Searching for the optimal number of response alternatives for the distress scale of the four-dimensional symptom questionnaire.

BACKGROUND: The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire designed to measure distress, depression, anxiety, and somatization. Prior to computing scale scores from the item scores, the three highest response alternatives ('Regularly', 'Often', and 'Very often or constantly present') are usually collapsed into one category to reduce the influence of extreme responding on item- and scale scores. In this study, we evaluate the usefulness of this transformation for the distress scale based on a variety of criteria. METHODS: Specifically, by using the Graded Response Model, we investigated the effect of this transformation on model fit, local measurement precision, and various indicators of the scale's validity to get an indication on whether the current practice of recoding should be advocated or not. In particular, the effect on the convergent- (operationalized by the General Health Questionnaire and the Maastricht Questionnaire), divergent- (operationalized by the Neuroticism scale of the NEO-FFI), and predictive validity (operationalized as obtrusion with daily chores and activities, the Biographical Problem list and the Utrecht Burnout Scale) of the distress scale was investigated. RESULTS: Results indicate that recoding leads to (i) better model fit as indicated by lower mean probabilities of exact test statistics assessing item fit, (ii) small (<.02) losses in the sizes of various validity coefficients, and (iii) a decrease (DIFF (SE's) = .10-.25) in measurement precision for medium and high levels of distress. CONCLUSIONS: For clinical applications and applications in longitudinal research, the current practice of recoding should be avoided because recoding decreases measurement precision for medium and high levels of distress. It would be interesting to see whether this advice also holds for the three other domains of the 4DSQ.

Person-fit feedback on inconsistent symptom reports in clinical depression care.

BACKGROUND: Depressive patients can present with complex and different symptom patterns in clinical care. Of these, some may report patterns that are inconsistent with typical patterns of depressive symptoms. This study aimed to evaluate the validity of person-fit statistics to identify inconsistent symptom reports and to assess the clinical usefulness of providing clinicians with person-fit score feedback during depression assessment. METHODS: Inconsistent symptom reports on the Inventory of Depressive Symptomatology Self-Report (IDS-SR) were investigated quantitatively with person-fit statistics for both intake and follow-up measurements in the Groningen University Center of Psychiatry (n = 2036). Subsequently, to investigate the causes and clinical usefulness of on-the-fly person-fit alerts, qualitative follow-up assessments were conducted with three psychiatrists about 20 of their patients that were randomly selected. RESULTS: Inconsistent symptom reports at intake (12.3%) were predominantly characterized by reporting of severe symptoms (e.g. psychomotor slowing) without mild symptoms (e.g. irritability). Person-fit scores at intake and follow-up were positively correlated (r = 0.45). Qualitative interviews with psychiatrists resulted in an explanation for the inconsistent response behavior (e.g. complex comorbidity, somatic complaints, and neurological abnormalities) for 19 of 20 patients. Psychiatrists indicated that if provided directly after the assessment, a person-fit alert would have led to new insights in 60%, and be reason for discussion with the patient in 75% of the cases. CONCLUSIONS: Providing clinicians with automated feedback when inconsistent symptom reports occur is informative and can be used to support clinical decision-making.

Identifying levels of general distress in first line mental health services: can GP- and eHealth clients' scores be meaningfully compared?

BACKGROUND: The Four-Dimensional Symptom Questionnaire (4DSQ) (Huisarts Wetenschap 39: 538-47, 1996) is a self-report questionnaire developed in the Netherlands to distinguish non-specific general distress from depression, anxiety, and somatization. This questionnaire is often used in different populations and settings and there is a paper-and-pencil and computerized version. METHODS: We used item response theory to investigate whether the 4DSQ measures the same construct (structural equivalence) in the same way (scalar equivalence) in two samples comprised of primary mental health care attendees: (i) clients who visited their General Practitioner responded to the 4DSQ paper-and-pencil version, and (ii) eHealth clients responded to the 4DSQ computerized version. Specifically, we investigated whether the distress items functioned differently in eHealth clients compared to General Practitioners' clients and whether these differences lead to substantial differences at scale level. RESULTS: Results showed that in general structural equivalence holds for the distress scale. This means that the distress scale measures the same construct in both General Practitioners' clients and eHealth clients. Furthermore, although eHealth clients have higher observed distress scores than General Practitioners' clients, application of a multiple group generalized partial credit response model suggests that scalar equivalence holds. CONCLUSIONS: The same cutoff scores can be used for classifying respondents as having low, moderate and high levels of distress in both settings.

Paternal influences on treatment outcome of behavioral parent training in children with attention-deficit/hyperactivity disorder.

This study aims to explore the influence of paternal variables on outcome of behavioral parent training (BPT) in children with attention-deficit/hyperactivity disorder (ADHD). 83 referred, school-aged children with ADHD were randomly assigned to BPT plus ongoing routine clinical care (RCC) or RCC alone. Treatment outcome was based on parent-reported ADHD symptoms and behavioral problems. Moderator variables included paternal ADHD symptoms, depressive symptoms, and parenting self-efficacy. We conducted repeated measures analyses of variance (ANOVA) for all variables, and then analyzed the direction of interaction effects by repeated measures ANOVA in high and low scoring subgroups. Paternal ADHD symptoms and parenting self-efficacy played a moderating role in decreasing behavioral problems, but not in decreasing ADHD symptoms. Paternal depressive symptoms did not moderate either treatment outcome. BPT is most beneficial in reducing children's behavioral problems when their fathers have high levels of ADHD symptoms or high-parenting self-efficacy.

Cause-specific mortality among patients with psychosis: disentangling the effects of age and illness duration.

BACKGROUND: There is a large mortality gap between patients with a nonaffective psychotic disorder and those in the general population, is associated with both natural and nonnatural death causes. OBJECTIVE: This study aims to assess whether mortality risks vary for different causes of death according to the duration since diagnosis and age in a large sample of patients with nonaffective psychotic disorder. METHODS: Data of patients with nonaffective psychotic disorder (n = 12,580) from 3 Dutch psychiatric registers were linked to the cause of death register of Statistics Netherlands and compared with personally matched controls (n = 124,143) from the population register. Death rates were analyzed by duration since the date of the registered diagnosis of the (matched) patient and their age using a Poisson model. RESULTS: Among patients, the rates of all-cause death decreased with longer illness duration. This was explained by lower suicide rates. For example, among those between 40 and 60 years of age, the rate ratios (RR) of suicide during 2-5 and > 5 years were 0.52 and 0.46 (p = 0.002), respectively, when compared with the early years after diagnosis. Compared with controls, patients experienced higher rates of natural death causes during all stages and in all age categories, rate ratios 2.35-5.04; p < 0.001-0.025. There was no increase in these rate ratios with increasing duration or increasing age for patients when compared with controls. CONCLUSIONS: The high risk of natural death causes among patients with nonaffective psychotic disorder is already present at a comparatively young age. This suggests caution in blaming antipsychotics or the accumulating effects of adverse lifestyle factors for premature death. It is better to proactively monitor and treat somatic problems from the earliest disease stages onward.

A web-based tool to support shared decision making for people with a psychotic disorder: randomized controlled trial and process evaluation.

BACKGROUND: Mental health policy makers encourage the development of electronic decision aids to increase patient participation in medical decision making. Evidence is needed to determine whether these decision aids are helpful in clinical practice and whether they lead to increased patient involvement and better outcomes. OBJECTIVE: This study reports the outcome of a randomized controlled trial and process evaluation of a Web-based intervention to facilitate shared decision making for people with psychotic disorders. METHODS: The study was carried out in a Dutch mental health institution. Patients were recruited from 2 outpatient teams for patients with psychosis (N=250). Patients in the intervention condition (n=124) were provided an account to access a Web-based information and decision tool aimed to support patients in acquiring an overview of their needs and appropriate treatment options provided by their mental health care organization. Patients were given the opportunity to use the Web-based tool either on their own (at their home computer or at a computer of the service) or with the support of an assistant. Patients in the control group received care as usual (n=126). Half of the patients in the sample were patients experiencing a first episode of psychosis; the other half were patients with a chronic psychosis. Primary outcome was patient-perceived involvement in medical decision making, measured with the Combined Outcome Measure for Risk Communication and Treatment Decision-making Effectiveness (COMRADE). Process evaluation consisted of questionnaire-based surveys, open interviews, and researcher observation. RESULTS: In all, 73 patients completed the follow-up measurement and were included in the final analysis (response rate 29.2%). More than one-third (48/124, 38.7%) of the patients who were provided access to the Web-based decision aid used it, and most used its full functionality. No differences were found between the intervention and control conditions on perceived involvement in medical decision making (COMRADE satisfaction with communication: F1,68=0.422, P=.52; COMRADE confidence in decision: F1,67=0.086, P=.77). In addition, results of the process evaluation suggest that the intervention did not optimally fit in with routine practice of the participating teams. CONCLUSIONS: The development of electronic decision aids to facilitate shared medical decision making is encouraged and many people with a psychotic disorder can work with them. This holds for both first-episode patients and long-term care patients, although the latter group might need more assistance. However, results of this paper could not support the assumption that the use of electronic decision aids increases patient involvement in medical decision making. This may be because of weak implementation of the study protocol and a low response rate.

Flexible Assertive Community Treatment, Severity of Symptoms and Psychiatric Health Service Use, a Real life Observational Study.

BACKGROUND: Introduction of Flexible Assertive Community Treatment (FACT) may be associated with increased remission rates and changes in patterns of care. The present paper reports on differences in psychosocial functioning and health care use between patients in FACT and two groups of patients not currently provided with a specific model of community service. METHODS: The ongoing "Pharmacotherapy Monitoring and Outcome Survey" provided routine outcome measures of patients using antipsychotics in the north of the Netherlands. Level of psychosocial functioning was assessed using the Health of the Nations Outcome Scales (HoNOS) and matched with psychiatric health care consumption obtained from the Psychiatric Case Register. Patients who never received FACT, patients ever in FACT but not at assessment date, and patients in FACT were identified. Data were subjected to multilevel linear regression analysis. RESULTS: Data showed that most patients in FACT also had non-FACT episodes after the start of FACT. Furthermore, patients in FACT displayed higher levels of psychosocial functioning and used more outpatient care than the other two groups. CONCLUSIONS: Patients in FACT receive more outpatient care and have better psychosocial functioning. However, causal inferences cannot be derived from these data. In addition, membership of a FACT-team in this setting did not last indefinitely.

Usability evaluation of a web-based support system for people with a schizophrenia diagnosis.

BACKGROUND: Routine Outcome Monitoring (ROM) is a systematic way of assessing service users' health conditions for the purpose of better aiding their care. ROM consists of various measures used to assess a service user's physical, psychological, and social condition. While ROM is becoming increasingly important in the mental health care sector, one of its weaknesses is that ROM is not always sufficiently service user-oriented. First, clinicians tend to concentrate on those ROM results that provide information about clinical symptoms and functioning, whereas it has been suggested that a service user-oriented approach needs to focus on personal recovery. Second, service users have limited access to ROM results and they are often not equipped to interpret them. These problems need to be addressed, as access to resources and the opportunity to share decision making has been indicated as a prerequisite for service users to become a more equal partner in communication with their clinicians. Furthermore, shared decision making has been shown to improve the therapeutic alliance and to lead to better care. OBJECTIVE: Our aim is to build a web-based support system which makes ROM results more accessible to service users and to provide them with more concrete and personalized information about their functioning (ie, symptoms, housing, social contacts) that they can use to discuss treatment options with their clinician. In this study, we will report on the usability of the web-based support system for service users with schizophrenia. METHODS: First, we developed a prototype of a web-based support system in a multidisciplinary project team, including end-users. We then conducted a usability study of the support system consisting of (1) a heuristic evaluation, (2) a qualitative evaluation and (3) a quantitative evaluation. RESULTS: Fifteen service users with a schizophrenia diagnosis and four information and communication technology (ICT) experts participated in the study. The results show that people with a schizophrenia diagnosis were able to use the support system easily. Furthermore, the content of the advice generated by the support system was considered meaningful and supportive. CONCLUSIONS: This study shows that the support system prototype has valuable potential to improve the ROM practice and it is worthwhile to further develop it into a more mature system. Furthermore, the results add to prior research into web applications for people with psychotic disorders, in that it shows that this group of end users can work with web-based and computer-based systems, despite the cognitive problems they experience.

Supported housing and supported independent living in the Netherlands, with a comparison with England.

Research into community housing programs for people with severe mental illness is underexposed. The Dutch UTOPIA study describes characteristics of their service users, which may predict their allocation to either supported housing or supported independent living programs. Additionally, a comparison is made with English studies. 119 Care coordinators of Dutch residential care institutes and 534 service users participated in a cross-sectional survey which includes socio-demographic data, clinical data, measures of functioning, needs for care and quality of life. Differences between Dutch residents and independent living service users were small, making predictions of care allocation difficult. This similarity suggests a possible lack of methodical assessment in the allocation procedure of people who are eligible for residential housing or independent living programs. This is largely comparable to the English situation. In comparison with their English counterparts, Dutch service users have more met needs and are more engaged in occupational activities.

Treatment plans in psychiatric community housing programs: do they reflect rehabilitation principles?

OBJECTIVE: This study examined the extent to which treatment plans of service users of community housing programs measure up to rehabilitation principles according to the Choose-Get-Keep model of psychiatric rehabilitation. The study evaluates whether these plans correspond with service-user and key-worker perspectives on unmet needs for care. METHOD: A representative sample of key workers and service users of 16 Dutch Regional Institutes for Residential Care (RIRCs) participated in a cross-sectional survey. Sociodemographic and clinical data and an assessment of needs for care of 240 service users were collected. In addition, we received an anonymous copy of each participant's most recent written treatment plan. First, we developed a method to measure adherence to rehabilitation principles of written treatment plans, based on the Choose-Get-Keep model of psychiatric rehabilitation. Next, treatment plans were screened on the degree of adherence, expressed in a score from 0 to 10 for overall quality, and correlated with needs for care. RESULTS: RIRCs mostly seem to succeed in sufficiently integrating rehabilitation principles in their treatment plans. Adherence to rehabilitation principles was neither associated with the service-user perspective nor with the key worker perspective on needs for care. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Rehabilitation principles are rather well documented in the majority of written treatment plans, although apparently without substantial consequences for needs for care among the service users. Further research is needed to validate our method and to investigate not only the adherence to rehabilitation principles in written treatment plans, but also in the actual care provision itself.

Partner attachment as a predictor of long-term response to treatment with couples therapy.

Vulnerability factors such as insecure attachment may have a lasting effect on the outcome of couples therapy, even long after discharge from treatment. Given that attachment has never been examined as an outcome predictor for couples therapy in the long term, the authors studied its effect on outcome during and after couples therapy. This prospective study included 71 inpatients participating in group couples therapy who the authors measured at baseline, immediately posttreatment at 2 months, and at 8 and 20 months, regarding two outcomes: problem-solving capacity (using the Interactional Problem Solving Questionnaire) and psychopathology (using the 90-item Symptom Check List). At baseline, the authors measured partner attachment (using the Experiences in Close Relationships Questionnaire). Mixed model analyses showed that attachment-related dysfunctional working models of self and others predicted less improvement in psychopathology (p = .04) and problem-solving capacity (p = .01), respectively. Special attention to insecure attachment in couples therapy may therefore prove valuable in terms of outcome in the long run.

Evaluating the CANSAS self-report (CANSAS-P) as a screening instrument for care needs in people with psychotic and affective disorders.

We examined agreement between the CANSAS self-report version (CANSAS-P) and the Camberwell Assessment of Need (CAN) interview in 200 long-term patients with affective and psychotic disorders. Intra-class correlations were fair to good for unmet needs. Overall, more unmet needs were reported on the CANSAS-P than in the CAN interview. No differences were found for patients with psychotic versus affective disorders. We conclude from this that the CANSAS-P is a promising screening instrument to detect unmet needs in people with severe mental illnesses.

Does monitoring need for care in patients diagnosed with severe mental illness impact on Psychiatric Service Use? Comparison of monitored patients with matched controls.

BACKGROUND: Effectiveness of services for patients diagnosed with severe mental illness (SMI) may improve when treatment plans are needs based. A regional Cumulative Needs for Care Monitor (CNCM) introduced diagnostic and evaluative tools, allowing clinicians to explicitly assess patients' needs and negotiate treatment with the patient. We hypothesized that this would change care consumption patterns. METHODS: Psychiatric Case Registers (PCR) register all in-patient and out-patient care in the region. We matched patients in the South-Limburg PCR, where CNCM was in place, with patients from the PCR in the North of the Netherlands (NN), where no CNCM was available. Matching was accomplished using propensity scoring including, amongst others, total care consumption and out-patient care consumption. Date of the CNCM assessment was copied to the matched controls as a hypothetical index date had the CNCM been in place in NN. The difference in care consumption after and before this date (after minus before) was analysed. RESULTS: Compared with the control region, out-patient care consumption in the CNCM region was significantly higher after the CNCM index date regardless of treatment status at baseline (new, new episode, persistent), whereas a decrease in in-patient care consumption could not be shown. CONCLUSIONS: Monitoring patients may result in different patterns of care by flexibly adjusting level of out-patient care in response to early signs of clinical deterioration.

Behavioral parent training as an adjunct to routine care in children with attention-deficit/hyperactivity disorder: moderators of treatment response.

OBJECTIVE: To investigate predictors and moderators of outcome of behavioral parent training (BPT) as adjunct to ongoing routine clinical care (RCC), versus RCC alone. METHODS: We randomly assigned 94 referred children (4-12 years) with attention-deficit/hyperactivity disorder (ADHD) to BPT plus RCC or RCC alone. Outcome was based on parent-reported behavioral problems and ADHD symptoms. Predictor/moderator variables included children's IQ, age, and comorbidity profile, and maternal ADHD, depression, and parenting self-efficacy. RESULTS: Superior BPT treatment effects on behavioral problems and ADHD symptoms were present in children with no or single-type comorbidity-anxiety/depression or oppositional defiant disorder (ODD)/conduct disorder (CD)-and when mothers had high parenting self-efficacy, but absent in children with broad comorbidity (anxiety/depression and ODD/CD) and when mothers had low parenting self-efficacy. In older children ADHD symptoms tended to decrease more through BPT than in younger children. CONCLUSIONS: Adjunctive BPT is most useful when mothers have high parenting self-efficacy and in children with no or single-type comorbidity.

Reprint of: Negative symptoms predict high relapse rates and both predict less favorable functional outcome in first episode psychosis, independent of treatment strategy.

BACKGROUND: In first episode psychosis (FEP) baseline negative symptoms (BNS) and relapse both predict less favorable functional outcome. Relapse-prevention is one of the most important goals of treatment. Apart from discontinuation of antipsychotics, natural causes of relapse are unexplained. We hypothesized that BNS, apart from predicting worse functional outcome, might also increase relapse risk. METHODS: We performed a post-hoc analysis of 7-year follow-up data of a FEP cohort (n = 103) involved in a dose-reduction/discontinuation (DR) vs. maintenance treatment (MT) trial. We examined: 1) what predicted relapse, 2) what predicted functional outcome, and 3) if BNS predicted relapse, whether MT reduced relapse rates compared to DR. After remission patients were randomly assigned to DR or MT for 18 months. Thereafter, treatment was uncontrolled. OUTCOMES: BNS and duration of untreated psychosis (DUP) predicted relapse. Number of relapses, BNS, and treatment strategy predicted functional outcome. BNS was the strongest predictor of relapse, while number of relapses was the strongest predictor of functional outcome above BNS and treatment strategy. Overall and within MT, but not within DR, more severe BNS predicted significantly higher relapse rates. Treatment strategies did not make a difference in relapse rates, regardless of BNS severity. INTERPRETATION: BNS not only predicted worse functional outcome, but also relapses during follow-up. Since current low dose maintenance treatment strategies did not prevent relapse proneness in patients with more severe BNS, resources should be deployed to find optimal treatment strategies for this particular group of patients.

Negative symptoms predict high relapse rates and both predict less favorable functional outcome in first episode psychosis, independent of treatment strategy.

BACKGROUND: In first episode psychosis (FEP) baseline negative symptoms (BNS) and relapse both predict less favorable functional outcome. Relapse-prevention is one of the most important goals of treatment. Apart from discontinuation of antipsychotics, natural causes of relapse are unexplained. We hypothesized that BNS, apart from predicting worse functional outcome, might also increase relapse risk. METHODS: We performed a post-hoc analysis of 7-year follow-up data of a FEP cohort (n = 103) involved in a dose-reduction/discontinuation (DR) vs. maintenance treatment (MT) trial. We examined: 1) what predicted relapse, 2) what predicted functional outcome, and 3) if BNS predicted relapse, whether MT reduced relapse rates compared to DR. After remission patients were randomly assigned to DR or MT for 18 months. Thereafter, treatment was uncontrolled. OUTCOMES: BNS and duration of untreated psychosis (DUP) predicted relapse. Number of relapses, BNS, and treatment strategy predicted functional outcome. BNS was the strongest predictor of relapse, while number of relapses was the strongest predictor of functional outcome above BNS and treatment strategy. Overall and within MT, but not within DR, more severe BNS predicted significantly higher relapse rates. Treatment strategies did not make a difference in relapse rates, regardless of BNS severity. INTERPRETATION: BNS not only predicted worse functional outcome, but also relapses during follow-up. Since current low dose maintenance treatment strategies did not prevent relapse proneness in patients with more severe BNS, resources should be deployed to find optimal treatment strategies for this particular group of patients.

Clinical recovery in first-episode psychosis.

INTRODUCTION: Generally agreed outcome criteria in psychosis are required to evaluate the effectiveness of new treatment strategies. The aim of this study is to explore clinical recovery in first-episode patients, defined by meeting criteria for both symptomatic and functional remission. METHOD: In a sample of first-episode patients (N = 125), symptomatic and functional remission during the last 9 months of a 2-year follow-up period were examined, as well as recovery and its predictors. RESULTS: Half the patients (52.0%) showed symptomatic remission and a quarter (26.4%) functional remission, while one-fifth (19.2%) met both criteria sets and were considered recovered. Recovery was significantly associated with short duration of untreated psychosis and better baseline functioning. CONCLUSION: Most functionally remitted patients were also symptomatically remitted, while a minority of symptomatically remitted patients were also functionally remitted. Treatment delay may affect chance of recovery.

Reconstructing continuity of care in mental health services: a multilevel conceptual framework.

Continuity of mental health care is a key issue in the organization and evaluation of services for patients with disabling chronic conditions. Over many years, health services researchers have been exploring the conceptual boundaries between continuity of care and other service characteristics. On the basis of papers published over the past decade, we argue that while conceptual consensus is growing, there is room to improve continuity measures, and the development of practical interventions is still at an early stage. There is growing consensus that continuity of care is a multidimensional concept. We identified four core elements: continuous care; care of an individual patient; cross-boundary care; and care recorded objectively. These elements help clarify conceptual boundaries, and incorporate measurement guidelines. With reference to these core elements, we define types of continuity of care, including informational continuity, management continuity, relational continuity and contact continuity. In order to improve continuity of care, better understanding is needed of the complex inter-relationship of core elements and types of continuity. A multilevel perspective on continuity of care can guide research to develop and evaluate new interventions. Achieving continuity of care is hindered by the lack of standard measures and administrative data appropriate to assessing continuity. Account should be taken not only of the nature of the patient population, but also of local conditions. To address these topics and identify best practices, research should be multidisciplinary and take a comparative, naturalistic form.

Personal Recovery Among Service Users Compared With Siblings and a Control Group: A Critical Note on Recovery Assessment.

OBJECTIVE: One way to boost the implementation of a recovery-oriented practice in psychiatric care may be by including outcome measures assessing recovery. However, the five core processes of personal recovery-connectedness, hope and optimism about the future, identity, meaning in life, and empowerment (collectively known as CHIME)-are not service user-specific and can be relevant to nonservice users as well. It is unknown whether recovery processes are measurably different among users and nonusers of mental health services. This study aimed to compare scores on the 24-item Recovery Assessment Scale (RAS) among service users with psychosis (in remission and not in remission), their siblings, and a control group, after the validation of the RAS Dutch version. METHODS: Psychometric evaluation and comparative analyses (analysis of variance and tests of clinical significance) were performed on data from service users (N=581), their siblings (N=632), and control group members (N=372) in the longitudinal Genetic Risk and Outcome in Psychosis study in the Netherlands. RESULTS: Results showed that the psychometric validity of the RAS Dutch version was adequate. A significant, moderate effect was found for the RAS total score (F=31.73, df=3 and 1,559, p<0.001; Cohen's f=0.25). However, clinical significance analysis showed that a substantial number of service users had recovered, including those in remission and those not in remission, and that substantial numbers of siblings and control group members had not recovered. CONCLUSIONS: The findings call into question the usefulness of the RAS in outcome assessment, given that the differences detected in recovery between service users, siblings, and control group members had limited clinical relevance.

Are sexual side effects of prolactin-raising antipsychotics reducible to serum prolactin?

OBJECTIVE: To assess the degree to which sexual side effects (SSE) are associated with prolactin-raising antipsychotics, and to what degree such SSE are reducible to serum prolactin levels. METHOD: A large sample (n=264) of patients treated for 6 weeks with prolactin-raising and prolactin-sparing antipsychotics was assessed for changes in sexual performance in terms of libido, arousal and orgasm using the Antipsychotics and Sexual Functioning Questionnaire. For men also erection and ejaculation were evaluated. At 6 weeks, prolactin levels were assessed and analyzed in relation to sexual performance. RESULTS: Men and women reported SSE (libido and orgasm) with about the same frequency. Prolactin-raising medication induced significantly more SSE than prolactin-sparing medication (adjusted OR=3.4, 95% CI: 1.8, 6.5) with 43% of emerging SSE attributable to prolactin-raising medication. When adjusted for serum prolactin, the association between prolactin-raising medication and SSE was reduced but remained significant (OR=2.1, 95% CI: 1.0, 4.5); 27% of emerging SSE remained attributable to prolactin-raising medication. For erectile and ejaculatory dysfunction in men, the attributable fraction due to prolactin-raising medication was 32% before, and 11% after adjustment for serum prolactin. CONCLUSIONS: Around 40% of emerging SSE in schizophrenia are attributable to the prolactin-raising properties of antipsychotic medication. Of this attributable fraction, around one-third to two-thirds is directly reducible to the effects of serum prolactin.