Different measures for auditory hallucinations in populations with psychosis. The Validation of the Spanish versions of the Auditory Vocal Hallucination Rating Scale (AVHRS) and the Positive and Useful Voices Inquiry (PUVI).

INTRODUCTION: An updated summary of the most used instruments assessing auditory hallucinations in population with psychosis, allows us to underline the scarceness and need of Spanish versions of important instruments. The aim of the study is to examine the psychometric characteristics of two different and complementary instruments for assessing auditory hallucinations, the Spanish version of the Auditory Vocal Hallucination Scale (AVHRS) and the Spanish version of the Positive and Useful Voices Inquiry (PUVI). MATERIALS AND METHODS: A sample of 68 patients from four different centres, with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder presenting with auditory hallucinations were included. Apart from the AVHRS and the PUVI, the Psychotic Symptom Rating Scales-Auditory Hallucinations subscale (PSYRATS-AH) and the Positive and Negative Syndrome Scale (PANSS) were also administered to all patients, plus an acceptability questionnaire. RESULTS: The Spanish version of the AVHRS showed a good internal consistency, a moderate to high inter-rater reliability, a medium to moderate test-retest reliability, and a good convergent and discriminant validity. The Spanish version of the PUVI showed a good internal consistency and a heterogeneous, but in general moderate, test-retest reliability. CONCLUSIONS: The Spanish versions of the AVHRS and the PUVI have good psychometric properties and are well accepted among patients.

Different measures for auditory hallucinations in populations with psychosis. The Validation of the Spanish versions of the Auditory Vocal Hallucination Rating Scale (AVHRS) and the Positive and Useful Voices Inquiry (PUVI).

INTRODUCTION: An updated summary of the most used instruments assessing auditory hallucinations in population with psychosis, allows us to underline the scarceness and need of Spanish versions of important instruments. The aim of the study is to examine the psychometric characteristics of two different and complementary instruments for assessing auditory hallucinations, the Spanish version of the Auditory Vocal Hallucination Scale (AVHRS) and the Spanish version of the Positive and Useful Voices Inquiry (PUVI). MATERIALS AND METHODS: A sample of 68 patients from four different centres, with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder presenting with auditory hallucinations were included. Apart from the AVHRS and the PUVI, the Psychotic Symptom Rating Scales-Auditory Hallucinations subscale (PSYRATS-AH) and the Positive and Negative Syndrome Scale (PANSS) were also administered to all patients, plus an acceptability questionnaire. RESULTS: The Spanish version of the AVHRS showed a good internal consistency, a moderate to high inter-rater reliability, a medium to moderate test-retest reliability, and a good convergent and discriminant validity. The Spanish version of the PUVI showed a good internal consistency and a heterogeneous, but in general moderate, test-retest reliability. CONCLUSIONS: The Spanish versions of the AVHRS and the PUVI have good psychometric properties and are well accepted among patients.

Religiosity in young adolescents with auditory vocal hallucinations.

The current exploratory study examined the associations between auditory vocal hallucinations (AVH) and delusions and religiosity in young adolescents. 337 children from a population-based case-control study with and without AVH, were assessed after five years at age 12 and 13, on the presence and appraisal of AVH, delusions and religiosity. AVH status (persistent, remittent, incident or control) was examined in relationship to religiosity. Results demonstrated a non-linear association between AVH and religiosity. Moderately religious adolescents were more likely to report AVH than non-religious adolescents (O.R.=2.6). Prospectively, moderately religious adolescents were more likely to have recently developed AVH than non-religious adolescents (O.R.=3.6) and strongly religious adolescents (O.R.=7.9). Of the adolescents reporting voices in this sample (16.3%), more than half reported positive voices. Religious beliefs were often described as supportive, useful or neutral (82%), regardless of the level of religiosity, for both adolescents with and without AVH. Co-occurrence of AVH and delusions, and severity of AVH were not related to religiosity. The present findings suggest there may be a non-linear association between religiosity and hearing voices in young adolescents. A speculative explanation may be that religious practices were adopted in response to AVH as a method of coping.

From phenomenology to neurophysiological understanding of hallucinations in children and adolescents.

Typically reported as vivid, multisensory experiences which may spontaneously resolve, hallucinations are present at high rates during childhood. The risk of associated psychopathology is a major cause of concern. On the one hand, the risk of developing further delusional ideation has been shown to be reduced by better theory of mind skills. On the other hand, ideas of reference, passivity phenomena, and misidentification syndrome have been shown to increase the risk of self-injury or heteroaggressive behaviors. Cognitive psychology and brain-imaging studies have advanced our knowledge of the mechanisms underlying these early-onset hallucinations. Notably, specific functional impairments have been associated with certain phenomenological characteristics of hallucinations in youths, including intrusiveness and the sense of reality. In this review, we provide an update of associated epidemiological and phenomenological factors (including sociocultural context, social adversity, and genetics, considered in relation to the psychosis continuum hypothesis), cognitive models, and neurophysiological findings concerning hallucinations in children and adolescents. Key issues that have interfered with progress are considered and recommendations for future studies are provided.

Course of auditory vocal hallucinations in childhood: 5-year follow-up study.

BACKGROUND: In a baseline study among 7- and 8-year-old children with auditory vocal hallucinations, only limited functional impact was observed. AIMS: To assess 5-year course and predictors of auditory vocal hallucinations, as well as 5-year incidence and its risk factors. METHOD: A sample of 337 children, 12 and 13 years of age, were reassessed on auditory vocal hallucinations and associated symptoms after a mean follow-up period of 5.1 years. RESULTS: The 5-year persistence and incidence rates were 24% and 9% respectively, with more new cases arising in urban areas.Both persistent and incident auditory vocal hallucinations were associated with problem behaviour in the clinical range of psychopathology as measured with the Child Behavior Checklist, particularly at follow-up, as well as with other psychotic symptoms, particularly at baseline. Persistence was predicted by baseline auditory vocal hallucinations severity,particularly in terms of external attribution of voices and hearing multiple voices, and was associated with worse primary school test scores and lower secondary school level. CONCLUSIONS: First onset of auditory vocal hallucinations in middle childhood is not uncommon and is associated with psychopathological and behavioural comorbidity. Similarly,persistence of auditory vocal hallucinations in childhood is not uncommon and is associated with psychopathological,behavioural and cognitive alterations.

Psychotic symptoms in the general population - an evolutionary perspective.

Our ideas about the intrinsically pathological nature of hallucinations and delusions are being challenged by findings from epidemiology, neuroimaging and clinical research. Population-based studies using both self-report and interview surveys show that the prevalence of psychotic symptoms is far greater than had been previously considered, prompting us to re-evaluate these psychotic symptoms and their meaning in an evolutionary context. This non-clinical phenotype may hold the key to understanding the persistence of psychosis in the population. From a neuroscientific point of view, detailed investigation of the non-clinical psychosis phenotype should provide novel leads for research into the aetiology, nosology and treatment of psychosis.

Prevalence and correlates of auditory vocal hallucinations in middle childhood.

BACKGROUND: Hearing voices occurs in middle childhood, but little is known about prevalence, aetiology and immediate consequences. AIMS: To investigate prevalence, developmental risk factors and behavioural correlates of auditory vocal hallucinations in 7- and 8-year-olds. METHOD: Auditory vocal hallucinations were assessed with the Auditory Vocal Hallucination Rating Scale in 3870 children. Prospectively recorded data on pre- and perinatal complications, early development and current problem behaviour were analysed in children with auditory vocal hallucinations and matched controls. RESULTS: The 1-year prevalence of auditory vocal hallucinations was 9%, with substantial suffering and problem behaviour reported in 15% of those affected. Prevalence was higher in rural areas but auditory vocal hallucinations were more severe and had greater functional impact in the urban environment. There was little evidence for associations with developmental variables. CONCLUSIONS: Auditory vocal hallucinations in 7- and 8-year-olds are prevalent but mostly of limited functional impact. Nevertheless, there may be continuity with more severe psychotic outcomes given the serious suffering in a subgroup of children and there is evidence for a poorer prognosis in an urban environment.

Effects of bilateral repetitive transcranial magnetic stimulation on treatment resistant auditory-verbal hallucinations in schizophrenia: a randomized controlled trial.

BACKGROUND: Neuroimaging findings implicate bilateral superior temporal regions in the genesis of auditory-verbal hallucinations (AVH). This study aimed to investigate whether 1 Hz repetitive transcranial magnetic stimulation (rTMS) of the bilateral temporo-parietal region would lead to increased effectiveness in the management of AVH, compared to left rTMS or placebo. METHODS: 38 patients with schizophrenia (DSM-IV) and medication-resistant AVH were randomly assigned to 1 Hz rTMS treatment of the left temporo-parietal region, bilateral temporo-parietal regions, or placebo. Stimulation was conducted over 6 days, twice daily for 20 min, at 90% of the motor threshold. Effect measures included the Auditory Hallucination Rating Scale (AHRS), Positive and Negative Affect Scale (PANAS), and a score for hallucination severity obtained from the Positive and Negative Syndrome Scale (PANSS). RESULTS: All groups showed some improvement on the total AHRS. Hallucination frequency was significantly reduced in the left rTMS group only. The bilateral rTMS group demonstrated the most remarkable reduction in self-reported affective responsiveness to AVH. A modest, but significant decrease on the PANSS hallucination item was observed in the combined rTMS treatment group, whereas no change occurred in the placebo group. The left rTMS group showed a significant reduction on the general psychopathology subscale. CONCLUSION: Compared to bilateral or sham stimulation, rTMS of the left temporo-parietal region appears most effective in reducing auditory hallucinations, and additionally may have an effect on general psychopathology. Placebo effects should however not be ruled out, since sham stimulation also led to improvement on a number of AVH parameters.

Cost-effectiveness analysis in severe mental illness: outcome measures selection.

BACKGROUND: Most economic evaluations conducted in mental healthcare did not include widely recommended preference-based health outcomes like the QALY (Quality-Adjusted Life Years). Instead, studies have mainly been designed as cost-effectiveness analyses that include single outcome measures aimed at a (disease) specific aspect of health. AIMS OF THE STUDY: To raise awareness about the potential problems related to the selection of outcome measures for economic studies in patient populations with severe mental illness. Furthermore, to make suggestions that may prevent these problems in future economic evaluations. METHODS: Data of a previously conducted economic evaluation assessing the cost-effectiveness of the HIT (Hallucination focused Integrative Treatment) intervention in patients with schizophrenia were used for the analyses presented in the current paper. Economic analyses based on the results of the selected primary health outcome (Positive and Negative Syndrome Scale: PANSS) were compared with results based on various other health outcomes assessed during the study, including QALYs. RESULTS: No relevant differences between groups were found on the single primary health outcome initially included in the cost-effectiveness analysis. In contrast, relevant and significant differences were identified on three of the four additionally assessed health outcomes. Conclusions based on the results of multiple cost-effectiveness analyses and acceptability curves were strongly in favour of the experimental intervention when including these three additional instruments. QALY results did not show differences between groups. DISCUSSION: Selecting between outcome measures for cost-effectiveness analysis in the field of mental healthcare appears to be a complicated process, which may have considerable consequences for the results of economic studies and subsequent policy decisions. It was argued that inconsistent results across the selected primary health outcome and additionally assessed health outcomes should explicitly be presented to decision-makers. Until there is consensus on a preference-based instrument suited for severe mental illness, QoL instruments could be applied instead of instruments aimed at specific aspects of health. IMPLICATIONS FOR HEALTH POLICIES: Decision-makers in the field of mental healthcare should be careful when interpreting results of economic studies that included outcome measures aimed at a specific aspect of health. Such instruments may provide too narrow a view on relevant changes in health and findings may be difficult to generalise. Due to current reservations on the use of QALYs in mental healthcare, QALY outcomes should be considered in the context of the results of additionally assessed health outcomes.

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.

"Hitting" voices of schizophrenia patients may lastingly reduce persistent auditory hallucinations and their burden: 18-month outcome of a randomized controlled trial.

OBJECTIVE: This study aimed to investigate the outcome of an 18-month randomized controlled trial (RCT) on subjective burden and psychopathology of patients suffering from schizophrenia. METHOD: An RCT was used to compare hallucination-focused integrative treatment (HIT) and routine treatment (RT) in schizophrenia patients who persistently hear voices. We performed an intent-to-treat analysis on each of the 63 patients who were assessed at baseline, 9, and 18 months. On each of the 3 occasions, the differential effects of the treatment conditions were tested repeatedly. Sex, age, education, and illness (hallucination) duration were used as covariates. RESULTS: Patients in the experimental group retained improvements over time. Improvements in hallucinations, distress, and negative content of voices remained significant at the 5% level. CONCLUSION: HIT seems to be an effective treatment strategy with long-lasting effects for treatment-refractory voice-hearing patients.

Changes in quality of life in chronic psychiatric patients: a comparison between EuroQol (EQ-5D) and WHOQoL.

It has often been postulated that simple, short questionnaires are unable to reflect complex changes in well-being of individuals with chronic psychiatric disorders. To investigate these assumptions we included two recently developed instruments to measure quality of life (the WHOQoL-Bref and the EuroQoL EQ-5D) in a randomised control trial (RCT) in which two treatment conditions were compared. Aims of the study were to assess the sensitivity and validity of these quality of life (QoL)-instruments, to establish their relationship and to examine the predictors of changes in QoL. Subjective changes in QoL were measured on three assessments waves in a period of 18 months and compared to objective changes in psychopathology and social functioning in a sample of 76 chronic schizophrenic patients who participated in the RCT. Results indicated that both WHOQoL-Bref and EuroQoL EQ-5D are capable of detecting changes in QoL over time in physical and psychological well-being. The instruments partly measure the same aspects of QoL, indicated by 50% common variance on total scores. Reduction of positive psychotic symptoms appeared to be the most important factor in improving QoL. The weighted TTO-score of EuroQoL-5D, which is often used as an index in economic evaluations of health care, did however not correspond with these changes, which indicates that it is less sensitive to changes in social and psychological well-being. It's use as the core measure in (economic) health evaluation in the field of psychiatry therefore seems less appropriate.

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.

Hallucination focused integrative treatment: a randomized controlled trial.

Improvements in psychopathology, subjective burden, and coping with voices after hallucination focused integrative treatment (HIT) were studied in chronic schizophrenic patients with persistent (> 10 years), drug-refractory auditory hallucinations. In a randomized controlled trial, routine care was compared with HIT pre- and posttreatment at a 9-month interval. Independent raters used semistructured interviews to assess burden, symptoms, and coping. Within-group improvements in both burden and psychopathology were most significant in the experimental group (p < 0.05) after treatment. HIT patients showed change in applied coping strategies, but it did not reach statistical significance. Type and (change in) number of coping strategies did not seem related to outcome. The results suggest that HIT is a cost-effective practice that positively affects mental state in general, subjective burden, quality of life, and social functioning.

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.