[Patient with a long history of disease in whom service dog contributed to recovery]. / Hulphond als geslaagde contextuele interventie voor herstel.

We describe a patient who reached recovery, after purchasing a dog and training it into an assistance dog. The patient has a long lasting (over 30 years) history in mental health care and was diagnosed with autism spectrum disorder, posttraumatic stress disorder and borderline personality disorder. All these years the patient did not reach symptomatic improvement or personal or social recovery. The patient suffered from severe emotional instability, feeling misunderstood, sleeping disorder because of nightmares and traumatic re-experiences, feeling unsafe and externalisation. There were repeated conflicts and periodical rejection of caregivers. A range of interventions and support options were offered. Medication intake was considerable aiming for sedation and numbness. After a second opinion an assistance dog was suggested. Two years after the purchase of the dog, her mood had improved, anxiety decreased, she slept better and stopped all medication. She feeled safe. Conflicts with others were reduced, she had some social contacts and the intensity of care had been reduced considerably.

[Daily practice of a FACT-team: results of an experience sampling study]. / De dagelijkse praktijk van een FACT-team: resultaten van een experience-samplingstudie.

BACKGROUND: Flexible assertive community treatment (FACT) teams are widespread in the Netherlands. Despite the presence of a model description and model fidelity scale, it is unclear what FACT workers actually do daily. AIM: Examination of the daily activities of FACT workers on weekdays in relation to the intended activities from the theoretical FACT framework. METHOD: Repeated momentary activity assessments were made among all employed staff (n = 54) of four FACT teams from three different organizations using the experience sampling method (ESM) yielding multiple reports on each workday for one week. 936 reports were analyzed with SPSS, providing a picture of the daily activities of FACT workers. RESULTS: Overall, employees spent 30% of their time with clients, 30% in consultation (4% with network partners), 20% on administration and 20% in travel time and personal activities (30-30-20-20). CONCLUSION: The actual time spent by FACT workers with clients does not match the expected production standards. Contact with relatives and network partners lags far behind the desired figures required for modern network-oriented care. The ESM-based results are different from actual methodologies and require careful interpretation. Applying ESM in FACT teams promises to support a quality development dialogue.

[Cost-effectiveness in Dutch mental health care: future because of ROM?]. / Doelmatigheid in de ggz: toekomst dankzij ROM?

BACKGROUND: The document reporting Dutch mental health care negotiations for 2014-2017 calls for a cost decrease based on cost-effectiveness. Thanks to ROM, the Dutch mental health care seems well prepared for cost-effectiveness research. AIM: Evaluate how valid cost-effectiveness research should be established in mental health care and the role of rom therein. METHOD: Evaluation of requirements of cost-effectiveness research, trends, and a translation to Dutch mental health care. RESULTS: Valid cost-effectiveness research in mental health care requires the application of a societal perspective, a long time-horizon and an adequate evaluation of quality of life of patients. Healthcare consumption, outcome of care and characterisation of the patient population should be measured systematically and continuously. Currently, rom-data are not suitable to serve as a basis for cost-effectiveness research, although a proper basis is present. Further development of rom could lead to a situation in which mental health care is purchased on the basis of cost-effectiveness. However, cost-effectiveness will only really be improved if quality of care is rewarded, rather than rewarding activities that are not always related to outcome of care. CONCLUSION: Cost-effectiveness research in mental health care should focus on societal costs and benefits, quality of life and a long time-horizon. If developed further, rom has the potential to be a basis for cost-effectiveness research in the future.

[Behavioural standard or coercive measure? Some considerations regarding the special issue on ROM]. / ROM: gedragsnorm of dwangmaatregel? Overwegingen bij het themanummer over routine outcome monitoring.

BACKGROUND: The cost of mental health care has possibly risen more than costs in other sectors of health care in the Netherlands. In an attempt to control the rising costs, new policies have been implemented that include the introduction of selective financial penalties for those in need of mental health care as well as the start of performance-based mental health care reimbursement. In order to achieve the latter goal, a nation-wide large-scale data collection was introduced based on clinical routine outcome monitoring (ROM) data, with a view to using these data for benchmarking. AIM: Closer inspection of the benchmarking efforts in terms of scientific validity. METHOD: Qualitative review and analysis. RESULTS: Analysis shows that the type of ROM data that is collected in the Netherlands is valid for tracking the outcomes of individual patients, but unsuitable for performance comparisons between institutions for reasons of case-mix, instrument-mix, bias and lack of sensitivity. CONCLUSION: Attempts to introduce benchmarking based on rom will probably have a negative impact on the practice of mental health care in the Netherlands. More input from mental health professionals and scientists is required in order to identify more rational and efficient ways of spending scarce resources.

The Importance of Context: An ESM Study in Forensic Psychiatry.

Experience Sampling Method (ESM) is a structured diary technique assessing variations in thoughts, mood, and psychiatric symptoms in everyday life. Research has provided ample evidence for the efficacy of the use of ESM in general psychiatry but its use in forensic psychiatry has been limited. Twenty forensic psychiatric patients participated. The PsyMate™ Device emitted a signal 10 times a day on six consecutive days, at unpredictable moments. After each "beep," the patients completed ESM forms assessing current context, thoughts, positive and negative affect, and psychotic experiences. Stress was measured using the average scores of the stress related items. Compliance rate was high (85% beeps responded). Activity stress was related to more negative affect, lower positive affect, and more psychotic symptoms. This finding was restricted to moments when a team member was present; not when patients were alone or with other patients. ESM can be useful in forensic psychiatry and give insights into the relationships between symptoms and mood in different contexts. In this study activity-related stress was contextualized. These findings can be used to personalize interventions.

Momentary assessment technology as a tool to help patients with depression help themselves.

OBJECTIVE: Given high relapse rates and residual symptoms in depression, new strategies to increase treatment effectiveness are required. A promising avenue is to investigate how electronic momentary assessment technology may contribute to clinical assessment and interventions in depression. METHOD: A literature search was conducted focusing on the potential contribution of momentary assessments to clinical applications in depression. RESULTS: Momentary assessments are able to reveal subtle, small but repetitive and relevant patterns of emotional expression that predict future course of depression. A momentary assessment tool may expose manageable pieces of daily life behaviour contributing to the depressive experience that patients can influence. The use of this explicit knowledge of daily life experience is understudied with regard to its contribution to diagnostic assessment, monitoring of treatment effects and feedback interventions in depressed patients. The clinical application of momentary assessments may stimulate a shift from passive consumption of treatment to an active role for patients in their recovery and increased patient ownership. CONCLUSION: The precise, prospective and fine-grained information that momentary assessment technology provides may contribute to clinical practice in various ways. Future studies should examine the clinical impact of its use and the feasibility of its implementation in mental health care.

[Development of a fidelity scale for function assertive community treatment (FACT)]. / Ontwikkeling van een modelgetrouwheidsschaal voor functie-assertive community treatment (FACT).

BACKGROUND: Assertive community treatment (ACT) is one of the most important models for the care and treatment, in the community, of people with severe mental illness (SMI). ACT is concerned primarily with smi-patients who have the most complex problems and it provides care by means of intensive assertive outreach. Function act (FACT) provides care for the entire group of SMI - patients and combines the principles of case management and ACT. For a long time it has been possible to measure the degree of ACT model reliability using the facts reliability scale. Throughout this time, however, a reliability scale for FACT was not available. AIM: To develop a reliability scale for fact teams. METHOD: Using the knowledge of experts and feedback from fact teams it has been possible to develop a reliability scale for fact teams. The scale was tested and subsequently adapted as a result of 10 pilot trials performed by 10 fact teams. RESULTS: The definitive version of the scale was confirmed in 2008 and is currently used in the field. CONCLUSION: With the ACT and FACT reliability scales the research field now have two instruments with which teams working with SMI - patients can measure model reliability. The DACTS and FACTS provide opportunities for quality improvement and transparency.

Digital assessment of working memory and processing speed in everyday life: Feasibility, validation, and lessons-learned.

OBJECTIVES: Cognitive functioning is often impaired in mental and neurological conditions and might fluctuate throughout the day. An existing experience-sampling tool was upgraded to assess individual's cognition in everyday life. The objectives were to test the feasibility and validity of two momentary cognition tasks. METHODS: The momentary Visuospatial Working Memory Task (mVSWMT) and momentary Digit Symbol Substitution Task (mDSST) were add-ons to an experience sampling method (ESM) smartphone app. Healthy adults (n = 49) between 19 and 73 years of age performed the tasks within an ESM questionnaire 8 times a day, over 6 consecutive days. Feasibility was determined through completion rate and participant experience. Validity was assessed through contextualization of cognitive performance within intrapersonal and situational factors in everyday life. FINDINGS: Participants experienced the tasks as pleasant, felt motivated, and the completion rate was high (71%). Social context, age, and distraction influenced cognitive performance in everyday life. The mVSWMT was too difficult as only 37% of recalls were correct and thus requires adjustments (i.e. fixed time between encoding and recall; more trials per moment). The mDSST speed outcome seems the most sensitive outcome measure to capture between- and within-person variance. CONCLUSIONS: Short momentary cognition tasks for repeated assessment are feasible and hold promise, but more research is needed to improve validity and applicability in different samples. Recommendations for teams engaging in the field include matching task design with traditional neuropsychological tests and involving a multidisciplinary team as well as users. Special attention for individual needs can improve motivation and prevent frustration. Finally, tests should be attractive and competitive to stimulate engagement, but still reflect actual cognitive functioning.

Mechanisms of gene-environment interactions in depression: evidence that genes potentiate multiple sources of adversity.

BACKGROUND: Previous work suggests that daily life stress-sensitivity may be an intermediary phenotype associated with both genetic risk for depression and developmental stress exposures. In the current analysis we hypothesized that genetic risk for depression and three environmental exposures over the course of development [prenatal stress, childhood adversity and adult negative life events (NLEs)] combine synergistically to produce the phenotype of stress-sensitivity. METHOD: Twin pairs (n=279) participated in a momentary assessment study using the Experience Sampling Method (ESM), collecting appraisals of stress and negative affect (NA) in the flow of daily life. Prospective data on birthweight and gestational age, questionnaire data on childhood adversity and recent NLEs, and interview data on depression were used in the analyses. Daily life stress-sensitivity was modelled as the effect of ESM daily life stress appraisals on ESM NA. RESULTS: All three developmental stress exposures were moderated by genetic vulnerability, modelled as dizygotic (DZ) or monozygotic (MZ) co-twin depression status, in their effect on daily life stress-sensitivity. Effects were much stronger in participants with MZ co-twin depression and a little stronger in participants with DZ co-twin depression status, compared to those without co-twin depression. NLE main effects and NLE genetic moderation were reducible to birthweight and childhood adversity. CONCLUSIONS: The findings are consistent with the hypothesis that adult daily life stress-sensitivity is the result of sensitization processes initiated by developmental stress exposures. Genes associated with depression may act by accelerating the process of stress-induced sensitization.

[An observational study of 'assertive outreach' with remission as outcome measure]. / Een observationele trial naar 'assertive outreach' met remissie als uitkomstmaat1.

BACKGROUND: Systems of intensive care such as the Function Assertive Community Treatment (Function-act) are advocated because they are reported to have achieved very promising results. However, comparative studies aimed at measuring the efficacy of such systems are mainly of short duration and the outcome measure is nearly always the amount of care provided. AIM: To investigate, via an observational study, changes that occurred in the number of patients going into remission and in the amount of care provided before and after the introduction of f-act. METHOD: f-act was introduced in Maastricht and the surrounding area (population 220,000) at the beginning of 2002. Cumulative routine measurements of the effect of care in the region had been performed since 1998. These measurements were used to compare the proportion of patients in remission in two non-overlapping patients cohorts, each covering a 4-year period, namely 1998-2001 and 2002-2005. results The proportion of patients who made the transition to remission increased from 19% in the period before the introduction of f-act to 31% in the period after its introduction (or = 2.21; 95% ci: 1.03-4.78), but after controlling for confounders the difference was no longer statistically significant. CONCLUSION: In routine clinical practice f-act can reduce the intensity of psychopathological symptoms, possibly because the care provided under f-act is less fragmented. However, more research is needed before the claimed beneficial effects of f-act can be proved conclusively.

[A psychosis proneness-persistence-impairment model of psychotic disorders]. / De ontogenese van psychotische stoornis;een model van kwetsbaarheid voor psychose, persistentie en belemmering.

There is evidence that the normally transitory developmental expression of psychosis (psychosisproneness) may first of all become abnormally persistent (persistence) and later on become clinically relevant (impairment), depending on the amount of environmental risk to which the person is exposed. According to the psychosis-proneness-persistence impairment model, genetic background factors can impact on a transitory expression of psychosis. Whether or not this will lead to a poor prognosis in terms of persistence and clinical need will depend on the interaction between environmental exposure and genetic risk.

[Coping matters in psychosis. Coping and the need for professional care in cases of subclinical psychosis]. / Coping en de kans op zorgbehoefte bij subklinische psychose.

BACKGROUND: Changes in the amount of care required in cases of subclinical psychosis are examined in relation to (1) the level of patient distress and (2) the level of dysfunctional coping. METHOD: The Netherlands Mental Health Survey and Incidence Study (nemesis) is a longitudinal investigation into the occurrence of psychopathology in the general population. In the first two measurements of the nemesis study 4722 individuals had not been diagnosed as having a psychotic disorder according to dsm-iii-r. In the third measurement, 83 of those 4.722 were found to have had at least one subclinical psychotic experience. A panel of experts decided on the level of care that patients required. results Of the various types of psychotic experiences it was only 'passivity phenomena', hearing voices' and 'non-verbal hallucinations' which were associated with the need for care. These associations were largely explained by distress associated with the psychotic experience, with the exception of hearing voices. There were qualitative differences between the various types of coping: in particular, 'symptomatic coping' with psychotic experiences was associated with less perceived control over the psychotic experience (or = 0,79; 95% CI (confidence interval) 0,63-0,98) and an increased probability of the need for care (or = 6,07; 95% CI 1,95-18,95). CONCLUSION: Various types of psychotic experiences require different levels of care. The need for care can arise when psychotic experiences begin to cause patient distress and/or dysfunctional coping. These factors may well play a role in turning an individual with subclinical psychotic experiences into a psychiatric patient.

The use of a Cumulative Needs for Care Monitor for individual treatment v. care as usual for patients diagnosed with severe mental illness, a cost-effectiveness analysis from the health care perspective.

AIMS: To study the systematic assessment of need for care and clinical parameters for use in treatment plans in patients diagnosed with severe mental illness. METHODS: The Cumulative Needs for Care Monitor (CNCM) includes various validated instruments, such as the Camberwell Assessment of Need. A Markov-type cost-effectiveness model (health care perspective, 5-year time horizon) was used to compare CNCM with care as usual (CAU). Two studies were used to determine model parameters: a before­after study (n = 2155) and a matched-control study (n = 937). RESULTS: The CNCM may lead to a gain in psychiatric functioning according to the models. CNCM patients remain in (outpatient) care, while CAU patients drop out more frequently. There is only a small difference in inpatient care. As a result, average costs per patient in the CNCM group are between €2809 (before­after model) and €5251 (matched-control model) higher. The iCER was between €45 127 and €57 839 per life year without psychiatric dysfunction gained. CONCLUSIONS: CNCM may be only cost-effective when willingness to pay for a life year without psychiatric dysfunction is higher than €45 000. However, this result is highly sensitive to the level of psychiatric dysfunctioning in patients who do not receive care.

Behavioural sensitization to daily life stress in psychosis.

BACKGROUND: Recent neurobiological models provide a possible mechanism of daily life stress directly affecting the intensity of psychotic experiences in vulnerable individuals. In order to validate such a mechanism, the impact of daily life stress on psychosis intensity was investigated in two groups at increased risk of onset (relatives) and relapse (patients) of psychosis. METHOD: Patients with psychosis in a clinical state of remission (n = 42), first-degree relatives (n = 47), and control subjects (n = 49) were studied with the Experiencing Sampling Method (ESM is a structured diary technique assessing current context and psychopathology in daily life) to assess (1) appraised subjective stress related to daily activities and events, and (2) intensity of subtle psychotic experiences in daily life. RESULTS: Multilevel regression analyses revealed significant increases in psychosis intensity associated with increases in subjective activity--and event-related stress in patients. First-degree relatives reported increases in psychosis intensity in relation to activity-related stress but not event-related stress. No association was found in control subjects. CONCLUSIONS: Subjects at increased risk for psychosis show continuous variation in the intensity of subtle psychotic experiences associated with minor stresses in the flow of daily life. Behavioural sensitization to environmental stress may therefore be a vulnerability marker for schizophrenia, reflecting dopaminergic hyper-responsivity in response to environmental stimuli.

Is the excess risk of psychosis-like experiences in urban areas attributable to altered cognitive development?

BACKGROUND: Rates of psychotic disorder and related attenuated psychotic experiences are higher in urban areas. We examined to what degree differences between urban and rural areas could be attributed to differences in cognitive development. METHOD: Scores on the nine subscales of the schizotypal personality questionnaire (SPQ) as well as IQ and specific neuropsychological functions of memory and attention were assessed in a representative sample of 943 young army conscripts from the 49 counties of Greece. RESULTS: Young men from urban areas had higher scores on the SPQ subscale Odd beliefs/magical thinking (OR = 1.99, 95% CI: 1.42, 2.78), but lower scores on Excessive social anxiety (OR = 0.63, 95 % CI: 0.49, 0.81) and No close friends (OR = 0.42, 95% CI: 0.29, 0.62). Adjustment for demographic factors, IQ and specific neuropsychological functions did not change the results. When the lower scores on Excessive social anxiety and No close friends were taken into account, the differences on the Odd beliefs/magical thinking subscale became even more pronounced (OR = 2.33, 95% CI: 1.56, 3.49). CONCLUSIONS: Young men from urban areas are socially more competent, but display higher levels of positive psychotic experiences, which are not mediated by lower IQ or higher levels of neuropsychological impairment.