Weak self-directed learning skills hamper performance in cumulative assessment.

BACKGROUND: Self-regulated learning is an important determinant of academic performance. Previous research has shown that cumulative assessment encourages students to work harder and improve their results. However, not all students seem to respond as intended. We investigated the influence of students' behavioral traits on their responsiveness to a cumulative assessment strategy. METHOD: The cumulative test results of a third-year integrated ten-week course unit were analyzed. The test was divided into three parts delivered at 4, 8 and 10 weeks. Low starters (below median) with low or high improvement (below or above the median) were identified and compared regarding their behavioral traits (assessed with the Temperament and Character Inventory questionnaire). RESULTS: A total of 295 students filled out the questionnaire. A percentage of 70% of the students below the median on the first two test parts improved during the final part. Students who were less responsive to improve their test results, scored low only on the TCI scale "self directedness" (t = 2.49; p = 0.011). CONCLUSION: Behavioral traits appear to influence student reactions to feedback on test results, with students with low self-directedness scores being particularly at risk. They can thus be identified and should receive special attention from student counselors.

Risk assessment by client and case manager for shared decision making in outpatient forensic psychiatry.

BACKGROUND: In outpatient forensic psychiatry, assessment of re-offending risk and treatment needs by case managers may be hampered by an incomplete view of client functioning. The client's appreciation of his own problem behaviour is not systematically used for these purposes. The current study tests whether using a new client self-appraisal risk assessment instrument, based on the Short Term Assessment of Risk and Treatability (START), improves the assessment of re-offending risk and can support shared decision making in care planning. METHODS: In a sample of 201 outpatient forensic psychiatric clients, feasibility of client risk assessment, concordance with clinician assessment, and predictive validity of both assessments for violent or criminal behaviour were studied. RESULTS: Almost all clients (98 %) were able to fill in the instrument. Agreement between client and case manager on the key risk and protective factors of the client was poor (mean kappa for selection as key factor was 0.15 and 0.09, respectively, and mean correlation on scoring -0.18 and 0.20). The optimal prediction model for violent or criminal behaviour consisted of the case manager's structured professional risk estimate for violence in combination with the client's self-appraisal on key risk and protective factors (AUC = 0.70; 95%CI: 0.60-0.80). CONCLUSIONS: In outpatient forensic psychiatry, self-assessment of risk by the client is feasible and improves the prediction of re-offending. Clients and their case managers differ in their appraisal of key risk and protective factors. These differences should be addressed in shared care planning. The new Client Self-Appraisal based on START (CSA) risk assessment instrument can be a useful tool to facilitate such shared care planning in forensic psychiatry.

Predictive validity of the Short-Term Assessment of Risk and Treatability for violent behavior in outpatient forensic psychiatric patients.

It remains unclear whether prediction of violence based on historical factors can be improved by adding dynamic risks, protective strengths, selection of person-specific key strengths or critical vulnerabilities, and structured professional judgment (SPJ). We examine this in outpatient forensic psychiatry with the Short-Term Assessment of Risk and Treatability (START) at 3 and 6 months follow-up. An incident occurred during 33 (13%) out of 252 3-month and 44 (21%) out of 211 6-month follow-up periods (n = 188 unique clients). Pearson correlations for all predictor variables were in the expected directions. Prediction of recidivism based on historical factor ratings (odds ratio [OR] = 1.10) could not be improved through the addition of dynamic risk, protective strength, or key or critical factor scores (all ORs ns). The addition of the SPJ improved the model to modest accuracy (area under the curve [AUC] = .64) but made no independent significant contribution (OR = 1.55, p = .21) for the 3-month follow-up. For the 6-month follow-up, SPJ scores also increased predictive accuracy to modest (AUC = .67) and made a significant independent contribution to the prediction of the outcome (OR = 1.98, p = .04). Multicollinearity limits were unviolated. Limitations apply, however, results are similar to those from clinical, researcher rated samples and are discussed in the light of setting specific characteristics. Although it is too early to advocate implementing risk assessment instruments in clinical practice, we can conclude that clinicians in a heterogeneous outpatient forensic psychiatric setting can achieve similar results with the START as clinicians and research staff in more homogeneous inpatient settings.

The effectiveness of EEG-feedback on attention, impulsivity and EEG: a sham feedback controlled study.

EEG-feedback, also called neurofeedback, is a training procedure aimed at altering brain activity, and is used as a treatment for disorders like Attention Deficit/Hyperactivity Disorder (ADHD). Studies have reported positive effects of neurofeedback on attention and other dependent variables. However, double-blind studies including a sham neurofeedback control group are lacking. The inclusion of such group is crucial to control for unspecific effects. The current work presents a sham-controlled, double-blind evaluation. The hypothesis was that neurofeedback enhances attention and decreases impulsive behavior. Participants (n=27) were students selected on relatively high scores on impulsivity/inattention questionnaires (Barrat Impulsivity Scale and Broadbent CFQ). They were assigned to a neurofeedback treatment or a sham group. (sham)Neurofeedback training was planned for 15 weeks consisting of a total of 30 sessions, each lasting 22 min. Before and after 16 sessions (i.e., interim analyses), qEEG was recorded and impulsivity and inattention was assessed using a stop signal task and reversed continuous performance task and two questionnaires. Results of the interim analyses showed that participants were blind with respect to group inclusion, but no trend towards an effect of neurofeedback on behavioral measures was observed. Therefore in line with ethical guidelines the experiment was ceased. These results implicate a possible lack of effect of neurofeedback when one accounts for non-specific effects. However, the specific form of feedback and application of the sham-controlled double-blind design may have diminished the effect of neurofeedback.

Effect of psychiatric consultation models in primary care. A systematic review and meta-analysis of randomized clinical trials.

OBJECTIVE: Psychiatric consultation in primary care is meant to enhance and improve treatment for mental disorder in that setting. An estimate of the effect for different conditions as well as identification of particularly effective elements is needed. METHODS: Database search for randomized controlled trials (RCTs) on psychiatric consultation in primary care. Validity assessment and data extraction according to Cochrane criteria were performed by independent assessors in duplicate. Meta-analysis was performed. RESULTS: Data were collected from 10 RCTs with a total of 3408 included patients with somatoform disorder or depressive disorder, which compared psychiatric consultation to care as usual (CAU). Meta-analysis irrespective of condition showed a weighted mean indicating a combined assessment of illness burden as outcome of psychiatric consultation, compared to CAU, of 0.313 (95% CI 0.190-0.437). The effect was especially large in somatoform disorder (0.614; 95% CI 0.206-1.022). RCTs in which after the consult, consultation advice was given by means of a consultation letter, showed a combined weighted mean effect size of 0.561 (95% CI 0.337-0.786), while studies not using such a letter showed a small effect of 0.210 (95% CI 0.102-0.319). Effects are highest on utilization of health care services with 0.507 (95% CI 0.305-0.708). CONCLUSION: Psychiatric consultation in the primary care setting is effective in patients with somatoform and depressive disorder. Largest effects are seen in reduction of utilization of health care services.

Routine violence risk assessment in community forensic mental healthcare.

We developed a method for periodic monitoring of violence risk, as part of routine community forensic mental healthcare. The feasibility of the method was tested, as well as its predictive validity for violent and risk enhancing behavior in the subsequent months. Participants were 83 clients who received forensic psychiatric home treatment, and six case managers. The method proved feasible and informative. Violent and risk enhancing behavior could be predicted to a reasonable extent (AUC = .77, 95% CI = .70-.85; respectively .76, .70-.82). Dynamic risk factors had an incremental predictive value over static factors in the prediction of violent behavior (OR = 4.30, 1.72-10.73). The professional judgment of the case managers added further predictive power (OR = 2.16, 1.40-3.33), corroborating the structured professional judgment approach. Finally, unmet needs for care of the client were associated with a reduced risk for violent and risk enhancing behavior (OR = .80, 0.69-0.93, and 0.84, 0.72-0.97). This latter finding suggests that in cases with unmet needs the case manager saw opportunities to do something about the risk. Currently we are testing whether using the method actually prevents violence.

The guideline "consultation psychiatry" of the Netherlands Psychiatric Association.

BACKGROUND: In 2008, the Netherlands Psychiatric Association authorized a guideline "consultation psychiatry." AIM: To set a standard for psychiatric consultations in nonpsychiatric settings. The main objective of the guideline is to answer three questions: Is psychiatric consultation effective and, if so, which forms are most effective? How should a psychiatric consultations be performed? What increases adherence to recommendations given by the consulting psychiatrist? METHOD: Systematic literature review. RESULTS: Both in general practice and in hospital settings psychiatric consultation is effective. In primary care, the effectiveness of psychiatric consultation is almost exclusively studied in the setting of "collaborative care." Procedural guidance is given on how to perform a psychiatric consultation. In this guidance, psychiatric consultation is explicitly looked upon as a complex activity that requires a broad frame of reference and adequate medical and pharmacological expertise and experience and one that should be performed by doctors. Investing in a good relation with the general practitioner, and the use of a "consultation letter" increased efficacy in general practice. In the hospital setting, investing in liaison activities and an active psychiatric follow-up of consultations increased adherence to advice. CONCLUSION: Psychiatric consultations are effective and constitute a useful contribution to the patients' treatment. With setting a standard consultations will become more transparent and checkable. It is hoped that this will increase the quality of consultation psychiatry.

Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy.

BACKGROUND: The long-term outcome of major depression is often unfavorable, and because most cases of depression are managed by general practitioners (GPs), this places stress on the need to improve treatment in primary care. This study evaluated the long-term effects of enhancing the GP's usual care (UC) with three experimental interventions. METHOD: A randomized controlled trial was conducted from 1998 to 2003. The main inclusion criterion was receiving GP treatment for a depressive episode. We compared: (1) UC (n=72) with UC enhanced with: (2) a psycho-educational prevention (PEP) program (n=112); (3) psychiatrist-enhanced PEP (n=37); and (4) brief cognitive behavioral therapy followed by PEP (CBT-enhanced PEP) (n=44). We assessed depression status quarterly during a 3-year follow-up. RESULTS: Pooled across groups, depressive disorder-free and symptom-free times during follow-up were 83% and 17% respectively. Almost 64% of the patients had a relapse or recurrence, the median time to recurrence was 96 weeks, and the mean Beck Depression Inventory (BDI) score over 12 follow-up assessments was 9.6. Unexpectedly, PEP patients had no better outcomes than UC patients. However, psychiatrist-enhanced PEP and CBT-enhanced PEP patients reported lower BDI severity during follow-up than UC patients [mean difference 2.07 (95% confidence interval (CI) 1.13-3.00) and 1.62 (95% CI 0.70-2.55) respectively] and PEP patients [2.37 (95% CI 1.35-3.39) and 1.93 (95% CI 0.92-2.94) respectively]. CONCLUSIONS: The PEP program had no extra benefit compared to UC and may even worsen outcome in severely depressed patients. Enhancing treatment of depression in primary care with psychiatric consultation or brief CBT seems to improve the long-term outcome, but findings need replication as the interventions were combined with the ineffective PEP program.

Stressful life events as a link between problems in nonverbal communication and recurrence of depression.

BACKGROUND: Interpersonal difficulties and stressful life events are important etiological factors in (recurrence of) depression. This study examines whether stressful life events mediate the influence of problems in nonverbal communication on recurrence of depression. METHODS: We registered nonverbal expressions of involvement from videotaped behavior of 101 remitted outpatients and their interviewers. During a 2-year follow-up, we assessed stressful life events and recurrence of depression. RESULTS: The less congruent the levels of nonverbal involvement behavior of participants and interviewers, the higher the incidence of stressful life events, and -via these - the risk of recurrence. LIMITATIONS: Nonverbal behavior was measured in an experimental setting. CONCLUSIONS: The results suggest that lack of nonverbal congruence during social interaction contributes to the occurrence of stressful life events, which in turn may trigger depression.

The association between levels of cortisol secretion and fear perception in patients with remitted depression predicts recurrence.

This study examines the association between cortisol secretion and fear perception in remitted patients to identify mechanisms underlying risk for recurrence of depression. We hypothesized that the stronger the association between cortisol secretion and fear perception in persons with remitted depression, the more recurrence would be experienced. We also investigated whether high levels of cortisol and fear perception per se predict more recurrence. These effects were assumed to be stronger in women than in men. In a prospective design, we investigated 77 outpatients with remitted depression and related the association between their 24-hour urinary free cortisol secretion and fear perception (from ambiguous faces and from vocal expressions) to recurrence of depression within 2 years. We applied Cox regression models, partial correlations, and Fisher z tests. In 21 patients, depression recurred. Irrespective the channel of perception (eye or ear), the interaction between fear perception and cortisol secretion was significantly related to recurrence of depression. Patients high or low on both variables are more at risk. This increased risk was also reflected by a significant association between cortisol secretion and facial fear perception, but only among subjects who experienced recurrence. A trend in the same direction was found for vocal fear perception. Fear perception and cortisol secretion per se did not predict recurrence. No gender differences were found. The association between cortisol secretion and fear perception (probably indicative for altered fear circuits in the brain) constitutes a mechanism underlying risk for recurrence of depression.

Lack of association between conversation partners' nonverbal behavior predicts recurrence of depression, independently of personality.

High neuroticism and low extraversion are related to depression and its recurrence. We investigated whether nonverbal involvement behavior during social interaction is one of the factors via which these relations are effectuated. We measured nonverbal expressions of involvement from videotaped behavior of remitted depressed outpatients (n=101) and their conversation partners, and assessed self-reported neuroticism and extraversion scores. During a 2-year follow-up, we assessed the recurrence of depression. Twenty-eight participants (27.7%) experienced a recurrent episode. Time to recurrence was predicted by neuroticism and extraversion, and also by the degree of association between levels of nonverbal involvement behavior of conversation partners. The behavioral effect did not explain the personality effect. Neuroticism moderated the behavioral effect. The results point to the independent relevance of personality and nonverbal behavior in the long-term course of depressive disorder.

The care provided by general practitioners for persistent depression.

PURPOSE: To examine the care provided by general practitioners (GPs) for persistent depressive illness and its relationship to patient, illness and consultation characteristics. SUBJECTS AND METHOD: Using the Composite International Diagnostic Interview-Primary Health Care Version (CIDI-PHC) a sample of 264 patients with ICD-10 depression was identified among consecutive primary care patients in the Netherlands. At 1-year follow-up 78 of these patients (30%) still fulfilled the criteria of an ICD-10 depression and were considered persistent cases. At baseline and follow-up the GPs specified their diagnosis and treatment. The extent of recognition as a mental health problem, accuracy of diagnosis as a depression and treatment in accordance with clinical guidelines for depression was examined. In addition it was examined whether these steps in adequate GP care for persistent depression were related to patient, illness and consultation characteristics. RESULTS: Twenty percent of the persistent depression cases were not recognized at baseline or during follow-up, 28% was recognized but not accurately diagnosed, 17% was accurately diagnosed, but did not receive adequate treatment and 35% was treated adequately. Recognition was associated with psychological reason for encounter; accurate diagnosis with absence of activity limitation days; and adequate treatment with severity of depression and higher educational level. CONCLUSION: Non-recognition, misdiagnosis and inadequate treatment are not limited to patients with a relatively mild and brief depression but are also prominent in patients with a persistent depression, who consulted their GP 8.2 times on average during the year their depression persisted.

Cognitive, physiological, and personality correlates of recurrence of depression.

BACKGROUND: The risk of recurrence in depressive disorder is high and increases with the number of episodes. We investigated whether individuals with a history of recurrent depression deviate from individuals with a single episode, as regards risk-related variables in 3 different domains of depression research. METHODS: Participants were 102 outpatients with major depressive disorder remitted from an episode (60 recurrent, 42 nonrecurrent). We assessed the perception of emotions from vocal stimuli, 24-h urinary free cortisol, and neuroticism. RESULTS: The recurrent group had higher cortisol levels than the nonrecurrent group, and recurrent women also had a more negative perception than nonrecurrent women. These results were independent of each other, and could also not be accounted for by neuroticism or residual symptoms. Gender differences were found in all 3 domains. LIMITATIONS: The cross-sectional design limits the possibility to draw conclusions on the causality of the observed effects. CONCLUSIONS: Remitted outpatients with recurrent depression deviate from remitted outpatients with single episode depression as regards physiology and social cognition, in a way that may increase their risk of the development of subsequent episodes. The results may have implications for prophylactic treatment strategies.

Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment.

BACKGROUND: Although good physician communication is associated with positive patient outcomes, it does not figure in current depression treatment guidelines. We examined the effect of depression treatment, communicative skills and their interaction on patient outcomes for depression in primary care. METHODS: In a cohort of 348 patients with ICD-10 depression in primary care, patient outcomes were studied over 3- and 12-month follow-ups. The association of these outcomes with both depression-specific process of care variables and a nonspecific variable-communicative skillfulness of GP-was examined. Patient outcomes consisted of change from baseline in symptomatology, disability, activity limitation days, and duration of the depressive episode. RESULTS: In accordance with treatment guidelines, some main effects of depression treatment were found, in particular on symptomatology, but these remained small (effect size<0.50). A moderate effect was found for treatment with a sedative, which proved to be related to worse patient outcomes at 12 months. An accurate GP diagnosis of depression and adequate antidepressant treatment were associated with better patient outcomes, but only when provided by GPs with good communicative skills. In contrast to the main effects, these interactions were seen on disability and activity limitation days, not on symptomatology. LIMITATIONS: The study is observational and does not permit firm conclusions about causal relationships. Communicative skillfulness of the GP was assessed by patient report only. CONCLUSION: Neither depression-specific interventions nor good GP communication skills seem to be sufficient for optimal patient improvement. Only the combination of treatments according to guidelines and good communication skills results in an effective antidepressive treatment.

Are effects of depression management training for General Practitioners on patient outcomes mediated by improvements in the process of care?

BACKGROUND: Depression treatment by General Practitioners (GPs) and patient outcomes improved significantly after a comprehensive 20-h training program of GPs. This study examines whether the effects on patient outcomes are caused by the improvements in the process of care. METHODS: Seventeen GPs participated in the training program. A pre-test-post-test design was used. A total of 174 patients (85 pre-test, 89 post-test) aged 18-65 met ICD-10 criteria for recent onset major depression. The main indicator of mediation was a drop in training effect size (eta2) on patient outcome after adjustment for individual and combined process of care variables. We evaluated depression-specific (recognition, accurate diagnosis, prescription of antidepressant, adequate antidepressant treatment) and a non-specific process of care variable (communicative skillfulness of the GP) as well as the combination of adequate antidepressant treatment and communicative skillfulness. Patient outcomes were assessed at 3 months and consisted of change in severity of symptomatology, level of daily functioning and activity limitation days from baseline. RESULTS: Depression-specific interventions mediated up to one third of the observed improvement in patient outcome. 'Adequate dosage and duration of an antidepressant' explained 36% of the training effect on patient outcome (eta2 from 0.044 to 0.028). 'Communicative skillfulness of the GP' only was a weak mediator (18% explained; eta2 from 0.044 to 0.036). However, the combination of both, that is adequate antidepressant treatment by a communicative skillful GP, proved to be the strongest mediator of the observed training effect on patient outcomes (59% explained; eta2 from 0.044 to 0.018). LIMITATIONS: The training effects on patient outcomes in this sample were small. Hence, the scope for mediation was limited. CONCLUSION: GP communication skills are important to enhance depression-specific interventions in bringing about improvements in patient outcomes and should be addressed in GP training programs for the treatment of depression.

Predictability of the one-year course of depression and generalized anxiety in primary care.

Several predictors of the course of depression and generalized anxiety have been identified. Whether these predictors provide a solid basis for primary care physicians (PCPs) to give an accurate prognosis remains unclear. A parallel study showed modest agreement between PCP prognosis and observed course (kappa< or = 0.21). It is the aim of the present study to establish the extent to which the one-year course of depression and generalized anxiety in primary care is in fact predictable. Predictability is operationalized as the combined predictive power of major prognostic factors identified in the literature. We identified 269 cases of ICD-10 depression and 134 of generalized anxiety among consecutive PCP attenders. For these patients a statistical model was built that provided optimal predictions of the one-year course of the disorder, based on the prognostic factors discerned. The predictions were compared with the actual course observed. Reasonable agreement (kappa = 0.37 for depression, kappa = 0.35 for anxiety) and good association (gamma = 0.66 for depression, gamma=0.67 for anxiety) were found between predicted and observed course. Nevertheless, the combined predictive power of the prognostic factors remains limited. A realistic evaluation of the accuracy of the PCP prognosis should take this limited predictability into account.