['When I talk with you about discrimination, I don't feel so small']. / 'Als ik met jou over discriminatie praat, voel ik me niet zo klein'.

Background   In recent years, diversity among therapists in terms of migratory background and openly expressed LGBTQ+ identity has increased. As a result, there are more often dyads in which the patient and therapist belong to the same minority. Aim   To illustrate how having a similar background can influence the therapeutic relationship. These illustrations can help practitioners reflect on how best make use of this similarity. Method   We describe two therapies where therapist and patient shared migratory background and a LGBTQ+ identity. Possible advantages and disadvantages of these similarities are discussed. Finally, we discuss the barriers that therapists can experience to introduce these themes in supervision and intervision. Results   In the case reports, both patients seemed to benefit from having a therapist from the same minority group, partly because he made the similarities in identity open to discussion. They felt that they were understood and were less afraid of negative reactions, which made them feel safe and supported to work on their own conflicts in this dyad. Conclusion   Discussing similarities in identity between therapist and patient can be of added value. With a shared migration background and LGBTQ+ identity, it seems that the same mechanisms often play a role.

[The underrepresentation of complex patient groups in scientific research: ethical considerations]. / De ondervertegenwoordiging van complexe patiëntengroepen in wetenschappelijk onderzoek: ethische overwegingen.

BACKGROUND: Subgroups of patients with severe mental illness are underrepresented in scientific research. One of the possible causes is the fact that in these patient groups barriers may exist to the giving of competent informed consent. AIM: Describing the ethical dilemmas that may occur when conducting research with these patient groups. METHOD: We present an overview of the Dutch legislation and regulation concerning participation in scientific research, and discuss the ethical dilemmas that arise in the mentioned patient groups. We present four directions for solutions. RESULTS: In research with these patient groups more attention is needed for the explicit assessment and enhancement of competence. For the subgroup that is persistently incompetent, the possibilities of doing research with existing patient data without informed consent, need further exploration. CONCLUSION: Further legislative development is needed for research with patients with severe mental illness who are persistently incompetent. Herein, it is crucial to involve ethicists and organizations representing patients' and relatives' perspectives.

[Compulsory abstinence: integrated treatment measure of schizophrenia combined with comorbid substance abuse]. / Duwen richting abstinentie: toepassing van drang en dwang bij schizofrenie met comorbide middelenafhankelijkheid.

Schizophrenia accompanied by comorbid substance use disorder is common and can complicate treatment. For the patient long-term compulsory abstinence can be seen as an extremely serious measure. Nevertheless, the measure can be justified both ethically and juridically as part of integrated treatment for psychosis and substance use disorder. We describe a case in which long-term compulsory abstinence kept the patient out of danger, increased her psychiatric stability and strengthened her autonomy.

Distinct white-matter aberrations in 22q11.2 deletion syndrome and patients at ultra-high risk for psychosis.

BACKGROUND: Patients with a deletion at chromosome 22q11.2 (22q11DS) have 30% lifetime risk of developing a psychosis. People fulfilling clinical criteria for ultra-high risk (UHR) for psychosis have 30% risk of developing a psychosis within 2 years. Both high-risk groups show white-matter (WM) abnormalities in microstructure and volume compared to healthy controls (HC), which have been related to psychotic symptoms. Comparisons of WM pathology between these two groups may specify WM markers related to genetic and clinical risk factors. METHOD: Fractional anisotropy (FA), axial diffusivity (AD), radial diffusivity (RD) and mean diffusivity (MD) were assessed using diffusion tensor magnetic resonance imaging (MRI), and WM volume with structural MRI, in 23 UHR patients, 21 22q11DS patients, and 33 HC. RESULTS: Compared to UHR patients 22q11DS patients had (1) lower AD and RD in corpus callosum (CC), cortical fasciculi, and anterior thalamic radiation (ATR), (2) higher FA in CC and ATR, and (3) lower occipital and superior temporal gyrus WM volume. Compared to HC, 22q11DS patients had (1) lower AD and RD throughout cortical fasciculi and (2) higher FA in ATR, CC and inferior fronto-occipital fasciculus. Compared to HC, UHR patients had (1) higher mean MD, RD, and AD in CC, ATR and cortical fasciculi, (2) no differences in FA. CONCLUSIONS: UHR and 22q11DS patients share a susceptibility for developing psychosis yet were characterized by distinct patterns of WM alterations relative to HC. While UHR patients were typified by signs suggestive of aberrant myelination, 22q11DS subjects showed signs suggestive of lower axonal integrity.

White-matter markers for psychosis in a prospective ultra-high-risk cohort.

BACKGROUND: Subjects at 'ultra high risk' (UHR) for developing psychosis have differences in white matter (WM) compared with healthy controls. WM integrity has not yet been investigated in UHR subjects in relation to the development of subsequent psychosis. Hence, we investigated a prospective cohort of UHR subjects comparing whole brain fractional anisotropy (FA) of those later developing psychosis (UHR-P) to those who did not (UHR-NP). METHOD: We recruited 37 subjects fulfilling UHR criteria and 10 healthy controls. Baseline 3 Tesla magnetic resonance imaging (MRI) scans and Positive and Negative Syndrome Scale (PANSS) ratings were obtained. UHR subjects were assessed at 9, 18 and 24 months for development of frank psychosis. We compared baseline FA of UHR-P to controls and UHR-NP subjects. Furthermore, we related clinical data to MRI outcome in the patient population. RESULTS: Of the 37 UHR subjects, 10 had transition to psychosis. UHR-P subjects showed significantly lower FA values than control subjects in medial frontal lobes bilaterally. UHR-P subjects had lower FA values than UHR-NP subjects, lateral to the right putamen and in the left superior temporal lobe. UHR-P subjects showed higher FA values, compared with UHR-NP, in the left medial temporal lobe. In UHR-P, positive PANSS negatively correlated to FA in the left middle temporal lobe. In the total UHR group positive PANSS negatively correlated to FA in the right superior temporal lobe. CONCLUSIONS: UHR subjects who later develop psychosis have differences in WM integrity, compared with UHR subjects who do not develop psychosis and to healthy controls, in brain areas associated with schizophrenia.

Early intervention in patients at ultra high risk of psychosis: benefits and risks.

OBJECTIVE: Prediction of transition to psychosis in the prodromal phase of schizophrenia has raised interest in intervention prior to the onset of frank psychosis. The aim of this review was to examine whether interventions in the prodromal phase have a favourable benefit/risk ratio. METHOD: A literature search in PubMed, EMBASE and PsycINFO was performed. RESULTS: Three randomized clinical trials with antipsychotic medication and/or cognitive behavioural therapy as clinical intervention suggested a positive effect at the end of treatment, but no significant differences were found at the end of follow-up periods from 1 to 4 years. Naturalistic studies present a hypothesis about a possible preventive effect of antidepressive medication. The results of eight other studies are more difficult to interpret. Side-effects of antipsychotic medication and non-adherence with medication are essential problems. CONCLUSION: At the present time, the data concerning the benefits and risks do not justify prodromal intervention as standard clinical practice.