[Effects of a smoke-free policy on healthcare staff attitudes and aggression in psychiatry]. / Effecten van een rookvrijbeleid op attitudes zorgpersoneel en agressie in de psychiatrie.

Background The prevalence of smoking among patients with psychiatric disorders is 3-4 times higher than the general population. However, smoking is still permitted in many psychiatric clinics. The National Prevention Agreement (2018) mandates that all psychiatric wards be smoke-free by 2025. The UMC Utrecht clinics have been smoke-free since November 2020. Aim To examine healthcare workers’ attitudes before and after implementing the smoke-free policy. Method In an observational study with quantitative data analysis, data were collected in one center from healthcare workers in psychiatry departments with surveys. We collected demographic information, smoking status, attitudes towards the smoke-free policy, and its impact on patients and care. Incidents of aggression were prospectively recorded and reported in the MAP (aggression incidents in patient care). Results Out of 172 healthcare workers invited to participate, 30% (n = 52) completed the pre-implementation survey, and 20% (n = 34) completed the post-implementation survey. Prior to implementation, 62% (n = 32/52) of healthcare workers had a positive attitude towards the smoke-free policy, which increased to 77% (n = 26/34) post-implementation. Expectations of increased aggression incidents were reported by 62% (n = 32/52) during the pre-implementation phase. The number of aggression incidents was 46 in the one-year period before implementation (November 2019 – February 2020) and 45 incidents after implementation (November 2020 – February 2021). Conclusion This study supports the implementation of a smoke-free policy in psychiatric clinics due to the lack of a significant increase in aggression incidents. Healthcare workers perceived this outcome and observed quicker granting of ‘green’ freedoms.

[Making meaning of mental distress; discourse analysis of service-users' narratives]. / Betekenis geven aan psychische problematiek; discoursanalyse van ervaringsverhalen.

BACKGROUND: Processes of meaning-making are central to personal recovery in mental distress. Scientific inquiry of meaning-making is scarce within psychiatry, while it has the potential to better attune care to the lived-experience and views of service-users. AIM: To gain insight into how service-users make meaning of mental distress; how this meaning is shaped by mental health discourses, and how these discourses influence the search for identity and recovery. METHODS: Qualitative study of service-users’ narratives (N = 25) from the Psychiatry Story Bank. Narratives were collected through an open interview and analyzed with discourse analysis. RESULTS: We identified four patterns of meaning: Mental distress as ‘weakness’, as ‘social isolation’, as ‘necessity for care’ and as ‘disconnection’. Disposal - and integration - of various discourses apparently helped participants to find meaning, attuned to their recovery phase and the particular recognition they pursued. The quest for recovery was complicated when they experienced a clash between their own meaning-making and dominant ideals in care. CONCLUSION: Caretakers can stimulate the creation of helpful meaning, by attuning to their patients’ context, recovery phase and plea for recognition. Awareness of the effects and limitations of their own assumptions on mental distress is of importance as well.

[Epidemiology and treatment of aggression in patients with psychotic disorders]. / Epidemiologie en behandeling van agressie bij patiënten met een psychotische stoornis.

BACKGROUND: Aggression is a major problem within psychiatry. During the recent years, a lot of research has been done, but many clinical decisions are still not evidence-based. AIM: This article describes three studies of the thesis 'Aggression in Psychiatry'. The overarching goal was to contribute to the current knowledge on aggression with clinically relevant results. The three studies described in this article are focused on psychotic disorders. METHOD: The first study is a survival analysis with data from a 6-year follow-up study. The second study is focused on associations between aggression and clinical factors and the effect of antipsychotics on aggression in first episode psychosis patients. The third study is a meta-analysis focused on the effectiveness of typical versus atypical antipsychotics on aggression. RESULTS: The yearly incidence of aggression in patients with psychotic disorders is around 2%. Patients with symptoms such as impulsivity, but also childhood trauma are at risk for aggression. Amisulpride appears effective against aggression during the first weeks of treatment. In patients with more persistent aggression, clozapine is most effective. CONCLUSION: Aggression is complex and heterogeneous. More research is needed, but with the findings of these three studies, we contribute to the current knowledge of aggression and treatment options.

[Knowledge discovery in clinical psychiatry: learning from electronic health records]. / Kennisontwikkeling in de klinische psychiatrie: leren van elektronische patiëntendossiers.

BACKGROUND: Today, almost every psychiatric care institution registers information concerning the care they provide in an electronic health record (EHR). By analyzing these health care data with innovative and advanced techniques, they can be an important source of new knowledge in the near future, and thereby contribute to improving psychiatric care. AIM: To investigate how data from EHRs can provide relevant knowledge and insights for psychiatric care. METHOD: We designed and discussed solutions for some technical, organizational and ethical barriers surrounding unlocking health care data, in order to make analysis possible. We then analyzed the obtained health care data using techniques from knowledge discovery, the process in which new and useful information is extracted from data. We used techniques from data visualization, machine learning and natural language processing, among others, to demonstrate which types of results can be achieved. RESULTS: Our approach showed that it is possible to find new and interesting insights that are hidden in EHRs on an aggregated level, in collaboration with healthcare professionals and patients. In particular we showed how the risk of violent behavior can effectively and accurately be assessed based on clinical text in the EHR. CONCLUSION: After addressing some of the important challenges surrounding analyzing EHR data, learning from data from EHRs is a new and interesting approach with clear potential for improving psychiatric care.

[Ethics of (big) data applications in psychiatric practice]. / Ethiek van (big)datatoepassingen in de psychiatrische praktijk.

BACKGROUND: Due to rapid digitalization, an increasing amount of data is available in healthcare settings; big data and artificial intelligence (AI) have also made their appearance. AIM: To provide insight into various ethical dilemmas that need to be considered when applying big data in clinical practice. METHOD: Description and analyses of the ethical aspects associated with the use of clinical data in the context of psychiatric care. RESULTS: Various ethical aspects play a role in four phases; data collection, analysis, dissemination and application of results. In order to use clinical data and AI in a responsible manner, these aspects must be taken into account. CONCLUSION: The use of big data and AI in healthcare should aim to stimulate learning and improving care together with patients and professionals. Big data and AI should not be seen as the holy grail, but as a supporting tool in healthcare - a field in which many of the aspects that play a role in clinical care cannot be converted into measurable data.

[Psychosis as an evolutionary adaptive mechanism to environmental changes; A plea for a functional explanatory model]. / Psychose als evolutionair adaptief mechanisme bij omgevingsverandering; pleidooi voor een functioneel verklaringsmodel.

BACKGROUND: From an evolutionary perspective it is remarkable that psychotic disorders, mostly occurring during fertile age and decreasing fecundity, maintain in the human population.
AIM: To argue the hypothesis that psychotic symptoms may not be viewed as an illness but as an adaptation phenomenon.
METHOD: Philosophical consideration and literature study.
RESULTS: Until now, biomedical research has not unraveled the definitive etiology of psychotic disorders. Findings are inconsistent and show non-specific brain anomalies and genetic variation with small effect sizes. However, compelling evidence was found for a relation between psychosis and stressful environmental factors, particularly those influencing social interaction. Psychotic symptoms may be explained as a natural defense mechanism or protective response to stressful environments. This is in line with the fact that psychotic symptoms most often develop during adolescence. In this phase of life, it is important for an individual's development to leave the familiar and safe home environment, and to build new social networks. This could cause symptoms of 'hyperconsciousness' and calls on the capacity for social adaptation. This mechanism can become out of control due to different underlying brain vulnerabilities and external stressors, leading to social exclusion. CONCLUSIONS There is theoretical ground to consider psychotic symptoms as an evolutionary maintained phenomenon. Research investigating psychotic disorders may benefit from a focus on underlying general brain vulnerabilities or prevention of social exclusion, instead of regarding psychotic symptoms as abnormal phenomena.

[Data science in psychiatry]. / Datascience in de psychiatrie.

BACKGROUND: The information society is digitalising at a fast pace. New technology enables the collection of real life and real time information from sources that were inaccessible before. This creates an inordinate amount of dynamic data and, consequently, opportunities to introduce new insights and improvement of treatment in the field of psychiatry.
AIM: To clarify the definition of big data and how a big data approach can reform care into a data driven, patient oriented dynamic system which is constantly learning.
METHOD: Brief description of a pilot effected at the UMC Utrecht where the Cross Industry Standard Process for Interactive Data Mining (CRISP-IDM) was performed and description of applications in the future.
RESULTS: The described approach and examples from literature show that there are possibilities to realise quick improvements in practice and implement new insights from existing data sources.
CONCLUSION: Introduction of data science in psychiatric practice offers new prospects.

[Psychosis: recognising the symptoms and disorders in children and adolescents]. / Psychose: symptomen en stoornissen onderscheiden bij kinderen en adolescenten.

BACKGROUND: Psychotic symptoms can occur during normal development, but they can also indicate the presence of or an increased risk of a psychotic disorder. By studying children who are at risk of developing a psychotic disorder we can obtain information that will help to distinguish more accurately between developmental phenomena and psychopathology. AIM: To present the current state of our knowledge about the development of psychotic symptoms and psychotic disorders and to discuss the importance of continuing research into subpopulations of children who are at risk of developing a psychotic disorder. METHOD: We give an epidemiological and clinical description of psychosis in childhood and we report on recent Dutch and international studies about children with an increased risk of developing psychotic disorders. RESULTS: Results so far indicate that these children tend to have an increased risk of developing not only psychotic disorders but also a wide range of psychopathological conditions in later life. The degree of risk depends on the nature and number of risk factors involved. CONCLUSION: More research is needed to follow the development of children with an increased risk of psychotic disorders.

Macroscale EEG characteristics in antipsychotic-naïve patients with first-episode psychosis and healthy controls.

Electroencephalography in patients with a first episode of psychosis (FEP) may contribute to the diagnosis and treatment response prediction. Findings in the literature vary due to small sample sizes, medication effects, and variable illness duration. We studied macroscale resting-state EEG characteristics of antipsychotic naïve patients with FEP. We tested (1) for differences between FEP patients and controls, (2) if EEG could be used to classify patients as FEP, and (3) if EEG could be used to predict treatment response to antipsychotic medication. In total, we studied EEG recordings of 62 antipsychotic-naïve patients with FEP and 106 healthy controls. Spectral power, phase-based and amplitude-based functional connectivity, and macroscale network characteristics were analyzed, resulting in 60 EEG variables across four frequency bands. Positive and Negative Symptom Scale (PANSS) were assessed at baseline and 4-6 weeks follow-up after treatment with amisulpride or aripiprazole. Mann-Whitney U tests, a random forest (RF) classifier and RF regression were used for statistical analysis. Our study found that at baseline, FEP patients did not differ from controls in any of the EEG characteristics. A random forest classifier showed chance-level discrimination between patients and controls. The random forest regression explained 23% variance in positive symptom reduction after treatment in the patient group. In conclusion, in this largest antipsychotic- naïve EEG sample to date in FEP patients, we found no differences in macroscale EEG characteristics between patients with FEP and healthy controls. However, these EEG characteristics did show predictive value for positive symptom reduction following treatment with antipsychotic medication.

[Prevention and treatment of somatic complications arising from the use of antipsychotics]. / Preventie en behandeling van somatische complicaties bij antipsychoticagebruik.

BACKGROUND: Antipsychotics are effective drugs that are prescribed frequently for a large group of patients. However, they also have many side-effects which can lead ultimately to serious somatic complications. These complications fall into various categories: metabolic, cardiovascular, neurobiological, haematological, gastro-intestinal and urogenital. AIM: To make an inventory of the side-effects and advise on ways of monitoring and preventing them. method The multidisciplinary working group on somatic complications arising from the use of antipsychotics (Werkgroep Somatische Complicaties) has collected literature on the subject and has discussed it at a number of consensus meetings. results The most frequent somatic complications are described on the basis of specific risk profiles and advice is given on how to identify these complications and on how to treat them when necessary. It is essential to monitor, systematically and regularly, somatic complications arising from the use of antipsychotics; furthermore, polypharmacy should be avoided. The person ultimately responsible for this is the doctor who has prescribed the antipsychotics. In addition, it is important to draw patients' attention to the general rules for a healthy lifestyle: no smoking, a balanced diet and adequate exercise. CONCLUSION: It is very important that somatic complications should be monitored carefully and accurately. So far, the Netherlands has no official guidelines on ways to identify and treat somatic complications.

Are Proactive and Reactive Aggression Meaningful Distinctions in Adolescents? A Variable- and Person-Based Approach.

This study was designed to examine whether proactive and reactive aggression are meaningful distinctions at the variable- and person-based level, and to determine their associated behavioral profiles. Data from 587 adolescents (mean age 15.6; 71.6 % male) from clinical samples of four different sites with differing levels of aggression problems were analyzed. A multi-level Latent Class Analysis (LCA) was conducted to identify classes of individuals (person-based) with similar aggression profiles based on factor scores (variable-based) of the Reactive Proactive Questionnaire (RPQ) scored by self-report. Associations were examined between aggression factors and classes, and externalizing and internalizing problem behavior scales by parent report (CBCL) and self-report (YSR). Factor-analyses yielded a three factor solution: 1) proactive aggression, 2) reactive aggression due to internal frustration, and 3) reactive aggression due to external provocation. All three factors showed moderate to high correlations. Four classes were detected that mainly differed quantitatively (no 'proactive-only' class present), yet also qualitatively when age was taken into account, with reactive aggression becoming more severe with age in the highest affected class yet diminishing with age in the other classes. Findings were robust across the four samples. Multiple regression analyses showed that 'reactive aggression due to internal frustration' was the strongest predictor of YSR and CBCL internalizing problems. However, results showed moderate to high overlap between all three factors. Aggressive behavior can be distinguished psychometrically into three factors in a clinical sample, with some differential associations. However, the clinical relevance of these findings is challenged by the person-based analysis showing proactive and reactive aggression are mainly driven by aggression severity.

Effect of clozapine on caudate nucleus volume in relation to symptoms of schizophrenia.

OBJECTIVE: Studies have found that caudate volume increased after treatment with typical antipsychotics in patients with schizophrenia but decreased after treatment was changed to clozapine. In the current study the authors examined whether this volume decrease was related to clinical improvement. METHOD: Twenty-eight patients with schizophrenia who had not responded to treatment with typical antipsychotics were included in the study; 22 completed the study. Caudate volume was assessed by using magnetic resonance imaging during treatment with typical antipsychotics and after 24 weeks and 52 weeks of clozapine treatment. Symptoms were assessed just before clozapine treatment and once a month thereafter. RESULTS: Clozapine treatment resulted in a significant reduction in left caudate volume in patients who responded to the drug but not in patients who did not respond to clozapine at 52 weeks of treatment. Overall, the degree of reduction in left caudate volume was significantly related to the extent of improvement in positive and general symptoms but not in negative symptoms. CONCLUSIONS: These findings suggest that the caudate nucleus plays a role in the positive and general symptoms of schizophrenia.

The effect of olanzapine treatment on monoamine metabolite concentrations in the cerebrospinal fluid of schizophrenic patients.

The mechanism of action of both typical antipsychotics and the atypical antipsychotic, clozapine, may be related to the (changing) interaction of dopamine and serotonin in schizophrenia. This study examined the effect of olanzapine in schizophrenic patients on cerebrospinal fluid (CSF) metabolites of dopamine (homovanillic acid, HVA) and serotonin (5-hydroxyindoleacetic acid, 5-HIAA). Twenty-three male schizophrenic patients, who were drug-free for at least 2 weeks (mean drug-free period of 35 days +/- 43; median 16 days), underwent a lumbar puncture (LP). Patients were subsequently treated with olanzapine 10 mg/day for 6 weeks, after which the LP was repeated. CSF was assayed for HVA and 5-HIAA concentrations. Psychiatric symptoms were rated once a week. Olanzapine significantly increased HVA concentrations and the HVA/5-HIAA ratio while 5-HIAA concentrations were not altered. These changes did not significantly correlate with treatment response. A negative correlation was found between HVA concentrations and negative symptoms after olanzapine treatment. In conclusion, olanzapine treatment increases HVA concentrations and the HVA/5-HIAA ratio in CSF of schizophrenic patients, but these changes are unrelated to its clinical efficacy.

The effect of clozapine on caudate nucleus volume in schizophrenic patients previously treated with typical antipsychotics.

Typical antipsychotics have been reported to enlarge the caudate nucleus in schizophrenic patients. The atypical antipsychotic, clozapine, is associated with a decrease in caudate size in patients previously treated with typical antipsychotics. The present study investigates whether a change in caudate volume after switching from treatment with typical antipsychotics to treatment with clozapine is related to improvement in symptoms or tardive dyskinesia (TD). Twenty-six schizophrenic patients participated in this open study. Caudate nucleus volume and TD were assessed before discontinuing typical antipsychotics and after 24 weeks of treatment with clozapine. After discontinuing typical antipsychotics, symptoms were assessed in a 3 days drug-free period and subsequently once a month. Treatment with clozapine resulted in a decrease in caudate volume, improvement in symptoms and amelioration of TD. However, no difference in caudate volume changes was found between responders and non-responders to clozapine and no correlations were found between caudate volume changes and reduction of TD. In conclusion, this study replicates earlier findings that clozapine decreases caudate volume in patients previously treated with typical antipsychotics and suggests that this effect is unrelated to treatment response or to amelioration of TD.

The effect of olanzapine treatment on m-chlorophenylpiperazine-induced hormone release in schizophrenia.

In addition to dopamine, serotonin (5-hydroxytryptamine, 5-HT) has been reported to play an important role in schizophrenia. Besides blocking dopamine, atypical antipsychotics also block 5-HT receptors. The clinical efficacy of the atypical antipsychotic clozapine is associated with the 5-HT antagonistic action of the drug and a high serotonergic tone before treatment. The atypical antipsychotic olanzapine has a receptor-binding profile similar to that of clozapine. The present study investigated whether treatment with olanzapine blocks hormone release induced by the 5-HT2c agonist m-chlorophenylpiperazine (m-CPP) and, if so, whether this 5-HT antagonistic effect is related to treatment response. Eighteen male schizophrenic patients participated in this study. All patients were challenged with m-CPP (0.5 mg/kg orally) in a double-blind, randomized, placebo-controlled design after a drug-free period of at least 2 weeks. Adrenocorticotropic hormone (ACTH), cortisol, and prolactin plasma levels were measured every 30 minutes up to 210 minutes after challenge. Patients were treated for 6 weeks with 10 mg olanzapine daily in an open design, after which the challenge tests were repeated. Olanzapine significantly blocked m-CPP-induced ACTH, cortisol, and prolactin release, suggesting that it is a potent 5-HT2c antagonist in vivo. This 5-HT antagonistic effect of olanzapine was not significantly correlated with treatment response. Also, no significant correlation was found between m-CPP-induced hormone release before treatment and clinical response after treatment with olanzapine. These findings suggest that olanzapine is a potent 5-HT2c antagonist in vivo but that this is unrelated to its clinical efficacy in this nonrefractory sample of schizophrenic patients.