[Assessment of the suicidal state with the CASE approach: a closer look at the design]. / Beoordeling van de suïcidale toestand met de CASE-benadering.

BACKGROUND: Shawn Shea's Chronological Assessment of Suicide Events (CASE approach) is worldwide, including the Netherlands, a well-known and widely used method for clinical interviewing a patient's suicidal state. However, the original description of the author is not always followed. AIM: Comparing the Dutch CASE approach with the original description. METHOD: The Dutch CASE approach has been explored on the basis of the text of the Dutch multidisciplinary guideline and current handbooks. This approach is compared with the original description. RESULTS: Three differences emerge. The main difference is that in the original CASE approach, seven validity techniques represent the foundation for investigation the suicidal state, while these are missing from the Dutch texts. Second, the chronological interview system in the Netherlands is interpreted differently than in the original CASE approach. Third, in the Netherlands, in contrast to the original approach, risk factors and protective factors are included in the study of the suicidal state. CONCLUSION: In the Netherlands, the CASE approach has been adopted in a simplified form, which is useful as a basic skill in the study of suicidal behavior. The diagnosis of suicidality can gain in depth, especially for advanced mental health professionals, by paying attention in training and education to the interviewing techniques of the original CASE approach.

[Online schema therapy: a cross-sectional survey among Dutch therapists]. / Schematherapie via beeldbellen; crosssectioneel onderzoek onder therapeuten.

BACKGROUND: Long waiting lists exist for the treatment of personality disorders, which can be shortened by using videoconference treatment. During the COVID-19 pandemic, by necessity, videoconferencing was used to provide schema therapy, a specific treatment for personality disorders. AIM: To investigate therapist experience of schema therapy via videoconferencing during the pandemic. METHOD: In an observational cross-sectional study, 83 schema therapists completed a questionnaire about the period prior to, and during the COVID-19 pandemic. We investigated their experience, use of, and attitude toward videoconferencing, as well as the extent to which the effectiveness of videoconferencing and face to face (F2F) schema therapy for personality disorders was found to be comparable. RESULTS: Schema therapists rated their experience with videoconferencing therapy for personality disorders during the COVID-19 pandemic positively, its use increased during this period, and therapists’ attitudes became more positive. However, the majority found videoconferencing therapy less effective than F2F treatment. Almost half of the therapists used shorter sessions or adapted exercises during videoconferencing therapy. CONCLUSION: Although therapists were increasingly positive about video conferencing therapy, they believed that F2F treatment is more effective. Randomized efficacy studies of videoconferencing therapy compared to F2F therapy are needed, also examining patients’ experiences with both forms.

[Suicide prevention: challenges and recommendations]. / Suïcidepreventie: uitdagingen en aanbevelingen.

Background DESPITE VARIOUS NATIONAL INITIATIVES AND A STRONG MENTAL HEALTH CARE SYSTEM, THE NUMBER OF SUICIDES IN THE NETHERLANDS AND FLANDERS HAS NOT CHANGED AS HOPED. Aim TO PROVIDE INSIGHT INTO THE CURRENT SUICIDE PREVENTION POLICY IN THE NETHERLANDS AND FLANDERS, AND THE EVIDENCE ON THEIR EFFECTIVENESS. Method DISCUSSION OF UNIVERSAL, SELECTIVE AND INDICATED PREVENTION INITIATIVES, AND OF THE EVIDENCE FOR THE VARIOUS INITIATIVES, BASED ON THE USE OF REVIEWS AND META-ANALYSIS. Results THERE IS A NATIONAL SUICIDE PREVENTION AGENDA IN BOTH THE NETHERLANDS AND FLANDERS. IT IS DIFFICULT TO DEMONSTRATE THE DIRECT EFFECT OF THE VARIOUS INITIATIVES ON NATIONAL SUICIDE RATES, BECAUSE OF THE LOW BASE RATE, AND BECAUSE OF ITS MULTIPLE CAUSES. Conclusion THERE ARE LITTLE EVIDENCE FOR SUICIDE PREVENTION STRATEGIES. THIS DOES NOT MEAN SUICIDE PREVENTION HAS NO USE, BUT MODESTY SEEMS IN PLACE. Key words EVALUATION, POLICY, RCT, SUICIDE PREVENTION TIJDSCHRIFT VOOR PSYCHIATRIE 63(2021)2, 133-137.

[Suicide in individuals with mild intellectual disabilities]. / Suïcide bij mensen met een lichte verstandelijke beperking.

BACKGROUND: Little is known about suicide among individuals with mild intellectual disabilities (mid).
AIM: To explore risk factors for suicide among a small group of clients with mid who committed suicide.
METHOD: Case files of 11 clients with mid were analysed using the Integrated Motivational Volitional model.
RESULTS: Most suicides seem to have taken place impulsively and not on the basis of a predetermined plan. Most clients had comorbid mental health problems, predominantly trauma-related, impulse control and externalizing behavioural problems. The (imminent) loss of contact, such as in the case of transfer from one ward to another ward or to a facility, seems an important risk factor for suicide.
CONCLUSION: Clients with mid residing in a treatment facility may have an increased risk of suicide because of an interaction between client characteristics and treatment context.

[Developments in mental health care in Dutch general practices: an overview of recent studies]. / Ontwikkelingen in de Nederlandse huisartsenzorg voor psychische problemen: een overzicht van recente studies.

BACKGROUND: Dutch policy aims to strengthen mental health care in general practices, to keep health care affordable. Recently, a new function (mental health nurses) and a new referral model for patients with mental health problems were introduced.
AIM: To explore to what extent the volume of mental health care in Dutch general practices has increased and to what extent the content changed in the period 2010-2015.
METHOD: This study employed: 1. analyses of medical records, and 2. a case study in a primary health care centre.
RESULTS: The number of general practices with at least one mental health nurse increased from 20% in 2010 to almost 90% in 2015. In the period 2010-2014, general practitioners (gps) and mental health nurses treated increasing numbers of patients with mental health problems. No task shifting from gps to mental health nurses was observed. In the period 2011-2015, the number of antidepressant prescriptions increased slightly. In 2014, gps in a well-prepared primary care centre allocated 87% of their patients with mental health problems to a treatment setting in line with the referral model.
CONCLUSION: Dutch general practices have recently provided more mental health care, thereby emphasising their important role in the mental health care system.

[Suicidal behaviour and attempted suicide occurring during assessment by the outreach psychiatric emergency service]. / Het vóórkomen van suïcidaal gedrag en suïcidepogingen bij de psychiatrische crisisdienst.

BACKGROUND: The outreach emergency psychiatric service plays an important role in recognising, arranging interventions and preventing suicide and suicidal behaviour. However, little is known about the assessments that members of the emergency team make when faced with patients showing suicidal behaviour.
AIM: To describe the relationships that are revealed between patient characteristics, suicidal thoughts and attempted suicide during assessments made by the emergency psychiatric service in The Hague.
METHOD: The emergency service kept a detailed record of 14,705 consultations. We compared the characteristics of patients who had suicidal thoughts with those of patients who had no such thoughts and we also compared the characteristics of patients who had attempted to commit suicide with those of patients who had not. We drew these comparisons by using logistic regression models, adjusting for clustering.
RESULTS: 32.2% of the patients showed signs of suicidal behaviour and 9.2 % appeared likely to attempt suicide. Suicidal behaviour occurred most often in patients with depression. Suicidal patients were more often admitted to hospital than were non-suicidal patients and they were more likely to have been referred by a general practitioner or a general hospital. Medication was the most frequent means employed in attempts to commit suicide.
CONCLUSION: In about one third of the consultations of the outreach emergency psychiatric service, the patient showed suicidal behaviour. The actions and the policy of the emergency psychiatric service with regard to suicidal behaviour were diverse and dependent on factors that could change over the course of time.

[The proportion of suicides committed by patients with a mental health disorder for which treatment costs are now no longer reimbursed by health insurance]. / Het aandeel suïcides door patiënten met een stoornis waarvan de ggz-behandeling thans niet meer vergoed wordt.

BACKGROUND: Suffering from a psychiatric disorder is a well-known risk factor for suicide and suicidal behavior. Treatment of psychiatric disorders can reduce the risk of suicidal behavior and suicide. In the Netherlands, however, since 2012 the treatment costs of some psychiatric disorders have no longer been covered by health insurance.
AIM: To find out what proportion of suicides were committed by patients with a psychiatric disorder for which treatment costs are no longer covered by health insurance since the rules changed in 2012.
METHOD: We studied the files of 314 patients who were known to one of the large mental health hospitals in the Netherlands and who had committed suicide between 1 January 1999 and January 2012. We were able to determine the various psychiatric disorders from which the patients were suffering at the time they died.
RESULTS: About 6% of the patients who committed suicide between 1999 and 2012 suffered from a psychiatric disorder for which treatment costs are now no longer covered by health insurance.
CONCLUSION: Given the results of this study, the increased rates of suicide in the Netherlands and the importance of scientific research into the characteristics of suicide, we recommend that patients with suicidal behavior are not excluded from adequate treatment in the event they may or may not have met the criteria for a DSM-IV classification.

Explaining heterogeneity of individual treatment causal effects by subgroup discovery: An observational case study in antibiotics treatment of acute rhino-sinusitis.

OBJECTIVES: Individuals may respond differently to the same treatment, and there is a need to understand such heterogeneity of causal individual treatment effects. We propose and evaluate a modelling approach to better understand this heterogeneity from observational studies by identifying patient subgroups with a markedly deviating response to treatment. We illustrate this approach in a primary care case-study of antibiotic (AB) prescription on recovery from acute rhino-sinusitis (ARS). METHODS: Our approach consists of four stages and is applied to a large dataset in primary care dataset of 24,392 patients suspected of suffering from ARS. We first identify pre-treatment variables that either confound the relationship between treatment and outcome or are risk factors of the outcome. Second, based on the pre-treatment variables we create Synthetic Random Forest (SRF) models to compute the potential outcomes and subsequently the causal individual treatment effect (ITE) estimates. Third, we perform subgroup discovery using the ITE estimates as outcomes to identify positive and negative responders. Fourth, we evaluate the predictive performance of the identified subgroups for predicting the outcome in two ways: the likelihood ratio test, and whether the subgroups are selected via the Akaike Information Criterion (AIC) using backward stepwise variable selection. We validate the whole modelling strategy by means of 10-fold-cross-validation. RESULTS: Based on 20 pre-treatment variables, four subgroups (three for positive responders and one for negative responders) were identified. The log likelihood ratio tests showed that the subgroups were significant. Variable selection using the AIC kept two of the four subgroups, one for positive responders and one for negative responders. As for the validation of the whole modelling strategy, all reported measures (the number of pre-treatment variables associated with the outcome, number of subgroups, number of subgroups surviving variable selection and coverage) showed little variation. CONCLUSIONS: With the proposed approach, we identified subgroups of positive and negative responders to treatment that markedly deviate from the mean response. The subgroups showed additive predictive value of the outcome. The modelling approach strategy was shown to be robust on this dataset. Our approach was thus able to discover understandable subgroups from observational data that have predictive value and which may be considered by the clinical users to get insight into who responds positively or negatively to a proposed treatment.

Comparing machine learning to a rule-based approach for predicting suicidal behavior among adolescents: Results from a longitudinal population-based survey.

INTRODUCTION: Suicidal thoughts and suicide attempts are one of the most prominent public health concerns in adolescents and therefore early detection is important to initiate preventive interventions and closer monitoring. METHOD: We examined whether the Machine Learning models Random Forest and Lasso Regression better predict future suicidal behavior than a simple decision rule that classifies every adolescent with history of suicide ideation at baseline as at risk (current practice). We used data from a general population of students in second and fourth year of secondary education in Amsterdam, the Netherlands. RESULTS: Both the Random Forest and the Lasso Regression resulted in slightly better prediction. The AUC of the Random Forest (0.79) and Lasso regression (0.76) were both higher than the AUC of the decision rule (0.64). The Random Forest achieved slightly (but non-significantly) higher sensitivity than the decision rule (0.37 versus 0.34), with the same specificity (0.94). With Lasso Regression the sensitivity increased significantly (0.52), but at the expense of the specificity (0.85). LIMITATIONS: The loss of cases after merging the data, the use of self-reported data, confidential data collection and the use of only four questions to measure suicidal behavior. CONCLUSIONS: This is the first study applying Machine Learning techniques to predict future suicidal behavior on survey data collected in a general population of adolescents. Our study showed that integrating machine learning techniques in screening practice will result in a small improvement in the ability to predict suicide. The models need to be further optimized to improve accuracy.

Exploring the psychology of suicidal ideation: A theory driven network analysis.

Two leading theories within the field of suicide prevention are the interpersonal psychological theory of suicidal behaviour (IPT) and the integrated motivational-volitional (IMV) model. The IPT posits that suicidal thoughts emerge from high levels of perceived burdensomeness and thwarted belongingness. The IMV model is a multivariate framework that conceptualizes defeat and entrapment as key drivers of suicide ideation. We applied network analysis to cross-sectional data collected as part of the Scottish Wellbeing Study, in which a nationally representative sample of 3508 young adults (18-34 years) completed a battery of psychological measures. Network analysis can help us to understand how the different theoretical components interact and how they relate to suicide ideation. Within a network that included only the core factors from both models, internal entrapment and perceived burdensomeness were most strongly related to suicide ideation. The core constructs defeat, external entrapment and thwarted belonginess were mainly related to other factors than suicide ideation. Within the network of all available psychological factors, 12 of the 20 factors were uniquely related to suicide ideation, with perceived burdensomeness, internal entrapment, depressive symptoms and history of suicide ideation explaining the most variance. None of the factors was isolated, and we identified four larger clusters: mental wellbeing, interpersonal needs, personality, and suicide-related factors. Overall, the results suggest that relationships between suicide ideation and psychological risk factors are complex, with some factors contributing direct risk, and others having indirect impact.

[Trends in suicidal behaviour in Dutch general practice, 1983-2013]. / Suïcidepreventie in de huisartsenpraktijk, 1983-2013* * Dit onderzoek werd eerder gepubliceerd in BMJ Open (2016;6:e010868) met als titel 'Trends in suicidal behaviour in Dutch general practice 1983-2013: a retrospective observational study'. Afgedrukt met toestemming. NIVEL Nederlands instituut voor onderzoek van de gezondheidszorg, Utrecht.Dr. D.P. de Beurs, klinisch psycholoog; dr.ir. M. Hooiveld, epidemioloog; dr.ir. J.C. Korevaar, epidemioloog; dr. G.A. Donker, huisarts-epidemioloog. Vrije Universiteit, afd. Klinische Psychologie, Amsterdam.Prof.dr. A.J.F.M. Kerkhof, klinisch psycholoog.Contactpersoon: dr. G.A. Donker (g.donker@nivel.nl).

OBJECTIVE: We investigated trends in suicidal behaviour as reported by Dutch general practices from 1983 to 2013. Also, we analysed the relationship with patient characteristics and with the financial crisis of 2008. DESIGN: Retrospective observational study. METHOD: We estimated age-adjusted and gender-specific trends in suicides (342) and attempted suicides (1614), as registered in 1983-2013 under ICPC code P77 by 40 Dutch general practices participating in the NIVEL Primary Care Database sentinel station. Secondary outcomes, on the basis of supplementary questions in the GP Information System (Huisartsen Informatie Systeem), were the relationship between suicidal behaviour, earlier treatments and patient characteristics. Also, we analysed separate frequencies for the periods 1983-2007 and 2008-2013. RESULTS: Join-point analyses revealed a significant rise in male suicides from 2008 (b = 0.32, SE = 0.1, p = 0.008), and an increase in male suicide attempts since 2009 (b = 0.19, SE = 0.04, p < 0.001). Female suicidal behaviour showed a steady decrease in 1989-2013: b = -0.03, SE = 0.007, p < 0.0001 for female suicide, b = -0.02, SE = 0.002, p < 0.001 for female attempts. Almost half of the suicidal patients had visited their GP one month before the event. In 31% of these patients, the GP had recognized suicidal behaviour. CONCLUSIONS: Since 2008, there was a rise in the male suicide rate while female suicide behaviour has continued to decline. Training in the early recognition of suicide ideation in depressive patients might improve suicide prevention in primary care.

[Do mental health nurses take over care from general practitioners?] / Verlicht de POH-GGZ de werkdruk van de huisarts?

OBJECTIVE: The objective of this study was to examine mental health care provided by general practitioners and by mental health nurses working in general practices. DESIGN: Observational research. METHOD: We analysed how many consultations with patients with mental health problems were recorded in Dutch general practices in the period 2010-2014. General practices with and without a mental health nurse were compared, and we investigated which patients were mainly treated by mental health nurses. RESULTS: An increasing number of patients visited the GP for mental health problems in the period 2010-2014. GPs collaborating with a mental health nurse recorded a somewhat higher number of patients with mental health problems than GPs without a mental health nurse, but used as many consultations per patient. Mental health nurses mainly treat females, adult patients, and patients with common mental health problems. CONCLUSION: Mental health nurses do not take over care from GPs, but provide additional mental health care to patients with mental health problems. Collaborating with a mental health nurse might increase GPs' alertness to record mental health problems.

Psychological Distress Because of Asking about Suicidal Thoughts: A Randomized Controlled Trial among Students.

The aim of this study was to investigate the effect of the questions from the Beck Scale for Suicide Ideation on psychological well-being among healthy participants. In a randomized controlled study, 301 participants completed the same 4 questionnaires on psychopathology. The experimental group additionally answered 21 items of the Beck Scale for Suicide Ideation. The control group answered 19 items on Quality of Life. The experimental group showed a significantly smaller decrease of negative affect compared to the control condition. When analyzing participants with an increase in distress, 80% were part of the experimental group. For most participants, answering questions about suicide does not affect their mood. A small group of participants did react with some distress to the questions about suicide. As the questions about suicide were administered immediately before the questions about negative affect, the questions about suicide could have worked as a negative mood challenge. Future experimental research should further investigate the effect of questions about suicide among healthy participants, especially on the long term.

Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects.

BACKGROUND: The present meta-analysis aimed to examine to what extent combined pharmacotherapy with psychotherapy results in a different response to treatment compared to psychotherapy or pharmacotherapy alone in adults with major depression at six months or longer postrandomization. METHODS: A systematic literature search resulted in 23 randomized controlled trials with 2184 participants. Combined treatment was compared to either psychotherapy or anti-depressant medication alone in both the acute phase and the maintenance phase. Odds ratios of a positive outcome were calculated for all comparisons. RESULTS: In acute phase treatment, combined psychotherapy with antidepressants outperformed antidepressants alone at six months or longer postrandomization in patients with major depressive disorder (OR=2.93, 95%CI 2.15-3.99, p<0.001). Heterogeneity was zero (95%CI 0-57%, p>0.05). However, combined therapy resulted in equal response to treatment compared to psychotherapy alone at six months or longer postrandomization. As for the maintenance treatment, combined maintenance psychotherapy with antidepressants resulted in better-sustained treatment response compared to antidepressants at six months or longer postrandomization (OR=1.61, 95%CI 1.14-2.27, p<0.05). Heterogeneity was zero (95%CI 0-68%, p>0.05). CONCLUSIONS: Combined therapy results in a superior enduring effect compared to antidepressants alone in patients with major depression. Psychotherapy is an adequate alternative for combined treatment in the acute phase as it is as effective as combined treatment in the long-term.