its potential contribution to the treatment of people with a psychotic illness.
RESULTS: In a pilot study TREAT was judged as user friendly and useful. TREAT seemed to increase the integration of ROM-results in treatment and the advice offered new view points for practioners.
CONCLUSION: TREAT is a novel application which combines routine outcome monitoring results with current treatment guidelines and standards of care in order to generate personalised treatment recommendations in the context of a psychiatric treatment trajectory. A multicentre study is being conducted in different provinces in the Netherlands to investigate the effectiveness of TREAT.

[Development of the renewed Flexible ACT scale: F-ACT fidelity 2017]. / De ontwikkeling van de vernieuwde Flexible ACT-schaal: F-ACT-s 2017.

BACKGROUND: An important model for the organisation of care for people with severe mental illness is flexible assertive community treatment (F-ACT). F-ACT combines case management with assertive crisis intervention. Quality control was implemented in 2008 using a model fidelity scale. Research has shown that the norms used for the F-ACT fidelity scale no longer correspond with current norms concerning restorative and evidence-based care, as established in treatment guidelines.
AIM: To develop a new model fidelity scale for F-ACT teams.
METHOD: Using knowledge of experts, relevant articles and feedback from professionals, researchers, interest groups and family members, a new model fidelity scale was developed: the F-ACTs 2017. The revised scale was tested by trained auditors in 21 F-ACT teams and adjusted in two pilot rounds.
RESULTS: In 2017 the final version was presented to the stakeholders and was approved by the board of auditors; the final version is currently in use. CONCLUSIONS With the availability of F-ACTs 2017, the (research) field has state-of-the-art instrument to monitor the quality of care of persons with severe mental illness. It uses field standards to evaluate the degree of model fidelity of teams that focus on patients with severe mental illness in a rapidly changing context.

[A valid quality system for mental health care: from accountability and control in institutionalised settings to co-creation in small areas and a focus on community vital signs]. / Een valide kwaliteitskader voor de ggz: van benchmark-ROM aan de achterkant naar regionale regie en cocreatie aan de voorkant.

BACKGROUND: In a given year, around 25% of the Dutch population may experience significant mental health problems, much more than the mental health service can attend to, given a maximum capacity of 6% of the population per year. Due to the lack of a public mental health system, there is fierce competition over who gets to receive care from mental health services and little control over how the level of needs can be matched with the appropriate intensity of care. As a result, resources are being wasted and both overtreatment and undertreatment are prevalent.
AIM: To propose a valid quality system that benefits the mental health of the entire population and does not simply attend to the symptoms of a strategically selected group.
METHOD: Literature review from an epidemiological and public mental health perspective.
RESULTS: In our view, a valid quality system for mental health care needs to focus on two distinct areas. The first area involves the analysis of about 20 quantitative population parameters or 'Community Vital Signs' (care consumption, pharmaco-epidemiological indicators, mortality, somatic morbidity, social care, housing, work, benefits, involuntary admissions). This analysis will reveal regional variation in the mental health of the entire population rather than in the relatively small, selected group receiving mental health care. The second area to which attention needs to be directed comprises a system of simple qualitative visits to mental health care institutions based on 10 quality parameters that currently remain invisible; these parameters will measure the impact at local community level. The focus of these will be on a transition from accountability and control in large institutions to provision of care in small areas that was co-designed with users and other stakeholders.
CONCLUSION: A valid quality system for mental health care is within reach, provided it is combined with a novel system of public mental health and transition of care to a system of co-design with users in small areas.

[Model fidelity of flexible assertive community treatment (F-ACT) teams: five years of audit results]. / Modelgetrouwheid van flexible assertive community treatment(F-ACT)-teams: resultaten van vijf jaar auditeren.

BACKGROUND: 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.
METHOD: Analysis of the ccaf database, which holds the data of audits conducted between 2009 and 2014.
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.

[Mental health in Bonaire - an inspiration for the Dutch New Mental Health Movement]. / De ggz in Bonaire - een inspiratie voor de beweging 'de nieuwe ggz'.

BACKGROUND: In 2010 the bes-islands in the Caribbean became a special municipality of the Netherlands. Healthcare was upgraded to match Dutch standards over a short period of time. With a population of 15,518 inhabitants in 2010 (19,408 in 2016), Bonaire received its own fact-team (flexible assertive community treatment). It subsequently became a unique experiment for the Dutch New Mental Health Movement.
AIM: To describe the development of a modern mental health care system in a limited geographic area.
METHOD: Site visitation, interviews and analysis of historical data sources.
RESULTS: The local mental health team takes integral responsibility for all the mh care needs in Bonaire. There is no intricate diagnostic referral system. Consultation access lines are short. The team was able to dramatically reduce the need for hospitalization. Collaboration with the somatic hospital and general practitioners runs smoothly and the facilities offer complementary care. Societal integration is insured due to mental health professionals living interspersed in the neighborhood, the low threshold allowing them to respond to signals efficiently. There is a natural development of the following three domains of care: reduction of symptoms, societal participation and personal remission.
CONCLUSION: Integrated mental health services in a geographically small area, as presented by the Dutch New Mental Health Movement, enables the possibility of recovery oriented care.

[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.

[A study of cost-effectiveness of treating serious mental illness: challenges and solutions]. / Doelmatigheidsonderzoek bij mensen met een ernstige psychische aandoening: uitdagingen en oplossingen.

BACKGROUND People with serious mental illness (SMI) often suffer high healthcare costs and enduring loss of quality of life. Increasing our understanding of the cost-effectiveness of people with SMI is important when striving for optimal health at affordable costs. AIM To describe aspects that can be important for cost-effectiveness research targeting people with SMI. METHOD These aspects are demonstrated by considering pro-active care, rehabilitation and involuntary treatment RESULTS The possible involvement of a large number of stakeholders outside of healthcare requires cost-effectiveness research to also map the costs and benefits outside of healthcare, preferably for each stakeholder specifically. Availability of data, the possibility to combine datasets, and ways to deal with dropouts require extra attention. CONCLUSION Cost-effectiveness research targeting people with SMI could be enhanced when solutions are found for the availability of data inside and outside of healthcare and when dropout can be compensated for by other sources of data, such that costs and benefits for each stakeholder can be estimated more reliably.

[Functional remission of people with serious mental illness (SMI): psychometric properties of a new ROM-instrument]. / Functionele remissie bij mensen met een ernstige psychiatrische aandoening; psychometrische eigenschappen van een nieuw 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.

[Consensus regarding the definition of persons with severe mental illness and the number of such persons in the Netherlands]. / Consensus over de definitie van mensen met een ernstige psychische aandoening (EPA) en hun aantal in Nederland.

BACKGROUND: Insurance companies and mental health service planners need to have information about the prevalence of severe mental illness (SMI) and about the numbers of persons affected. They require these data in order to be able to develop, implement and evaluate innovative mental health care for such patients. This information lets them draw up their budgets and define their priorities. AIM: To reach a consensus regarding the number of patients with SMI in the Netherlands. METHOD: A consensus was reached regarding the definition of SMI, and the prevalence of SMI was determined on the basis of epidemiological literature and policy papers relating to mental health care in the Netherlands. When figures from the literature were inaccurate or unavailable, estimates were checked by a group of experts. RESULTS: The definition of SMI was adjusted and amended in relation to psychiatric comorbidity. An analysis of the care-loads of all the mental health care providers yielded an estimate of 160,000 SMI patients aged 18-65, including those receiving addiction care and forensic care (1.6% of the adult population). When children and adolescents (< 18 years) and the elderly (> 65 years) were included, the total number of patients came to 216,000 (1.3%). The prevalence among the population was estimated to be 281,000 (1.7%). CONCLUSION: The Consensus group is of the opinion that the consensus document estimates of the number of SMI patients in the Netherlands are as accurate as they can possibly be. Of course, the document contains assumptions and extrapolations which will require further research. The figures will be confirmed or adjusted in the future as soon as new evidence becomes available.

Delayed affective recovery to daily-life stressors signals a risk for depression.

OBJECTIVE: The aim of this study is to investigate the time to affective recovery from daily-life stressors between healthy controls (HC) and two groups with an increased risk for developing depression: individuals with subclinical symptoms of depression (SSD), and individuals remitted from a depressive episode with residual symptoms of depression (RRS). METHOD: The experience sampling method (ESM) was used to measure affective recovery to daily-life stressors. Affective recovery was defined as the moment that negative affect (NA) returned to baseline level following the first stressful event of the day. We assessed two different operationalizations of the baseline: NA at the moment before the stressful event (t-1), and mean-person NA. The effect of stress intensity, and cumulative stress were also assessed. RESULTS: Survival analyses showed significantly longer recovery times for the at risk groups in comparison to healthy individuals, albeit no significant difference was found between the two at risk groups (i.e. SSD and RRS). There was also an effect of cumulative stress, but not stress intensity on time to recovery in that cumulative stress resulted in significantly longer recovery times for all three groups. LIMITATIONS: The present study is limited by the ESM sampling design, assessments take place post-stress and therefore do not capture peak stress. Additionally, we are only able to assess patterns at the group level. Finally, there is a significant age difference between groups. CONCLUSION: Individuals at risk for depression display a delayed recovery to daily-life stressors when compared to healthy controls, which is not explained by differences in stress intensity or cumulative stress. Understanding what is driving this delay may help combat the development of depression.