Recovery for all in the community; position paper on principles and key elements of community-based mental health care.

BACKGROUND: Service providers throughout Europe have identified the need to define how high-quality community-based mental health care looks to organize their own services and to inform governments, commissioners and funders. In 2016, representatives of mental health care service providers, networks, umbrella organizations and knowledge institutes in Europe came together to establish the European Community Mental Health Services Provider (EUCOMS) Network. This network developed a shared vision on the principles and key elements of community mental health care in different contexts. The result is a comprehensive consensus paper, of which this position paper is an outline. With this paper the network wants to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe. MAIN TEXT: The development of the consensus paper started with an expert workshop in April 2016. An assigned writing group representing the workshop participants built upon the outcomes of this meeting and developed the consensus paper with the input from 100 European counterparts through two additional work groups, and two structured feedback rounds via email. High quality community-based mental health care: 1) protects human rights; 2) has a public health focus; 3) supports service users in their recovery journey; 4) makes use of effective interventions based on evidence and client goals; 5) promotes a wide network of support in the community and; 6) makes use of peer expertise in service design and delivery. Each principle is illustrated with good practices from European service providers that are members of the EUCOMS Network. CONCLUSIONS: Discussion among EUCOMS network members resulted in a blueprint for a regional model of integrated mental health care based upon six principles.

Overgeneral autobiographical memory predicts higher prospective levels of depressive symptoms and intrusions in borderline patients.

Overgeneral memory (OGM), the tendency to retrieve categories of events from autobiographical memory instead of single events, is found to be a reliable predictor for future mood disturbances and post-traumatic symptom severity. Patients with borderline personality disorder (BPD) often report co-morbid episodes of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Therefore, we investigated whether OGM would predict depression severity and (post-traumatic) stress symptoms in BPD patients. At admission (N = 54) and at six-month follow-up (N ≥ 31), BPD patients completed the Structured Clinical Interview for DSM-IV Disorders, the Assessment of DSM-IV Personality Disorders, the Autobiographical Memory Test, the Beck Depression Inventory-2nd edition (BDI-II), and the Impact of Event Scale. OGM at baseline predicted (a) higher levels of depressive symptoms at follow-up and (b) more intrusions related to a stressful event over and above baseline levels of borderline symptoms, depressive symptoms, and intrusions, respectively. No association was found between memory specificity and event-related avoidance at follow-up. Despite previous findings suggesting that OGM in BPD is less robust than in MDD and PTSD, our results suggest that memory specificity in BPD patients may have some relevance for the course of depressive and stress symptomatology in BPD.

Psychometric properties of the multidimensional perfectionism scale of Hewitt in a dutch-speaking sample: associations with the big five personality traits.

We administered the Dutch Multidimensional Perfectionism Scale of Hewitt and Flett (1991, 2004) in a large student sample (N = 959) and performed a confirmatory factor analysis to test the factorial structure proposed by the original authors. The existence of a method factor referring to the negatively keyed items in the questionnaire was investigated by including it in the tested models. Next, we investigated how the 3 perfectionism dimensions are associated with the Five-factor model (FFM) of personality. The 3-factor structure originally observed by the authors was confirmed, at least when a method factor that refers to the negatively keyed items was included in the model. Self-oriented and socially prescribed perfectionism were both distinguished by low extraversion and low emotional stability. Self-oriented perfectionism's positive relationship with both conscientiousness and openness to experience differentiated the 2 perfectionism dimensions from each other. Other-oriented perfectionism was not well-characterized by the Big Five personality traits.

Patient involvement in mental health care: one size does not fit all.

BACKGROUND: Involvement of mental health-care patients in the decision-making processes is considered to be an ethical requirement. Health-care systems worldwide are increasingly emphasizing the value of participatory approaches. There is, however, no consensus on the definition of patient involvement. The literature is particularly inconsistent and lacks clarity. OBJECTIVE: The purpose of this article is to clarify the concept of patient involvement in mental health care (MHC), taking into account its multidimensional nature. SEARCH STRATEGY: We searched the literature in online databases from January 1998 until August 2010 using synonyms of 'patient involvement', combined with the terms 'mental health(care)'. DATA SYNTHESIS: Based on 45 different descriptions found in the literature, we constructed a definition of patient involvement and we drew up a model identifying its determinants and outcomes. RESULTS: We propose a comprehensive model of patient involvement to be used in MHC. This model can serve as a guide for policy makers and field workers to shape policies to stimulate involvement. DISCUSSION AND CONCLUSIONS: There are three main problems in the literature concerning patient involvement. First, there is a proliferation of conceptualizations of the topic, leading to conceptual vagueness. Furthermore, there is a lack of quantitative data, and some aspects of involvement remain underexposed, such as the involvement of specific target groups and practical ways to shape the involvement processes. Involvement processes should be tailored to the specific target group and context.

Physical activity correlates in persons with binge eating disorder: a systematic review.

Understanding the factors that influence physical activity in persons with binge eating disorders can aid the design of more effective interventions. In order to address this, the present paper provides a systematic quantitative review of the correlates of physical activity in people with binge eating disorder. We searched PsycINFO, PubMed and PEDro from inception until June 2013. Keywords included 'binge eating' with 'physical activity' or 'exercise', or 'physical inactivity' or 'sedentary'. Nine papers involving 636 (489 women) persons with binge eating disorders and evaluating 24 correlates were included. No consistent physical activity correlates were reported in four or more studies. The only significant correlate with lower physical activity participation reported in more than one study was a negative body attitude. Further research is required to address this current gap in literature.

Clinical correlates of global functioning in obese treatment seeking persons with binge eating disorder.

BACKGROUND: In recent years, research has called for an increased emphasis on clinical outcomes that are meaningful to patients with binge eating disorder (BED). This cross-sectional study examined the Global Assessment of Functioning (GAF) and its relation to clinical and demographic factors in BED patients. SUBJECTS AND METHODS: Thirty-two patients (28 women and 4 men) with BED (age = 41.1 ± 10.7; body mass index = 38.9 ± 5.8) seeking treatment to a weekly multidisciplinary programme at the UPC KU Leuven, Campus Kortenberg in Belgium, were asked to participate at intake. All participants were assessed with the GAF scale, completed the Eating Disorder Inventory (EDI), the Body Attitude Test (BAT), the Symptoms Checklist-90, the Baecke Physical Activity Questionnaire (BPAQ), and performed a 6 minute walk test. RESULTS: The GAF-score (55.9 ± 13.9) was only significantly associated with the BPAQ score (7.0 ± 1.4) (r = 0.383, p = 0.03) and the BAT score (63.9 ± 16.1) (r=-0.443, p = 0.011). The regression model including both of these variables explained 25.3% of the variability in the GAF-score. CONCLUSIONS: This study highlights the value of clinicians assessing physical activity and body image in patients with BED. Research is needed to elucidate whether incorporating body image treatments and physical activity in the care of patients with BED can promote global functioning.

Missing data in long-term follow-up of patients with eating disorders using the body attitude test.

OBJECTIVE: Incompleteness of data is a major problem within clinical follow-up studies. The aim of present study was to compare different statistical models in the management of follow-up data in patients with eating disorders using the Body Attitude Test. METHOD: A prospective longitudinal investigation with repeated evaluations over fixed time intervals was conducted among 807 female patients with eating disorders using the Body Attitude Test as a dependent-variable. Three types of missing data mechanisms were explored: missing completely at random, missing at random and missing not at random. RESULTS: Multivariate analysis showed that the missing completely at random type of missing data mechanism is less reliable than the missing at random or missing not at random mechanisms. Five years after admission, the body experience of eating disorder patients is less deviant. Compared with normative data, 37% of the eating disorder patients still had a more negative body experience 5 years after admission. DISCUSSION: There is no single correct method for dealing with missing data. Therefore, it is recommended that multiple methods be used under different assumptions of absenteeism.

Variability in affective activation predicts non-suicidal self-injury in eating disorders.

We examined whether affective variability can predict non-suicidal self-injury (NSSI) in eating disorders. Affect was represented by valence (positive versus negative) and activation (high versus low). Twenty-one patients with anorexia nervosa-restricting type, 18 patients with anorexia nervosa-binge-purging type and 20 patients with bulimia nervosa reported their momentary affect at nine random times a day during a one week period using a hand-held computer. Affective variability was calculated as the within-person standard deviation of valence and activation over time. Results indicate that patients displaying greater variability in activation and using selective serotonin reuptake inhibitors have a higher probability to engage in lifetime NSSI after adjustment for depression and borderline personality disorder. Neither variability of valence nor mean level of valence and activation had any predictive association with engaging in NSSI. It is suggested that the treatment of NSSI should focus on affect stabilization rather than reducing negative affect.

Body dissatisfaction moderates weight curves in the inpatient treatment of Anorexia Nervosa.

OBJECTIVE: To examine whether drive for thinness, body dissatisfaction, and restrictive/binge eating-purging subtype at admission moderates the weight curves of patients with Anorexia Nervosa (AN) over the course of inpatient treatment. METHOD: The nature of weight curves, individual differences herein and moderating factors are examined in 92 AN patients by means of multilevel modeling. RESULTS: The average weight curve of AN patients is characterized by a linear weight increase during treatment that levels off near the end of treatment. Substantial individual differences exist in the shape of patients' weight curves. Patients with stronger body dissatisfaction at admission display a slower linear rate of weight gain over the course of treatment. Neither drive for thinness nor restrictive/binge eating-purging subtype predicted patients' weight curve over the course of treatment. DISCUSSION: Body dissatisfaction moderates patients' weight curves over the course of inpatient treatment but more research on factors determining weight curves is needed.

Exploring barriers to the implementation of evidence-based practice in psychiatry to inform health policy: a focus group based study.

This study aims to explore the obstacles to Evidence-Based Practice (EBP) experienced by Belgian Dutch-speaking psychiatrists. We used an inductive, qualitative research strategy. Thirty-nine psychiatrists participated in five focus groups organised between September 2004 and September 2006. Data-analysis was guided by a 'grounded theory approach'. Three major themes emerged from the data: (1) Characteristics of evidence, including the lack of (use of) evidence and the applicability of evidence; (2) Characteristics of other partners in mental health care, including government, patients and drug companies and (3) Discipline-related barriers, including the complexity of diagnoses, the importance of the therapeutic relationship and personal experience, and the different schools of thoughts. A problem tree was developed, linking all obstacles. Although context-specific, the problem tree can assist policy makers working in health care systems with similar characteristics in formulating objectives and developing strategies that facilitate EBP in the field of psychiatric care.

Evaluation of body experience questionnaires in eating disorders in female patients (AN/BN) and nonclinical participants.

OBJECTIVE: Body image disturbance is an important factor in the development and the treatment of eating disorders. Therefore, evaluations of different instruments for measuring body image disturbances are necessary. METHOD: Four widely used questionnaires are evaluated: The Body Attitude Test, The Eating Disorder Inventory, The Body Shape Questionnaire, and the Body Attitude Questionnaire. Psychometric properties of these questionnaires are investigated in 228 patients with eating disorder and 389 female controls. Normative values for a Flemish population are provided. RESULTS: All questionnaires have good psychometric properties. To separate patients from controls all four questionnairescan be used. To differentiate between patients with anorexia nervosa and bulimia nervosa, the Body Attitude Test and the Body Dissatisfaction subscale of the Eating Disorder Inventory show good criterion-related validity. CONCLUSION: All these measures are useful as preliminary screening devices to identify populations with a high proportion or risk for developing eating disorders. More research is needed because there is still a great lack of clarity about what constitutes the normal range of attitudes towards the body.

Body composition in girls and young women with anorexia nervosa: comparison of different equations.

OBJECTIVE: The weight percentage of body fat in anorexic adolescents on the basis of four distinct formulas (Siri; Lohman; Westrate and Deurenberg; Heyward and Stolarczyk) is compared. METHOD: The body composition of 238 anorexia nervosa (AN) patients, divided into four age categories (13-15, 15-17, 17-19, and 19-22 years), was measured by means of densitometry (underwater weighing). RESULTS: Depending on the formula, the results calculated by the formulas differ significantly in each age category. The Siri formula generally results in the highest mean fat percentage (12.76%-13.39%) whereas the Heyward and Stolarczyck formula shows the lowest figures (8.77%-9.31%). Applying the Lohman and the Heyward and Stolarczyck formulas to the 19-22 years category, results in negative fat percentages. CONCLUSION: A clinically useful formula is important for the estimation of body composition in specific age categories. We recommend with some restrictions, to apply the Siri formula in AN patients.

Cognitive confidence in obsessive-compulsive disorder: distrusting perception, attention and memory.

Previous studies have established that obsessive-compulsive disorder (OCD) is characterised by significant levels of distrust in memory (e.g. for actions). Ironically, this lowered confidence is at least in part due to repeated checking, which is assumed to lower perceptual processing and thereby reduces vividness and detail of the recollections. In a previous study, Hermans, D., Martens, K., De Cort, K., Pieters, G., and Eelen, P. [(2003). Reality monitoring and metacognitive beliefs related to cognitive confidence in OCD. Behaviour Research and Therapy, 41, 383-401] observed that OCD is not only characterised by reduced confidence in memory, but also by a similar distrust in attention (Hermans et al., 2003). The present study aimed at replicating and extending this finding. It was observed (a) that patients suffering from OCD showed less confidence in attention and memory than a clinical and a nonclinical control group; (b) that confidence in attention was uniquely related to checking behaviour, and (c) that repeated checking caused increased levels of distrust in attention. In addition, it was observed that cognitive distrust while performing OCD-related actions not only extends to attention, but also to perception. It is argued that research on metacognition in OCD should move beyond the study of memory.

Drive for thinness, affect regulation and physical activity in eating disorders: a daily life study.

Using Ecological Momentary Assessment, the within patient associations between drive for thinness, emotional states, momentary urge to be physically active and physical activity were studied in 32 inpatients with an eating disorder. Participants received an electronic device and had to indicate at nine random times a day during 1 week their momentary drive for thinness, positive and negative emotional states and their urge to be physically active and physical activity. Multilevel analyses indicated that patients with higher mean levels for urge to be physically active were characterized by lower body mass index (BMI) and chronically negative affect whereas patients with higher mean levels for physical activity were characterized by lower BMI and higher dispositions for drive for thinness. In addition, within patient relations between drive for thinness and urge to be physically active were moderated by BMI and chronically negative affect whereas within patient relations between drive for thinness and physical activity were moderated by BMI. Finally, also positive emotional states were significantly associated with physical activity within patients. By using a daily process design, characteristics of physical activity were revealed that have not been identified with assessment methods that have a lower time resolution.

Personality prototypes in eating disorders based on the Big Five model.

A three factor model of personality pathology was investigated in a clinical sample of 335 female eating disordered patients. Cluster analysis of the Big Five NEO-FFI scales (Costa & McCrae, 1992) yielded three distinct personality profiles, which were consistent with previous studies: (1) a resilient/high functioning cluster with no clinical elevations on the NEO-FFI scales; (2) an undercontrolled/emotionally dysregulated cluster with elevated scores on the Neuroticism scale and low scores on Conscientiousness and Agreeableness; (3) an overcontrolled/constricted cluster showing high scores on Neuroticism and Conscientiousness and low scores on Openness to Experience. Comparing the three personality prototypes with respect to Axis I and Axis II disorders,resilients reported systematically less clinical and personality problems than both undercontrollers and overcontrollers. Compared to the latter, undercontrollers showed more impulsive personality features and behaviors. Finally, cluster membership was not clearly associated with eating disorder subtypes, suggesting that there is considerable variance in personality features and/or pathology within the various eating disorder categories.

Reduced specificity of autobiographical memory: a mediator between rumination and ineffective social problem-solving in major depression?

BACKGROUND: Depressed individuals display a deficit in effectively solving social problem situations (e.g., []). Recent research suggests that rumination may interfere with such effective problem-solving (e.g., []). However, little is known, as yet, about the mechanisms that are underlying this relation between rumination and poor problem-solving. The present study investigated the role of reduced specificity of autobiographical memories as a mediator of this relationship. METHODS: 24 depressed patients (15 women) completed the Autobiographical Memory Test (AMT), the Means-Ends Problem-Solving Task (MEPS), the Ruminative Response Scale (RRS) and the Rumination on Sadness Scale (RSS). RESULTS: Consistent with previous studies, rumination, ineffective problem-solving and reduced memory specificity were significantly associated. Regression analyses further extended these findings by showing that reduced memory specificity mediated the association between rumination and problem-solving effectiveness. LIMITATIONS: The correlational nature of this study limits to some extent the conclusions that can be drawn on the directionality of the observed relationships. CONCLUSIONS: Results offer support for the idea that lack of autobiographical memory specificity mediates the known relationship between rumination and poor problem-solving.

Prescribing preferences in rapid tranquillisation: a survey in Belgian psychiatrists and emergency physicians.

BACKGROUND: The pharmacotherapeutic management of agitation is a common clinical challenge. Pharmacotherapy is frequently used, the use of published guidelines is not known. The purpose of this study was twofold; to describe the prescribing patterns of psychiatrists and emergency physicians and to evaluate to which extent guidelines are used. METHODS: A cross-sectional survey in the Dutch-speaking part of Belgium is carried out in 39 psychiatric hospitals, 11 psychiatric wards of a general hospital and 61 emergency departments. All physicians are asked for demographic information, their prescribing preferences, their use of guidelines and the type of monitoring (effectiveness, safety). For the basic demographic data and prescription preferences descriptive statistics are given. For comparing prescribing preferences of the drug between groups Chi square tests (or in case of low numbers Fisher's exact test) were performed. Mc Nemar test for binomial proportions for matched-pair data was performed to see if the prescription preferences of the participants differ between secluded and non-secluded patients. RESULTS: 550 psychiatrist and emergency physicians were invited. The overall response rate was 20% (n = 108). The number 1 preferred medication classes were antipsychotics (59.3%) and benzodiazepines (40.7%). In non-secluded patients, olanzapine (22.2%), lorazepam (21.3%) and clotiapine (19.4%) were most frequently picked as number 1 choice drug. In secluded patients, clotiapine (21.3%), olanzapine (21.3%) and droperidol (14.8%) were the three most frequently chosen number 1 preferred drugs. Between-group comparisons show that emergency physicians prefer benzodiazepines significantly more than psychiatrists do. Zuclopenthixol and olanzapine show a particular profile in both groups of physicians. Polypharmacy is more frequently used in secluded patients. Published guidelines and safety or outcome monitoring are rarely used. CONCLUSIONS: Our results show that prescription practice in Flanders (Belgium) in acute agitation shows a complex relationship with published guidelines. Prescription preferences differ accordingly to medical specialty. These findings should be taken into account in future research.

Fast psychomotor functioning in underweight anorexia nervosa patients.

To explore whether underweight anorexia nervosa patients show psychomotor differences relative to normal controls, 32 female hospitalised patients, aged between 14 and 25 years, were compared with 32 healthy, normal weight controls, matched for sex, age and educational level. Using computerised analysis of writing and drawing behaviour, reaction times and movement times and their different components were analysed, while cognitive and motor demands were manipulated in five drawing and copying tasks. Anorexia nervosa patients were, compared to normal weight controls, significantly faster in a drawing task and showed shorter reaction times in copying tasks. Movement times did not differ significantly between the two groups. In the most complex copying task, a significant group x complexity interaction for reaction time (patients shorter) and reinspection time (patients longer) was found. Patients also made more errors than controls. The finding of a consistent pattern of shorter reaction times in underweight anorexia nervosa patients seems to run contrary to previous findings of disturbed cognitive functioning (i.e. impaired attention) in these patients. The differences seem to be related to cognitive factors more than to motor (executive) components.

Reality monitoring and metacognitive beliefs related to cognitive confidence in obsessive-compulsive disorder.

The present study investigated general reality monitoring ability, and selective reality monitoring ability for anxiety relevant actions in a group of individuals with obsessive-compulsive disorder (OCD) and a group of non-anxious controls. In addition, reality monitoring confidence was assessed, as well as specific meta-cognitive beliefs related to cognitive confidence (by means of the Meta-Cognitions Questionnaire (MCQ)). No differences were found between both groups in actual reality monitoring ability. Unlike previous studies, the reality monitoring task included actions that were related to the individual concerns of the OCD patients and were ideographically selected. Nevertheless, no differential reality monitoring effect was observed for the anxiety relevant stimuli. Data from the MCQ, however, revealed that OCD patients had less overall confidence in their memory for actions and their reality monitoring ability. Analysis of the confidence ratings of the reality monitoring task showed that this reduced confidence was restricted to the neutral actions. No differences were observed for patients that reported low or high frequencies of checking behaviour. The whole of these data do not support memory deficit models of OCD, but are in line with recent emphasis on the importance of memory confidence and other meta-cognitive beliefs in OCD.