[Discussing survey results in client panels appears a beneficial approach for a client counsel]. / Enquêteresultaten bespreken in cliëntenpanels: nuttige aanpak voor cliëntenraad.

BACKGROUND: The Client Participation Act in Healthcare Institutions prescribes that information must be collected as low as possible in the organization. To meet this need, Arkin’s client council started experimenting with a new way to get in touch with clients. METHOD: We regularly send a short survey to clients about a number of themes and we invite clients to discuss these in a client panel. Two rounds of surveys and panel discussions have now been organized on the following themes: waiting times, participation in treatment, stigma, ROM, eHealth and relative or friend. RESULTS: The experiences with the chosen approach were favorable. The collection of quantitative survey data and qualitative information from the panel discussion complemented each other and led to further professionalization of the work of the client council. Clients were happy to be involved in the work of the client council in this way. A better insight was gained into how they experience policy decisions and the client council was better able to present this information to the board of directors and the executive board of Arkin. CONCLUSION: The new approach has strengthened the position of the client council within Arkin. We consider this a good approach to implement the Client Participation Act.

[Mental health care in times of corona: experiences of professionals with eHealth]. / Zorgverlening in tijden van corona: ervaringen van behandelaars met zorg-op-afstand.

BACKGROUND: Due to the COVID-19 pandemic, most treatments in mental health care are provided through video calling. AIM: To poll what they think of remote care among 605 care providers of Arkin. METHOD: We surveyed 605 professionals on their experiences. RESULTS: Enthusiasm for remote care was found predominantly among psychologists who worked in curative care. They reported practical benefits for the patient and for the process of care provision. Psychiatrists and clinical psychologists who provided care to patients with complex and/or chronic problems. They feared a deterioration in quality of care and a decline in their job satisfaction. Nurses were also critical, especially those who provided FACT and outreaching care. Their patients often lacked the resources or skills required to access digital care. CONCLUSION: This assessment of remote care was likely adversely affected by the corona measures. Employees were suddenly forced to alter their usual work habits and had not been optimally trained in the new method were more critical. Moreover, they were forced to work from home and lacked informal professional contact with colleagues. Nevertheless, professionals have a nuanced and predominantly positive opinion of video calling: it is not suitable for everyone or appropriate under all circumstances, but remote care is seen as a useful addition to the existing arsenal of treatment modalities.

[The PTSD Checklist for DSM-5 (PCL-5): comparing responsivity with the Outcome Questionnaire (OQ-45) and practical utility]. / De PTSS Checklist voor DSM-5 (PCL-5) voor ROM: een vergelijking van de responsiviteit met de Outcome Questionnaire (OQ-45) en praktische bruikbaarheid.

BACKGROUND: The PTSD Checklist for the DSM-5 (PCL-5) may be a suitable addition for routine outcome monitoring (ROM) for patients with PTSD.
AIM: To determine whether the PCL-5 is worth the extra effort that administration requires from the patient.
METHOD: Pretest and retest measurement results of the PCL-5 and the OQ-45 were compared head-to-head in 464 patients from the Sinai Center of Arkin.
RESULTS: The correlations between scores on the instruments were high and analysis of variance for repeated measurements revealed no difference in responsiveness. Comparison of Cohen's d (0.49 vs. 0.43) and Delta T (5.0 vs. 4.4), indicated a slightly better responsiveness of the PCL-5 and also the proportion of recovered patients was greater according to the PCL-5 compared to the OQ-SD.
CONCLUSION: At first glance, the PCL-5 and the OQ-SD were equally sensitive to detect change during treatment. However, the PCL-5 provided more detailed information about the nature and severity of symptomatology in an individual patient and with the PCL-5 we were slightly better able to demonstrate clinical significant change than with the OQ-SD. We recommend to add the PCL-5 to ROM for patients with PTSD.

[A plea for better detection of psychopathology in detention]. / Een pleidooi voor betere detectie van psychische klachten in detentie.

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[Shared decision making in mental health care; evaluation of the added value for patients and clinicians]. / Samen beslissen in de ggz; onderzoek naar toegevoegde waarde voor patiënten en behandelaars.

BACKGROUND: Although the evidence is expanding, in mental health care shared decision making (SDM) is not widely applied. Moreover, little is known about the use of routine outcome monitoring (ROM) and eHealth in SDM.
AIM: PhD research on the added value of SDM using ROM and eHealth for patients and clinicians in mental health care.
METHOD: Three studies: 1. a literature research and a cross-sectional study on decisional conflict; 2. ROM implementation research and a cluster randomised trial on shared decision making using ROM (Breakthrough program); 3. a cluster randomised trial on shared decision making during the intake (regional).
RESULTS: The interventions did not lead to reduced decisional conflict for all patient groups. Decisional conflict gives insight into the patient's perspective on the quality of the decision making process and decisions being made. Only patients with depression, who participated in the national trial, reported less decisional conflict. This trial did not show a higher level of SDM, but did show increased usage of rom in clinical practice. Although the regional trial showed no results on decisional conflict, the application of SDM and treatment outcomes improved.
CONCLUSION: SDM in mental health care needs further improvement. We recommend investigating how to support patients better, taking into account the role that suits them.

Treatment Outcome, Duration, and Costs: A Comparison of Performance Indicators Using Data from Eight Mental Health Care Providers in The Netherlands.

Assessing performance of mental health services (MHS) providers merely by their outcomes is insufficient. Process factors, such as treatment cost or duration, should also be considered in a meaningful and thorough analysis of quality of care. The present study aims to examine various performance indicators based on treatment outcome and two process factors: duration and cost of treatment. Data of patients with depression or anxiety from eight Dutch MHS providers were used. Treatment outcome was operationalized as case mix corrected pre-to-posttreatment change scores and as reliable change (improved) and clinical significant change (recovered). Duration and cost were corrected for case mix differences as well. Three performance indicators were calculated and compared: outcome as such, duration per outcome, and cost per outcome. The results showed that performance indicators, which also take process variability into account, reveal larger differences between MHS providers than mere outcome. We recommend to use the three performance indicators in a complementary way. Average pre-to-posttreatment change allows for a simple and straightforward ranking of MHS providers. Duration per outcome informs patients on how MHS providers compare in how quickly symptomatic relief is achieved. Cost per outcome informs MHS providers on how they compare regarding the efficiency of their care. The substantial variation among MHS providers in outcome, treatment duration and cost calls for further exploration of its causes, dissemination of best practices, and continuous quality improvement.

[The reliability of Delta-T]. / De betrouwbaarheid van Delta-T.

BACKGROUND: In Dutch mental health care there is an ongoing debate about the benefits of rom and utility of benchmarking. Opinions vary regarding the reliability and validity of performance indicators.
AIM: Investigation of the reliability of the main indicator of Foundation Benchmark Mental Health Care (sbg), Delta-T, the indicator of treatment outcome.
METHOD: The reliability was established with two indices: the intraclass correlation coefficient (icc) for the agreement between repeated assessments of average treatment outcome and the consistency in rank order of mental health care providers over time.
RESULTS: The reliability of Delta-T proved to be excellent.
CONCLUSION: Reliability is a basic requirement, but only the first step in establishing the utility of Delta-T. Further investigation of its validity is ongoing, especially on how robust treatment outcome is for bias due to instrumentation, selection, and confounding by casemix composition. Ultimately, the usefulness of treatment outcome as indicator of quality of care needs to be demonstrated in practice.

[Providing insight into the construct decisional conflict and its usability to assess shared decision making]. / Het begrip 'beslissingsambivalentie' (decisional conflict) en de bruikbaarheid ervan bij de evaluatie van gedeelde besluitvorming.

BACKGROUND: The increased attention for shared decision making (sdm) in mental health care creates a need to evaluate its application. The construct decisional conflict, which refers to the satisfaction of patients regarding both the decision making process and the decisions made, could be of added value.
AIM: Clarifying decisional conflict and reflecting on its feasibility to evaluate sdm in mental health care.
METHOD: A literature study exploring the construct of decisional conflict was conducted, followed by a translation of the results into a visual model.
RESULTS: Decisional conflict is a multi-dimensional construct and consists of factors influencing the decision making process (information, support, values clarity), level of uncertainty concerning the options and the quality of the decision making. Decisional conflict can be illustrated by using a model and assessed with the Decisional Conflict Scale.
CONCLUSION: Decisional conflict is informative and useful in the evaluation of the application of sdm and improvement of the quality of the decision making in mental health care as well. This is of importance since patients who experienced less decisional conflict are more engaged in treatment and show better clinical outcomes.

[The future of ROM: computerised adaptive testing]. / De toekomst van ROM: computer-gestuurd adaptief testen.

BACKGROUND: Measurement instruments that are used for monitoring patients in mental health care are developed according to the principles of classical test theory. Because the assumptions underlying this theory are outdated, this is a good time to work towards a new method of measurement known as computerised adaptive testing (CAT), the method being based on item response theory. AIM: To introduce the CAT-methodology into Dutch mental health care, and provide an overview of the current and desirable developments. METHOD: We explain what CAT is and why mental health care should warmly welcome this new development. We also outline the limitations of CAT, summarise the developments that have already been made nationally and internationally and consider some developments we think are desirable. RESULTS: PROMIS item banks for anxiety and depression for adults show that CAT is more efficient than instruments currently in use and is able to produce very precise outcomes. CONCLUSION: The first CATs for anxiety and depression will be available late 2017 or early 2018 for adults receiving mental health care in the Netherlands. Recent results are very impressive and CAT-technology will increase the efficiency of symptom measurements, bringing these measurements to a higher level.

[Comorbidity on axis I and treatment outcome]. / Comorbiditeit op as I en de uitkomst van de behandeling.

BACKGROUND: Clinical practice shows that patients with complicated psychopathology are more difficult to treat than those with simple psychopathology. Comorbidity may be the complicating factor involved here. The prognostic value that comorbidity on axis I has on treatment outcome may be relevant for establishing the treatment plan for a patient and may also be relevant for the evaluation of aggregated treatment outcomes achieved by clinicians, treatment teams or institutes.
AIM: To investigate whether comorbidity on axis I can explain disappointing results and whether we should correct for comorbidity when comparing the aggregated treatment results achieved by clinicians, treatment teams or institutes.
METHOD: Our observational study involved a large group of patients (n = 25,651). Outcome data for a subgroup of patients (n = 7754) were available. Comorbidity in this subgroup was established by means of a structured diagnostic interview (MINI-Plus) performed by trained research nurses.
RESULTS: Comorbidity appeared to have some association with the treatment outcome, but the severity of symptoms seemed to be a much more powerful predictor of treatment outcome.
CONCLUSION: After correcting for baseline severity, we found that comorbidity had very little prognostic value as far as the treatment outcome was concerned.

[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.

Diagnostic accuracy of the Dutch version of the Somatic Symptom Disorder - B Criteria Scale (SSD-12) compared to the Whiteley Index (WI) and PHQ-15 in a clinical population.

OBJECTIVE: Somatic Symptom and Related Disorders(SSRD) are characterised by an intense focus on somatic symptoms that causes significant distress. A self-report scale developed to assess distress as symptom-related thoughts, feelings, and behaviors (SSD-12) has proved to be a reliable, valid and time-efficient measure for Somatic Symptom Disorder(SSD). This cross-sectional study aimed to compare the SSD-12 with psychiatric assessment as gold standard in a Dutch clinical population for SSRD compared to other widely used measures. METHODS: Data were collected from adult patients visiting a specialised mental health outpatient clinic for SSRD in the Netherlands, between 2015 and 2017. Analyses included item evaluation, scale reliability, construct validity, diagnostic utility and cut points. Performance of SSD-12, Whiteley Index(WI) and PHQ-15 were compared in Receiver operating characteristics (ROC) curves. RESULTS: 223 patients with SSD, Functional Neurological Disorder, Illness Anxiety(IA) and no SSRD participated. SSD-12 items were normally distributed; total scores correlated with measures of health anxiety, anxiety and depression. The optimal cut point for the SSD-12 was 22 (sensitivity 75.9%, specificity 63.6%). The ROC area under the curve for SSD-12 was 0.75 compared to 0.68 for the WI and 0.65 for the PHQ-15. Combinations of those questionnaires did not yield better results than for the SSD-12 alone. CONCLUSION: The SSD-12 alone outperformed the WI and PHQ-15 and combined scales in effectively distinguishing SSRDs from other mental disorders. This may suggest that distress is a more accurate indicator of SSRD than earlier diagnostic criteria as operationalised in the WI and PHQ-15.

Routine outcome monitoring in the Netherlands: practical experiences with a web-based strategy for the assessment of treatment outcome in clinical practice.

Routine outcome monitoring (ROM) is a method devised to systematically collect data on the effectiveness of treatments in everyday clinical practice. ROM involves documenting the outcome of treatments through repeated assessments. Assistants are employed who perform a baseline assessment comprising a standardized diagnostic interview, administration of rating scales and completion of several self-report measures by the patient. At fixed time intervals, assessments are repeated. Dedicated Web-based software has been developed to assist in this task. ROM informs therapists and patients on the severity of the complaints at intake, and the waxing and waning of symptoms over the course of treatment. Researchers can use ROM for effectiveness research, and managers can use it for benchmarking. The use of ROM for research is illustrated by presenting data on the diagnostic status of patients participating in ROM and data on treatment outcome of a subgroup of patients (with panic disorder) in our database. The results show that implementation of ROM is feasible, and after some initial reservations, most therapists now consider ROM to be a necessary and important adjunct to the clinical treatment. In addition, ROM furthers research as the data can be used to study the phenomenology of psychiatric disorders and the outcome of treatments delivered in everyday practice.

[Ethnic differences between pre-trial suspected offenders]. / Etnische verschillen tussen pro Justitia gerapporteerde verdachten.

BACKGROUND: Black and minority ethnic (BME) patients with a severe psychiatric disorder are compulsory admitted to psychiatric hospitals more often than Dutch native patients. AIM: To describe ethnic differences with regard to (1) the prevalence of psychiatric disorders, (2) the degree to which 'suspects' are considered to be accountable for their actions and (3) recommended treatment for reported pre-trial suspects. METHOD: 14,540 pre-trial reports in the Netherlands between 2000 and 2006 with a known ethnicity were assessed. Dutch native, Western, Turkish, Moroccan, Surinamese, Antillean, and other non-Western defendants were compared with chi-square tests and logistic regression models. RESULTS: Psychotic and behavioural disorders were more prevalent among bme suspects, whereas all other psychiatric disorders occurred less frequently in the BME group. Compared to Dutch native suspects, BME suspects were more often deemed to be fully accountable for their actions. Antillean, Moroccan, Surinamese, and other non-Western suspects were more often recommended for compulsory admission to a psychiatric hospital or received no treatment and much less out-patient treatment. There were no ethnic differences with regard to the frequency with which suspects were recommended for compulsory admission to a penitentiary hospital or with regard to medication. CONCLUSION: Compared to Dutch native suspects, BME suspects are, on one hand, more often deemed accountable for their actions but, on the other hand, are more often recommended for compulsory admission to a psychiatric hospital.

[The current psychometric state of risk assessment scales for adults in the Netherlands]. / Psychometrische stand van zaken van risicotaxatie-instrumenten voor volwassenen in Nederland.

BACKGROUND: Although Dutch forensic psychiatry is making increasing use of structural risk assessment scales, the controversy about the value and usefulness of these instruments continues unabated. AIM: To provide an overview of the psychometric qualities of the instruments used most often in the Netherlands for risk assessment in adults. METHOD: Dutch data about the Historical, Clinical, and Risk Management (HCR-20), the Sexual Violence Risk-20 (SVR-20), the Psychopathy Checklist-Revised (PCL-R) and two Dutch instruments, the 'Historische, Klinische en Toekomstige Risico-indicatoren-30' (HKT-30) and the 'Forensisch Psychiatrische Profielen' (FP-40) were reviewed. In addition, data relating to the unstructured clinical judgement were studied. RESULTS: The inter-rater reliability values of the instruments discussed were in general satisfactory, but the internal consistency was often unsatisfactory. Except in some studies, the predictive validity was in general reasonable. CONCLUSION: At present, caution is called for with regard to the assessment of the risk of recividism when this is based purely on risk assessment scales or purely on the unstructured judgement. Perhaps it is simply not possible to predict recividism more accurately. Until there are some new developments in this area, it seems advisable to combine as many data as possible about a person under investigation derived from assessment scales and clinical judgement and to compare the outcome with the conclusions of the other professionals.

Measuring treatment outcome in patients with anxiety disorders: A comparison of the responsiveness of generic and disorder-specific instruments.

BACKGROUND: For routine outcome monitoring, generic (i.e., broad-based) and disorder-specific instruments are used to monitor patient progress. While disorder-specific instruments may be more sensitive to therapeutic change, generic measures can be applied more broadly and allow for an assessment of therapeutic change, irrespective of a specific anxiety disorder. Our goal was to investigate whether disorder-specific instruments for anxiety disorders are a valuable (or even necessary) addition to generic instruments for an appropriate assessment of treatment outcome in groups of patients. METHODS: Data were collected from 2002 to 2013 from psychiatric outpatients in treatment for Social Phobia (SP; n = 834), Generalized Anxiety Disorder (GAD; n = 661), Panic Disorder (PD; n = 944), Obsessive-Compulsive Disorder (OCD; n = 460), and Posttraumatic Stress Disorder (PTSD; n = 691). Instruments used were the generic Brief Symptom Inventory (BSI), The Mood and Anxiety Symptoms Questionnaire (MASQ), and several disorder-specific instruments (e.g., Social Interaction Anxiety Scale, Social Phobia Scale, Panic Appraisal Inventory, etc.). Responsiveness (i.e., sensitivity to therapeutic change) was examined through correlational analyses, effect sizes (ES), and analysis of variance for repeated measures. RESULTS: The MASQ appeared generally more responsive than the BSI, except for the BSI Anxiety subscale for PD. Disorder-specific measures equaled the MASQ and BSI in responsiveness. When statistically significant differences occurred, the ES was small. DISCUSSION/CONCLUSIONS: For most anxiety disorder groups (i.e., SP, PD and OCD), the MASQ or BSI was equally suited as disorder-specific instruments to detect change at group level. Exceptions are GAD and PTSD. These findings suggest limited incremental information value of disorder-specific instruments over the MASQ and BSI for measuring change.

The tripartite model for assessing symptoms of anxiety and depression: psychometrics of the Dutch version of the mood and anxiety symptoms questionnaire.

AIM: The tripartite model conceptualizes symptoms of depression and anxiety in three groups: low positive affect and anhedonia, which is specific to depression, somatic arousal, which is unique to anxiety, and nonspecific general distress. The Mood and Anxiety Symptoms Questionnaire (MASQ) was developed to measure these symptom domains. This study reports on the psychometric properties of the Dutch translation of the MASQ. METHOD: The questionnaire was completed by a population-based sample and by patients with anxiety and/or mood disorders. Scores of these respondent groups were compared to assess the discriminant validity of the MASQ and evaluate the appropriateness of the tripartite model. RESULTS: The psychometric properties of the translated MASQ were highly satisfactory. In accordance with the model, we found the MASQ to comprise three main scales, which discriminate well between subgroups of patients with mood and anxiety disorders. DISCUSSION: Overall, like the English version the Dutch translation of the instrument appears to be a reliable and valid measure of symptoms of depression and anxiety, conceptualized as comprising three groups of symptoms. The Dutch MASQ is better able to distinguish unique aspects of mood and anxiety disorders than other self-report instruments.

[The MINI-International Neuropsychiatric Interview. A brief structured diagnostic psychiatric interview for DSM-IV en ICD-10 psychiatric disorders]. / Het Mini Internationaal Neuropsychiatrisch Interview (MINI). Een kort gestructureerd diagnostisch psychiatrisch interview voor DSM-IV- en ICD-10-stoornissen.

The MINI-International Neuropsychiatric Interview (MINI(-Plus)) is a structured diagnostic interview, developed to assess the diagnoses of psychiatric patients according to DSM-IV and ICD-10 criteria in less time than other diagnostic interviews such as the Structured Clinical Interview for DSM-IV disorders (SCID), the Composite International Diagnostic Interview (CIDI) or the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) tend to take. The good psychometric characteristics of the MINI (-Plus) make it a good choice for research purposes. Because of its brevity (20-30 minutes) the interview seems to be especially convenient for diagnosing psychiatric patients in everyday clinical practice. Initial experiences and results with the MINI-Plus in a selected group of Dutch psychiatric patients are described.

Treatment of panic disorder with agoraphobia: comparison of fluvoxamine, placebo, and psychological panic management combined with exposure and of exposure in vivo alone.

OBJECTIVE: The purpose of this comparative outcome study was to investigate whether the effects of exposure in vivo treatment for panic disorder with agoraphobia could be enhanced by adding interventions specifically for panic attacks before the start of exposure treatment. The additional effect of two types of treatment for panic attacks--pharmacological (fluvoxamine) and psychological (repeated hyperventilation provocations and respiratory training)--was examined. Thus, the combined treatment of panic interventions with exposure in vivo could be compared to exposure in vivo alone. METHOD: Ninety-six patients were randomly assigned to four treatment conditions: double-blind, placebo-controlled fluvoxamine followed by exposure in vivo, psychological panic management followed by exposure, and exposure in vivo alone. Outcome was assessed by self-report measures, a standardized multitask behavioral avoidance test, and continuous monitoring of panic attacks. Seventy-six patients completed the study. RESULTS: All four treatments were effective and resulted in a significant decrease of agoraphobic avoidance. Moreover, the combination of fluvoxamine and exposure in vivo demonstrated efficacy superior to that of the other treatments and had twice as large an effect size (difference between pre- and posttreatment scores) on self-reported agoraphobic avoidance. The other treatments did not differ among each other in effectiveness. CONCLUSIONS: Results of the study indicate that the short-term outcome of exposure in vivo treatment can be enhanced by adding fluvoxamine treatment. Psychological panic management combined with exposure was not superior to exposure alone of equal duration.