[Prediction of care consumption in addiction care; better with MATE intake-instrument than with DSM scores, but insufficient to base funding on]. / Voorspelling van de zorgconsumptie in de verslavingszorg; met MATE-intake-instrument beter dan met DSM-scores, maar onvoldoende als basis voor bekostiging.

background The ability to predict the level of care (care burden) on the basis of patient characteristics is important for both the indication for treatment and the funding of mental healthcare. Within the framework of an administrative agreement in mental healthcare, a care demand intensity model 1.0 was developed. However, since the predictive power of this model is rather limited it remains controversial. aim To ascertain whether prediction of the level of care using the care demand intensity model can be improved by using more and more precise patient characteristics. method Comparison between the care burden estimate based on patient characteristics at intake into an addiction care institute and the care burden estimate determined by the indicators in the care demand intensity model. results Taking into account both the increasing number and more precise patient characteristics at intake in addiction care explained a considerably larger proportion of the variance in care consumption than the care demand intensity model 1.0.
CONCLUSION: The estimate of the consumption of care can be greatly improved but remains an insufficient tool upon which to base funding.

[Why Dutch mental health care practitioners should have second thoughts about adopting the English cluster model]. / Het 'Engelse model' in de ggz ­ a fairy tale?

BACKGROUND: Administrators and policymakers in the Netherlands have concluded, after considerable deliberation, that the existing Dutch diagnosis-related group (drg)-based system of diagnosis treatment combinations for funding mental health care should be replaced by the so-called English model. The details, however, need to be analysed very carefully by Dutch professional health care practitioners.
AIM: To make the reader aware of the reasons why the English model should not be adopted in the Netherlands.
METHOD: We describe and analyse the English cluster model and the referral instrument (the Honos, supplemented by six items) and we demonstrate how it is applied in England. We also describe and analyse the actions and activities pursued by the Dutch Healthcare Authority (nza) to introduce the model in the Netherlands.
RESULTS: There are strong objections to the English model. One of the most important is that the mental health care system will suffer when its connections are severed between its funding sources from internationally recognised and scientifically important classification systems such as dsm, icd and icf. Another major objection is that the proposed clustering system is conceptually weak and is not based on convincing analyses. Furthermore, the Honos is an instrument for measuring outcomes and is not appropriate for assigning patients to specific types of care. In England the model is very rarely used as an instrument for assigning patients to care.
CONCLUSION: Dutch mental health care practitioners should have second thoughts about deciding to adopt the English model.

[Staging and profiling in addication]. / Stagering en profilering bij verslaving.

BACKGROUND: The existence or non-existence of the formal diagnosis 'substance' or 'dependence' is in fact of little consequence in terms of the severity of the affliction, the course of the disorder and the response to a specific type of treatment. Furthermore, the effective treatments that are currently available seem to work only in a minority of the patients in routine clinical practice. A possible reason for these discrepancies is too much heterogeneity within the diagnostic categories. The planned merging of the diagnoses 'substance abuse' and 'dependence' into a single diagnostic category 'substance use disorder' in DSM-5 is likely to increase the heterogeneity still further. AIM: To provide suggestions for improvement of diagnosis and treatment through staging and profiling of addiction and dependency. METHOD: Study of the relevant literature. RESULTS: A possible solution is to reduce the heterogeneity by the introduction of staging and profiling. Therefore, we present a model for addiction which is based on existing models in oncology and on current knowledge about the neurobiology of addiction. In addition, we demonstrate in what way individual patients with an addiction can be characterised and profiled in more detail through the use of phenotypical, endophenotypical and genetic information. CONCLUSION: The combination of diagnosis, staging and profiling will lead to more effective and efficient treatment for patients suffering from addiction.

[Five years of ROM in substance abuse treatment centres in the Netherlands]. / Vijf jaar 'routine outcome management' in de ambulante verslavingszorg.

BACKGROUND: Three substance abuse treatment centres set up a benchmarking project for routine outcome management (ROM) of structured cognitive behavioral treatments for outpatients with a substance use disorder. AIM: To present the results of five years benchmarking. METHOD: All patients were included at intake and the follow-up assessment was performed by a call-center nine months later. Twice a year aggregated data were fed back to management and treatment teams. RESULTS: Since 2005, clinical outcome data, including substance abuse data, have been collected for more than half of all 15.786 treated patients. At follow-up, nine months after intake, 23% was abstinent, 28% reported moderate substance use and 49% reported excessive substance use. CONCLUSION: The Dutch centres for the treatment of substance abuse were successful in setting up ROM projects to monitor and compare the development and the effects of outpatient addiction treatments. The clinical results are acceptable and correspond to the results of the American project called match. It is not yet clear whether the biannual feedback of aggregated outcomes to management and treatment teams has contributed to the creation of learning organisations, but it has provided transparency and has made it possible for teams to learn from the outcomes.

[Routine outcome monitoring and benchmarking: how can treatment results be compared in a responsible manner?]. / Routine outcome monitoring en benchmarking: hoe kunnen we behandelresultaten op een zorgvuldige manier vergelijken?

BACKGROUND: The structural measurement of the results of treatment under the Dutch mental health services and a comparison of these results between mental health centres help to provide insight into the effectiveness of treatment in general practice. AIM: To provide an overview of the issues that require attention when the results of mental health centres are being compared. METHOD: Documentation, policy information and practical experience with routine outcome monitoring were analysed. RESULTS: We describe the problems that can arise when results obtained by mental health centres are compared and we suggest some solutions for these problems. Important factors that have emerged from our study are as follows: working with routine outcome monitoring is a process of natural growth and involves experiences with several solutions and the making of definitive choices on the basis of experience. CONCLUSION: It is instructive to compare mental health centres with each other and with regards to so-called 'best practices' (benchmarking). However, mental health centres draw on a differing wide mix of patients and use different measurement procedures and instruments. In this article we express the view that in the near future it should be possible to draw meaningful comparisons.

The lifestyle of patients with chronic fatigue syndrome and the effect on fatigue and functional impairments.

BACKGROUND: Little is known about the lifestyle of patients with chronic fatigue syndrome (CFS) and its influence on symptoms of CFS. The present study aimed to investigate the lifestyle of patients with CFS, and to assess whether lifestyle factors are related to fatigue and functional impairments. METHODS: Two hundred and forty-seven patients fulfilling the Center for Disease Control criteria for CFS were included. Validated questionnaires were used to collect data on lifestyle factors, smoking, intake of alcohol, fat, fibres, fruit and vegetables, body mass index (BMI), fatigue severity and functional impairments. RESULTS: Of the CFS patients, 23% smoked, 32% had an unhealthy BMI, and none had an unhealthy alcohol intake. A majority had an unhealthy food intake: 70% had unhealthy fat, fruit and vegetable intake, and 95% had unhealthy fibre intake. Compared with the general Dutch population, significantly fewer CFS patients were overweight. Significantly more female CFS patients abstained from alcohol, and fewer male CFS patients smoked. Unhealthy lifestyle factors were not significantly associated with fatigue severity or functional impairments. CONCLUSIONS: CFS patients tend to lead a healthier lifestyle compared to the general Dutch population. However, no relationship was found between lifestyle factors and fatigue severity and functional impairments in CFS.

[Addiction and care for addicts]. / Verslaving en verslavingszorg.

In the course of the last 50 years our knowledge about the epidemiology, aetiology, pathogenesis, prevention, and treatment of addiction has increased dramatically. Since the 1980s treatment providers have had at their disposal effective psychotherapeutic interventions whereby insightful forms of treatment have been largely replaced by cognitive behavioural therapy aimed at bringing about changes in behaviour. Since the 1990s more and more pharmacological interventions have also been introduced and recently some new neurophysiological interventions have been carefully tested. Finally, considerable progress has been made in assigning patients to the most suitable forms of treatment.

How to optimise interventions for problem drinking among hospital outpatients?

In this article several suggestions on how to optimise interventions for problem drinking among hospital outpatients are enumerated. These interventions are especially important for patients with diagnoses that are alcohol related. The intervention has to be brief and easy to integrate into medical specialist's routine practice; an active role for the medical specialist and flexible involvement of a specialised nurse are suggested. Key elements of the intervention are: early identification of problem drinking; raising the issue of problem drinking; assessment of the drinking behaviour; reaching an agreement about change; follow-up; evaluation of the change. A feasible and attractive option is integrating the intervention into a broader lifestyle intervention. Those who perform the brief alcohol intervention need to be specially educated and trained.

[The practice guideline: 'Treatment of tobacco dependence']. / Richtlijn 'Behandeling van tabaksverslaving'.

The interdisciplinary guideline 'Treatment of tobacco dependence' discusses the approach to smoking patients. The point of departure is the concept that smoking is an addiction and that its treatment should be based on this fact. The effectiveness of treatment depends on the patient's motivation to stop smoking and on the intensity of the intervention. Pharmacotherapy may be of added value here, particularly for persistent smokers. The guideline aims at reaching as many smoking patients as possible, regardless of whether there is a relationship between their symptoms or ill health and smoking. Practitioners should ask about smoking habits regularly and smokers should be advised at least once to stop. Further treatment and guidance aims in particular to increase the motivation to quit and at those who are prepared to stop on the basis of the stages-of-change model. More intensive possibilities for treatment, by both general practitioners and specialists, are needed for persistent smokers. Such facilities are hardly available at all in The Netherlands at present, but will have to be developed to make the cost-effective treatment of tobacco addiction possible on a large scale.

Retention in substance dependence treatment: the relevance of in-treatment factors.

In addition to "fixed" patient demographic and background variables, treatment process constructs play an important role in the prediction of treatment retention in substance dependence treatment. The objective of this paper is to analyze the predictive role of repeated measures of treatment readiness and behavioral intention, and of patients' perception of the therapeutic alliance, while controlling for fixed patient-oriented variables. Ninety-three patients, both alcohol and drug dependents, enrolled in this study, which was conducted in an inpatient treatment setting. Patients completed questionnaires shortly after admission (t=0) and approximately 2 weeks later (t=1). Using these measures, 35% of variance of a length of stay in treatment of up to 30 days could be explained. Fixed patient-oriented variables accounted for 21% of variance. Of the cognitive factors, helping alliance was the most important, accounting for an additional 8% of variance. The implications of these results are discussed.

Supporting smoking cessation in the medical specialist practice.

Although smoking cessation reduces the cardiovascular risk of smoking, why this is so is still uncertain. Nevertheless, because they are strongly and authoritatively involved in much of the serious health damage caused by smoking, medical specialists should do all they can to support their patients in stopping. This indispensable support can be improved, however, when specialists adapt more motivational and behaviour change promoting attitudes and communicative techniques.

On the relationship between emotional and external eating behavior.

Although there is a strong relationship between emotional and external eating, separate subscales for these behaviors have been constructed in the Dutch Eating Behavior Questionnaire. This study tries to establish whether this distinction is justified. We studied relationships among self-reported ( 1) degree of emotional and external eating behavior and (2) problems with (a) emotional distress and relationships, (b) stimulus-boundness (inappropriate amounts of either too much or too little exercise, work, leisure activities, and spending money), and (c) problems with substance use (alcohol, illicit drugs, nicotine, or caffeine) in a sample of female students. No relationships were found between either type of eating behavior and problems with substance use. Furthermore, the significant relationship between emotional and external eating behavior and stimulus-boundness disappeared in the subsample who had problems with overeating. The fact that in all samples emotional eating was significantly related to problems with emotional distress and relationships (anxiety, depression, phobias, suicidal acts or ideations, intimate relations, and sexual contacts) but external eating was not, suggests that the two types of eating behaviors refer to independent constructs. Thus, the use of separate scales to measure these theoretically different aspects of overeating seems warranted.

Enrollment in a drug-free detention program: the prediction of successful behavior change of drug-using inmates.

Factors predicting the behavior change of drug-using detainees were investigated in detainees in two penitentiaries in The Netherlands. Subjects attended either a standard program or a Drug-Free Detention Program (DFDP) and were assessed at the beginning of detention, at release/transfer, and at 2 years after the end of detention. Predictors of postprogram contact with treatment agencies and changes in criminal recidivism, substance abuse, and psychosocial functioning were investigated using regression analysis. Detainees who started drug use early, without previous DFDP detention, and who frequently expressed self-esteem and who had many family problems realized meetings with drug treatment agencies more often. Those with a legal source of income showed decreases in addiction severity and in the number of days in which hard drugs were used. Comparison of the normal program and the DFDP showed that only for the normal wing could changes in substance use and psychosocial functioning be predicted. Results show the value of multiple-outcome criteria in criminal recidivism research and call for more studies investigating change processes.

Effects of alcohol and expectancy on self-disclosure and anxiety in male and female social drinkers.

To study the effects of alcohol consumption and expectancy on self-disclosure and self-reported anxiety during a social interaction, 32 male and 32 female social drinkers were assigned to one of four groups comprising a 2 x 2 factorial balanced-placebo design. Alcohol expectancy reduced the intimacy level of self-disclosure but not the amount of self-disclosure. Alcohol consumption had no effect. Thus, in contrast to the common view that alcohol functions as a "social lubricant," it served to inhibit social interaction. There was a three-way interaction among alcohol consumption, expectancy, and gender of subjects, such that the largest increase in anxiety was reported by male subjects who expected but did not receive alcohol. Thus, the previously reported inverse relationship between anxiety and self-disclosure was not confirmed, and alcohol's effect on anxiety seems unrelated to its effect on self-disclosure.

The effects of alcohol, expectancy, and alcohol beliefs on anxiety and self-disclosure in women: do beliefs moderate alcohol effects?

This study investigates the effects of alcohol, expectancy, and alcohol-related beliefs on self-reported anxiety and self-disclosure behavior in a social interaction situation. Seventy-two female social drinkers were assigned to eight conditions in a 2 x 2 x 2 factorial balanced-placebo design, controlling for drink content, expectancy, and beliefs. Results show that alcohol expectancy resulted in an anxiety reduction in subjects who believed that alcohol has a positive influence on social behavior, whereas expectancy had no effect in subjects with negative alcohol beliefs. Furthermore, subjects who expected alcohol were less anxious when they had positive alcohol beliefs than when they had negative beliefs, whereas beliefs made no difference in subjects who expected tonic. Our results suggest that the effect of alcohol expectancy on social anxiety in women is moderated by differences in the content of their alcohol-related beliefs. We conclude that the inconsistency in previous results about the effect of alcohol expectancy on social behavior might be explained by differences in subjects' alcohol beliefs. Finally, as neither of the three factors had any effect on self-disclosure behavior, we suggest that this behavioral measure is unrelated to self-reported anxiety.

The validity of the Self-Efficacy List for Drug Users (SELD).

In this study we evaluated the psychometric properties of the Self-Efficacy List for Drug users (SELD). Exploratory and confirmatory factor analyses on separate subject samples revealed that drug-users' self-efficacy was best described by three correlated dimensions: environmental factors, negative mood, and positive mood. The validity of this three-factor solution was supported by the pattern of associations with severity of drug use as assessed by the Addiction Severity Index. In addition, lower self-efficacy scores were related to a higher number of days of experiencing problems related to drug use. In conclusion we state that the SELD is a reliable and valid instrument to measure abstinence self-efficacy in drug users.

Alcohol and social anxiety in women and men: pharmacological and expectancy effects.

A replication study was conducted to determine pharmacological and expectancy effects of alcohol on self-reported anxiety in a social interaction situation. Thirty-two male and thirty-two female social drinkers were randomly assigned to four conditions in a 2 x 2 factorial balanced placebo design, controlling for drink content and expectations. Results show that in women alcohol expectancy reduced self-reported anxiety, whereas in men there was no significant effect of expectancy. Alcohol consumption reduced anxiety in both men and women. Controlling for beliefs increased some of the effects we found. We conclude that although cognitive factors do mediate the effects of alcohol on self-reported anxiety, this influence seems to be different for men and women and the role of pharmacological factors might be more crucial.

No effect of negative mood on the alcohol cue reactivity of in-patient alcoholics.

Forty in-patient alcoholics were exposed to an alcohol cue (holding and smelling an alcoholic drink) while in a negative mood, and while in a neutral mood. For the negative mood condition either a distressing or depressing Mood Induction Procedure (MIP) was used. In the control condition, a neutral MIP was used. In the negative mood condition, the subjects were found to be more distressed, more irritated, less calm, and less satisfied than in the neutral mood condition. In all conditions, following exposure to the alcohol cue, the desire to drink, systolic blood pressure, and heart rate variability increased, while self-efficacy beliefs to resist the urge to drink, and heart rate decreased. In sum, alcohol cue reactivity was observed, but not in response to a negative as opposed to a neutral mood or a distressed versus a depressed mood.

[Life style intervention for patients with alcohol-related somatic problems]. / Leefstijlinterventie bij patiënten met alcoholgerelateerde somatische problemen.

Three patients suffered from somatic complaints related to excessive alcohol use. For the first patient, a 42-year-old man, the simple advice to quit drinking was enough for him to stop. A second patient, a 61-year-old woman, continued to deny drinking excessively despite several signs of excessive alcohol use. The third patient, a 45-year-old man, changed his drinking behaviour after receiving lifestyle intervention from the internist. All three patients needed a structural intervention to tackle the drinking problems in addition to medical treatment. The first lifestyle-intervention session takes 10 minutes and subsequent sessions take 5 minutes each. The intervention includes five elements: screening, placing on the agenda, inventory, making an appointment about change and reverting to the appointment about change. A trained nurse could also perform part of the intervention. Although lifestyle interventions seem to be expensive and time-consuming activities in the short-term, in the longer term they save time and money and lead to a satisfactory result for both the patient and physician.