Barriers and facilitators associated with the upscaling of the Transmural Trauma Care Model: a qualitative study.

BACKGROUND: To assess the barriers and facilitators associated with upscaling the Transmural Trauma Care Model (TTCM), a multidisciplinary and patient-centred transmural rehabilitation care model. METHODS: Semi-structured interviews were conducted with eight trauma surgeons, eight hospital-based physiotherapists, eight trauma patients, and eight primary care physiotherapists who were part of a trauma rehabilitation network. Audio recordings of the interviews were made and transcribed verbatim. Data were analysed using a framework method based on the "constellation approach". Identified barriers and facilitators were grouped into categories related to structure, culture, and practice. RESULTS: Various barriers and facilitators to upscaling were identified. Under structure, barriers and facilitators belonged to one of five themes: "financial structure", "communication structure", "physical structures and resources", "rules and regulations", and "organisation of the network". Under culture, the five themes were "commitment", "job satisfaction", "acting as a team", "quality and efficiency of care", and "patients' experience". Under practice, the two themes were "practical issues at the outpatient clinic" and "knowledge gained". CONCLUSION: The success of upscaling the TTCM differed across hospitals and settings. The most important prerequisites for successfully upscaling the TTCM were adequate financial support and presence of "key actors" within an organisation who felt a sense of urgency for change and/or expected the intervention to increase their job satisfaction. TRIAL REGISTRATION: NL8163 The Netherlands National Trial Register, date of registration 16-11-2019.

The introduction of advanced practice physiotherapy within Dutch primary care is a quest for possibilities, added value, and mutual trust: a qualitative study amongst advanced practice physiotherapists and general practitioners.

BACKGROUND: Despite the increased deployment and added value of Advanced Practitioner Physiotherapy (APP) in musculoskeletal care internationally, APP is not yet widely accepted within Dutch primary care. This may be due to specific constraints in the implementation of APP within the Dutch healthcare system. This study aimed to explore the experiences and perceptions of Advanced Practitioner Physiotherapists (APPs) and General Practitioners (GPs) with respect to implementing APP within Dutch primary care. METHODS: This explorative and interpretive qualitative study included 12 APPs and 3 GPs who were in various stages of implementing an APP care model. Semi-structured interviews were conducted between January and March 2021. The topic list was based on existing literature, the personal input of researchers, and the Constellation Approach framework. Data were analysed using a thematic inductive approach. RESULTS: Four main themes emerged from the data; 1) Both GPs' trust in APP and a clear added value of APP are critical for starting implementation, 2) APPs need continuous support from GPs, 3) APPs believe that their position needs strengthening, and 4) Implementation of the APP model creates tension over ownership. These four themes highlight the perceived difficulties in gaining trust, lack of clarity over the added value of APP, ambiguity over APPs' professional profile and positioning, a need on behalf of GPs to maintain authority, lack of reimbursement structure, and the struggle APPs face to strike a balance with current care. CONCLUSION: This study demonstrates that implementing an APP model of care is challenging, in part, because the deployment of APP does not sufficiently align with the core values of GPs, while GPs appear reluctant to hand over control of elements of patient care to APPs. APPs do not appear to have ownership over the implementation, given their strong dependence on the practice, values and needs of GPs. TRIAL REGISTRATION: Ethical approval was obtained from the Medical Ethics Committee of VU University Medical Centre in Amsterdam; reference number 2020.17 . All participants were asked to provide written informed consent prior to participating in the study.

How important is income in explaining individuals having forgone healthcare due to cost-sharing payments? Results from a mixed methods sequential explanatory study.

BACKGROUND: Patients having forgone healthcare because of the costs involved has become more prevalent in recent years. Certain patient characteristics, such as income, are known to be associated with a stronger demand-response to cost-sharing. In this study, we first assess the relative importance of patient characteristics with regard to having forgone healthcare due to cost-sharing payments, and then employ qualitative methods in order to understand these findings better. METHODS: Survey data was collected from a Dutch panel of regular users of healthcare. Logistic regression models and dominance analyses were performed to assess the relative importance of patient characteristics, i.e., personal characteristics, health, educational level, sense of mastery and financial situation. Semi-structured interviews (n = 5) were conducted with those who had forgone healthcare. The verbatim transcribed interviews were thematically analyzed. RESULTS: Of the 7,339 respondents who completed the questionnaire, 1,048 respondents (14.3%) had forgone healthcare because of the deductible requirement. The regression model indicated that having a higher income reduced the odds of having forgone recommended healthcare due to the deductible (odds ratios of higher income categories relative to the lowest income category (reference): 0.29-0.49). However, dominance analyses revealed that financial leeway was more important than income: financial leeway contributed the most (34.8%) to the model's overall McFadden's pseudo-R2 (i.e., 0.123), followed by income (25.6%). Similar results were observed in stratified models and in population weighted models. Qualitative analyses distinguished four main themes that affected the patient's decision whether to use healthcare: financial barriers, structural barriers related to the complex design of cost-sharing programs, individual considerations of the patient, and the perceived lack of control regarding treatment choices within a given treatment trajectory. Furthermore, "having forgone healthcare" seemed to have a negative connotation. CONCLUSION: Our findings show that financial leeway is more important than income with respect to having forgone recommended healthcare due to cost-sharing payments, and that other factors such as the perceived necessity of healthcare also matter. Our findings imply that solely adapting cost-sharing programs to income levels will only get one so far. Our study underlines the need for a broader perspective in the design of cost-sharing programs.

Treatment Outcome of Adolescent Inpatients With Early-Onset and Adolescent-Onset Disruptive Behavior.

OBJECTIVE: Unlike adolescents with adolescent-onset (AO) disruptive behavior, adolescents with early-onset (EO) disruptive behavior may not benefit from treatment. METHOD: Using Symptom Checklist (SCL-90-R) ratings at admission and discharge of adolescent inpatients with EO (n = 85) and AO (n = 60) disruptive behavior treatment outcome was determined by (a) a change in mean scores and (b) the Reliable Change Index. For a subgroup, ratings on the Satisfaction Questionnaire Residential Youth Care for Parents (n = 83) were used to verify the treatment outcome. RESULTS: Inpatients with EO disruptive behavior had a higher risk of dropout (44.4%) from treatment than the AO group (24.7%). Among the treatment completers, both onset groups reported improvements on the SCL-90-R, with 26.9% recovering and 31.7% improving. Inpatients who reported improvement were mostly rated as improved by their parents (r = .33). CONCLUSION: As EO inpatients are more likely to drop out, interventions should aim at motivating youngsters to continue treatment, particularly given the poor outcome in this group. Treatment may benefit both groups because those EO youths who stayed in treatment improved to the same extent as AO inpatients.

Is desire to eat in response to positive emotions an 'obese' eating style: Is Kummerspeck for some people a misnomer?

Is desire to eat in response to positive emotions an 'obese' eating style: a style more prevalent in people with obesity? In other words: Is Kummerspeck (German: sorrow-fat) for some people a misnomer? This question was addressed in three studies on women. Study 1 (n = 188) tested the moderator effect of subjective well-being on the association of BMI with the scale on desire to eat in response to negative emotions (DEBQ-E). Study 2 tested in women (n = 832) whether items on desire to eat in response to positive emotions loaded on the same factor as those in response to negative emotions and body mass. Study 3 assessed in the total sample (n = 203) and an overweight subsample (n = 40) a) whether self-reported desire to eat in response to positive emotions predicted actual food intake and b) whether this also held true over and above self-reported desire to eat in response to negative emotions. Study 1 showed only for women with low positive affect a significant positive association of BMI with DEBQ-E. In Study 2, only items on desire to eat in response to negative emotions loaded on the same factor as BMI. Study 3: In the total sample, the significant effect on food intake of the scale on desire to eat in response to positive emotions disappeared when a scale on desire to eat in response to negative emotions was added to the model. In the overweight-subsample there was only an effect on food intake for desire to eat in response to negative emotions. It is concluded that only desire to eat in response to negative emotions is an 'obese' eating style, suggesting that Kummerspeck is not a misnomer.

Validation of the SDQ in a multi-ethnic population of young children.

BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is a valuable screening tool for identifying psychosocial problems. Its performance in a multi-ethnic society, common to many paediatric health care workers, has not been investigated. Because it is important that screening instruments are valid and reliable for all ethnic groups within one society, we examined differences in the SDQ's psychometric properties in a multi-ethnic society. METHODS: The SDQ parent (n = 8114) and teacher form (n = 9355) were completed as part of a preventive health check for children aged 5-6 years of Dutch and non-Dutch ethnic backgrounds. The Child Behaviour Checklist (CBCL)/Teacher Report Form (TRF) was administered to a subsample. RESULTS: Factor analysis of the parent-rated SDQ showed different rating patterns for two of the five subscales for non-Dutch children as compared with Dutch children. Cronbach's alpha for the total difficulties score varied by ethnic group (0.73-0.78 parent-rated SDQ, 0.80-0.83 teacher-rated SDQ), and coefficients were generally smaller for non-Dutch than for Dutch children (P < 0.05). Alpha coefficients for subscales varied between 0.31-0.85 for ethnic groups. Inter-rater correlations between parents and teachers for the total difficulties score varied between 0.20-0.41 between ethnic groups and were larger for Dutch than for non-Dutch children (P < 0.05). Concurrent validity was acceptable for most scales and most ethnic groups. CONCLUSION: The total difficulties score of the parent- and teacher-rated SDQ is valid and reliable for different ethnic groups within Dutch society. However, there are differences in reliability and validity of the subscales, which makes interpretation of the subscales difficult for certain ethnic groups.

Ethnicity, socioeconomic position and severity of problems as predictors of mental health care use in 5- to 8-year-old children with problem behaviour.

BACKGROUND: Empirical research on mental health care use and its determinants in young school-aged children is still scarce. In this study, we investigated the role of ethnicity, socioeconomic position (SEP) and perceived severity by both parents and teachers on mental health care use in 5- to 8-year old children with emotional and/or behavioural problems. METHODS: Data from 1,269 children with a high score([P90) on the Strengths and Difficulties Questionnaire (SDQ) in the school year 2008­2009 were linked to psychiatric case register data over the years 2010­2011. Cox proportional hazards models were used to predict mental health care use from ethnicity, SEP and perceived severity of the child's problems. RESULTS: During the follow-up period, 117 children with high SDQ scores (9.2 %) had used mental health care for the first time. Ethnic minority children were less likely to receive care than Dutch children (HR Moroccan/Turkish:0.26; 95 % CI 0.13-0.54, HR other ethnicity: 0.26; 95 %CI 0.12-0.58). No socioeconomic differences were found.After correction for previous care use, ethnicity and parental perceived severity, impact score as reported by teachers was significantly associated with mental healthcare use (HR 1.58; 95 % CI 1.01­2.46). CONCLUSIONS: Ethnicity is an important predictor of mental health care use in young children. Already in the youngest school-aged children, ethnic differences in the use of mental health care are present.A distinct predictor of care use in this age group is severity of emotional and behavioural problems as perceived by teachers. Therefore, teachers may be especially helpful in the process of identifying young children who need specialist mental health care.

Ethnic differences in problem perception and perceived need as determinants of referral in young children with problem behaviour.

An underrepresentation of ethnic minority children in mental health care settings is consistently reported. Parents of ethnic minority children are, however, less likely to perceive problem behaviour in their children. Our hypothesis was that, as a result of ethnic differences in problem perception, referral to care by a child health professional (CHP) would be lower for 5- to 6-year-old (high-risk) children from ethnic minority backgrounds than for their peers from the ethnic majority (Dutch origin). For 10,951 children in grade two of elementary school, parents and/or teachers completed the Strengths and Difficulties Questionnaire (SDQ) as well as questions on problem perception (PP) and perceived need for professional care (PN). Referral information was obtained from the Electronic Child Records (ECR) for 1,034 of these children. These children had a high (>90th percentile) SDQ score, and were not receiving mental health care. CHP's referred 144 children (14 %) during the routine health assessments. A lower problem perception was reported by parents of ethnic minority children (40-72 %) than by parents of the ethnic majority group (80 %; p < 0.001), but there were no ethnic differences in referral (OR range 0.9-1.9-p > 0.05). No ethnic differences were found for parental PN, nor for teacher's PP or PN. Despite a lower problem perception in ethnic minority parents when compared to ethnic majority parents, no ethnic differences were found in referral of children with problem behaviour in a preventive health care setting.

A Guided, Internet-Based Stress Management Intervention for University Students With High Levels of Stress: Feasibility and Acceptability Study.

BACKGROUND: Transitioning to adulthood and challenges in university life can result in increased stress levels among university students. Chronic and severe stress is associated with deleterious psychological and physiological effects. Digital interventions could succeed in approaching and helping university students who might be at risk; however, the experiences of students with internet-based stress management interventions are insufficiently understood. OBJECTIVE: This study aims to explore the feasibility; acceptability; and changes in perceived stress, depressive symptoms, and quality of life from baseline to posttest assessment of a 5-session, internet-based stress management intervention guided by an e-coach, developed for university students experiencing high levels of stress. METHODS: A single-arm study was conducted. Students were recruited from different channels, mainly from a web survey. Students were eligible if they (1) scored ≥20 on the Perceived Stress Scale-10, (2) were aged ≥18 years, and (3) were studying at one of the participating universities. Feasibility and acceptability of the intervention were investigated using several indications, including satisfaction (Client Satisfaction Questionnaire-8) and usability (System Usability Scale-10). We also investigated the indicators of intervention adherence using use metrics (eg, the number of completed sessions). Our secondary goal was to explore the changes in perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9), and quality of life (EQ-5D-5L scale) from baseline to posttest assessment. In addition, we conducted semistructured interviews with intervention completers and noncompleters to understand user experiences in depth. For all primary outcomes, descriptive statistics were calculated. Changes from baseline to posttest assessment were examined using 2-tailed paired sample t tests or the Wilcoxon signed rank test. Qualitative data were analyzed using thematic analysis. RESULTS: Of 436 eligible students, 307 (70.4%) students started using the intervention. Overall, 25.7% (79/307) completed the core sessions (ie, sessions 1-3) and posttest assessment. A substantial proportion of the students (228/307, 74.3%) did not complete the core sessions or the posttest assessment. Students who completed the core sessions reported high satisfaction (mean 25.78, SD 3.30) and high usability of the intervention (mean 86.01, SD 10.25). Moreover, this group showed large reductions in perceived stress (Cohen d=0.80) and moderate improvements in depression score (Cohen d=0.47) and quality of life (Cohen d=-0.35) from baseline to posttest assessment. Qualitative findings highlight that several personal and intervention-related factors play a role in user experience. CONCLUSIONS: The internet-based stress management intervention seems to be feasible, acceptable, and possibly effective for some university students with elevated stress levels. However, given the high dropout rate and qualitative findings, several adjustments in the content and features of the intervention are needed to maximize the user experience and the impact of the intervention. TRIAL REGISTRATION: Netherlands Trial Register 8686; https://onderzoekmetmensen.nl/nl/trial/20889. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1016/j.invent.2021.100369.

Ethnic differences in problem perception and perceived need for care for young children with problem behaviour.

BACKGROUND: Problem perception and perceived need for professional care are important determinants that can contribute to ethnic differences in the use of mental health care. Therefore, we studied ethnic differences in problem perception and perceived need for professional care in the parents and teachers of 5- to 6-year-old children from the general population who were selected for having emotional and behavioural problems. METHODS: A cross-sectional study with data of 10,951 children from grade two of the elementary schools in the Rotterdam-Rijnmond area, The Netherlands. Parents and teachers completed the strengths and difficulties questionnaire (SDQ) as well as questions on problem perception and perceived need for care. The SDQ was used to identify children with emotional and behavioural problems. We included Dutch, Surinamese, Antillean, Moroccan and Turkish children in our sample with high (>P90) SDQ scores (N = 1,215), who were not currently receiving professional care for their problems. RESULTS: Amongst children with high SDQ scores, problem perception was lower in non-Dutch parents than in Dutch parents (49% vs. 81%, p < 0.01). These lower rates of problem perception could not be explained by differences in socioeconomic position or severity of the problems. No ethnic differences were found in parental perceived need and in problem perception and perceived need reported by teachers. Higher levels of problem perception and perceived need were reported by teachers than by parents in all ethnic groups (PP: 87% vs. 63% and PN: 48% vs. 23%). CONCLUSIONS: Child health professionals should be aware of ethnic variations in problem perception as low problem perception in parents of non-Dutch children may lead to miscommunication and unmet need for professional care for the child.

From theory to practice: intervention fidelity in a randomized controlled trial aiming to optimize weight development during pregnancy.

BACKGROUND: Intervention fidelity is an increasingly important methodological concept in process evaluations. In this article, the authors investigated the intervention fidelity in a randomized controlled trial on excessive weight gain prevention in pregnancy. METHOD: A sample of 109 audiotaped counseling sessions, linked to 65 women in the intervention group of the New Life(style) trial, was drawn. The following criteria were quantitatively evaluated using a fidelity checklist: (a) reach, (b) dose, (c) adherence to study objectives, (d) adherence to underlying problem-solving treatment (PST) theory, and (e) counselor competence. RESULTS: A total of 60.4% received all counseling sessions. The dose of intervention components was generally moderate (50.9% to 60.4%), and the dose of PST components was low (17.3%). Adherence to study objectives was moderate (64.2%) and adherence to PST theory was low (43.2%). The counselors sufficiently stimulated the participant to optimize lifestyle (54.2% of the sessions), provided positive feedback (50.5%), and left the initiative regarding problem solving to the participant (71%). One of the two counselors performed significantly better on all measured criteria (p < .001). CONCLUSIONS: Intervention fidelity in the New Life(style) trial was generally low to moderate. In future interventions, it is recommended to put more emphasis on counselor recruitment, training, and intervention protocol contents. Fellow researchers are encouraged to embed a process evaluation into all study stages, taking into account all essential process elements, and to link process outcomes to more distal, health outcomes.

The Transmural Trauma Care Model can be implemented well but some barriers and facilitators should be considered during implementation: a mixed methods study.

QUESTIONS: What is the reach, dose delivered, dose received and fidelity of the Transmural Trauma Care Model (TTCM)? What are the barriers and facilitators associated with the implementation of the TTCM? DESIGN: Mixed-methods process evaluation with quantitative evaluation of the extent to which the TTCM was implemented as intended and qualitative evaluation of barriers and facilitators to its implementation. PARTICIPANTS: Focus group participants included trauma patients, trauma surgeons, hospital-based physiotherapists and primary care network physiotherapists. OUTCOME MEASURES: Implementation was assessed with reach, dose delivered, dose received and fidelity. DATA ANALYSIS: A framework method was used to analyse the focus groups and the 'constellation approach' was used to categorise barriers and facilitators into three categories: structure, culture and practice. RESULTS: The TTCM's reach was 81%, its dose delivered was 99% and 100%, and its dose received was 95% and 96% for the multidisciplinary TTCM consultation hours at the outpatient clinic for trauma patients and the primary care network physiotherapists, respectively. Various fidelity scores ranged from 66 to 93%. Numerous barriers and facilitators associated with the implementation of the TTCM were identified and categorised. CONCLUSION: This process evaluation showed that the TTCM was largely implemented as intended. Furthermore, various facilitators and barriers were identified that need to be considered when implementing the TTCM more widely. Differences were found among stakeholders but they were generally of the opinion that if the barriers were overcome, the quality of care and patient satisfaction were likely to improve significantly after implementing the TTCM. REGISTRATION: NTR5474.

The quality of treatment of eating disorders: a comparison of the therapists' and the patients' perspective.

OBJECTIVE: The aims of this study were to investigate the quality of treatment of eating disorders (EDs) from the therapists' and patients' perspective and to compare their views. METHOD: The Questionnaire for Eating Problems and Treatment (QEPT) was administered to 73 therapists working with patients with ED, to 156 current ED and 148 former ED patients. The QEPT addresses the quality of treatment of EDs. ED diagnosis was assessed by the Eating Disorder Examination Questionnaire. Answers were analyzed quantitatively and qualitatively. RESULTS: Both therapists and patients most often mentioned focus of treatment, therapeutic alliance, and communicational skills as important aspects of the quality of treatment. However, they valued similar topics differently. Therapists valued the focus on ED symptoms and behavioral change more highly, whereas patients underscored the importance of the therapeutic relationship and addressing underlying problems. Most therapists work from a cognitive behavioral orientation, but protocol-based treatment was not found important. CONCLUSION: There is an avid need for dissemination of evidence-based treatment. Therapists' and patients' views supplement current evidence-based knowledge on treatment quality of EDs. Optimal treatment of EDs will be facilitated when these three bodies of knowledge-the available evidence and the therapists' and patients' views-are integrated.

Examining differential effects of psychological treatment of depressive disorder: an application of trajectory analyses.

BACKGROUND: Although different psychological treatments of depression seem equally effective, studies in this area have not taken sufficient account of the heterogeneity among patients. Modern techniques for longitudinal data analysis can be helpful in examining differential effects of psychological interventions on specific subpopulations of patients. METHODS: Outpatients in mental health care, diagnosed with DSM-IV major depressive disorder, were randomly assigned to cognitive behavior therapy (N=199) or treatment as usual (N=226). Every 3 months for a total of 1.5 years, depressive symptomatology was measured using the SCL-90. Growth mixture modeling techniques were used to identify different trajectory classes of patients. The impact of type of treatment (treatment as usual vs. cognitive behavior therapy) was examined for each identified trajectory. RESULTS: On average, patients in both test conditions improved significantly from baseline to posttest, and no significant difference was found between the conditions. However, four different trajectory classes could be distinguished within the sample. Most patients were classified into the two classes with the lowest depression scores at baseline (31% and 33% of the total sample). For these two classes, no significant differences in the course of depressive symptoms were found between the two conditions. In the two classes with the more severe depression scores (10% and 26% of the sample), however, cognitive behavior therapy was significantly more effective than treatment as usual. CONCLUSIONS: Although different treatments may seem to be equally effective, this does not have to be true for all classes of patients. Longitudinal research on the treatment of mental disorders should take heterogeneity among patients into account.

Length of hospital stay and health services use of medical inpatients with comorbid noncognitive mental disorders: a review of the literature.

We reviewed 23 studies on the association between noncognitive mental disorders and the use of general health care services by medical patients admitted to a general hospital. Only studies with a prospective design and with a correction for possible confounding factors were included. In most studies, only service use during index admission was observed, but eight studies included a longer observation period during follow-up after hospital discharge. The 15 studies that were restricted to service use during index admission showed mixed results: length of hospital stay was related to common mental disorders in some studies, but other studies did not find such an association. The eight studies that used a longer observation period showed findings that are more consistent. They demonstrated mainly that symptoms or complaints of depression are related to a higher resource use within general medical services.

Personality traits of patients with mood and anxiety disorders.

Although it is well established that personality traits of patients with mental disorder differ significantly from the traits of other persons, differences in personality characteristics between different mental disorders have not been examined very thoroughly. In this study, we examine personality traits in a large sample of outpatients (N=640) with mood and anxiety disorders in differing patterns of comorbidity, using the five-factor model of personality. Mood and anxiety disorders were assessed using the Composite International Diagnostic Inventory, and personality traits were assessed with the NEO Five-Factor Inventory (NEO-FFI). Most of the mean scores on the NEO-FFI scales of the study population were found to be significantly different from the scale scores of the general population. Few differences between NEO-FFI scores for differing patterns of mood and anxiety disorders were found. However, clear differences were found for subjects with one (mood or anxiety) disorder, subjects with two, and subjects with three or more disorders. Neuroticism and agreeableness differed considerably in subjects with one disorder compared with subjects with two or more disorders. The main conclusion is that personality traits appear to be associated with comorbidity and less so with any specific disorder.

Validity and reliability of the strengths and difficulties questionnaire in 5-6 year olds: differences by gender or by parental education?

INTRODUCTION: The Strengths and Difficulties Questionnaire (SDQ) is a relatively short instrument developed to detect psychosocial problems in children aged 3-16 years. It addresses four dimensions: emotional problems, conduct problems, hyperactivity/inattention problems, peer problems that count up to the total difficulties score, and a fifth dimension; prosocial behaviour. The validity and reliability of the SDQ has not been fully investigated in younger age groups. Therefore, this study assesses the validity and reliability of the parent and teacher versions of the SDQ in children aged 5-6 years in the total sample, and in subgroups according to child gender and parental education level. METHODS: The SDQ was administered as part of the Dutch regularly provided preventive health check for children aged 5-6 years. Parents provided information on 4750 children and teachers on 4516 children. RESULTS: Factor analyses of the parent and teacher SDQ confirmed that the original five scales were present (parent RMSEA = 0.05; teacher RMSEA = 0.07). Interrater correlations between parents and teachers were small (ICCs of 0.21-0.44) but comparable to what is generally found for psychosocial problem assessments in children. These correlations were larger for males than for females. Cronbach's alphas for the total difficulties score were 0.77 for the parent SDQ and 0.81 for the teacher SDQ. Four of the subscales on the parent SDQ and two of the subscales on the teacher SDQ had an alpha <0.70. Alphas were generally higher for male children and for low parental education level. DISCUSSION: The validity and reliability of the total difficulties score of the parent and teacher SDQ are satisfactory in all groups by informant, child gender, and parental education level. Our results support the use of the SDQ in younger age groups. However, some subscales are less reliable and we recommend only to use the total difficulties score for screening purposes.

Childhood Characteristics of Adolescent Inpatients with Early-Onset and Adolescent-Onset Disruptive Behavior.

Childhood characteristics are associated with life-course-persistent antisocial behavior in epidemiological studies in general population samples. The present study examines this association in an inpatient sample. The purpose is to identify easily measurable childhood characteristics that may guide choice of treatment for adolescent psychiatric inpatients with severe disruptive behavior. Patients (N = 203) were divided into two groups with either early-onset (EO) or adolescent-onset (AO) disruptive behavior, based on ages at which professional care was used for disruptive behavior, referral to special education, and criminal offences. Both groups differed on several childhood characteristics. No gender differences in these characteristics were found. Logistic regression analysis indicated that individuals with grade retention in primary school, childhood impulsive behavior, and a history of physical abuse, had the highest probability of being member of the EO group. These characteristics are reasonably easy to identify, likely apply to other clinical samples as well, and may help clinicians to target their treatment.

A stepped care programme for depression management: an uncontrolled pre-post study in primary and secondary care in The Netherlands.

INTRODUCTION: Stepped care strategies are potentially effective to organise integrated care but unknown is whether they function well in practice. This paper evaluates the implementation of a stepped care programme for depression in primary care and secondary care. THEORY AND METHODS: We developed a stepped care algorithm for diagnostics and treatment of depression, supported by a liaison-consultation function. In a 2(1/2) year study with pre-post design in a pilot region, adherence to the protocol was assessed by interviewing 28 caregivers of 235 patients with mild, moderate, or severe major depression. Consultation and referral patterns between primary and secondary care were analysed. RESULTS: Adherence of general practitioners and consultant caregivers to the stepped care protocol proved to be 96%. The percentage of patients referred for depression to secondary care decreased significantly from 26% to 21% (p=0.0180). In the post-period more patients received treatment in primary care and requests for consultation became more concordant with the stepped care protocol. CONCLUSIONS: Implementation of a stepped care programme is feasible in a primary and secondary care setting and is associated with less referrals. DISCUSSION: Further research on all subsequent treatment steps in a standardised stepped care protocol is needed.

The patient's view on quality of life and eating disorders.

OBJECTIVE: This study investigated the personal views of eating disorder (ED) patients on their quality of life (QOL). METHOD: The views of 146 current ED patients and 146 former ED patients on their QOL were studied using a self-report questionnaire. Patients were requested to name the most important aspects of their life and they subsequently rated themselves on these aspects. Qualitative analysis clustered items into meaningful categories. RESULTS: A sense of belonging was mentioned most often (93.0%) by the participants. Work or education, health and well-being were also mentioned frequently. Furthermore, participants stated a sense of self, disease-specific psychopathology, life skills, leisure activities, a sense of purpose, financial situation, living condition, and pets. Current ED patients more frequently mentioned disease-specific psychopathology than former ED patients. Current ED patients reported poor QOL on most domains, particularly on self-image and well-being. Former ED patients reported better QOL than current ED patients, but ratings were just above average. CONCLUSION: The views on QOL of ED patients broadens the scope of relevant domains of QOL. The assessment of these views may be a useful adjunct to the use of standardized QOL measures.