Efficacy of antipsychotics in delusional infestation.

BACKGROUND: Data remain scarce for the first-line antipsychotic choice in treating delusional infestation (DI). OBJECTIVES: We evaluated the treatment responses associated with different antipsychotics in DI patients. METHODS: We undertook a multicentre, retrospective observational study using anonymised electronic patient records from two hospitals in the United Kingdom from 1 January 2011 to 1 January 2023. Eligible participants were adults (≥18 years) diagnosed with DI treated with an antipsychotic, and had both an assigned baseline and follow-up Clinical Global Impression Scale (CGI-S) score. The CGI-S is a validated psychiatric research tool. Participants were excluded if they had known limited or non-adherence to an antipsychotic, or if no CGI-S scores were present at follow-up. First clinic visits before the initiation of an antipsychotic were assigned as the baseline CGI-S score. The last available CGI-S score before the patient either changed antipsychotic or left the clinic for any reason was used to assign follow-up CGI-S scores. The primary outcome was the response to each individual antipsychotic treatment, measured by the difference in the baseline and last available follow-up CGI-S scores. Differences in CGI-S changes between antipsychotic episodes were tested by analysis of variance (ANOVA). RESULTS: In total, 414 patient records were analysed, and data were extracted. The mean age was 61.8 years (SD 14.1). One hundred seventy (41%) of 414 patients were men and 244 (59%) were women. In total, 156 (38%) of 414 patients were eligible, yielding a total of 315 antipsychotic prescribing episodes. The ANOVA, ranking in order of treatment response, showed that the highest mean score (expressing highest treatment response) was observed in amisulpride (31 [67%] of 46) and risperidone (95 [57%] of 167), followed by some distance by quetiapine (9 [36%] of 25), aripiprazole (13 [28%] of 46) and olanzapine (7 [25%] of 28). CONCLUSIONS: Amisulpride and risperidone were associated with a higher treatment response than quetiapine, aripiprazole and olanzapine. Amisulpride and risperidone should therefore be considered the first-line treatment options in DI patients.

Comparison of coercive practices in worldwide mental healthcare: overcoming difficulties resulting from variations in monitoring strategies.

BACKGROUND: Coercive or restrictive practices such as compulsory admission, involuntary medication, seclusion and restraint impinge on individual autonomy. International consensus mandates reduction or elimination of restrictive practices in mental healthcare. To achieve this requires knowledge of the extent of these practices. AIMS: We determined rates of coercive practices and compared them across countries. METHOD: We identified nine country- or region-wide data-sets of rates and durations of restrictive practices in Australia, England, Germany, Ireland, Japan, New Zealand, The Netherlands, the USA and Wales. We compared the data-sets with each other and with mental healthcare indicators in World Health Organization and Organisation for Economic Cooperation and Development reports. RESULTS: The types and definitions of reported coercive practices varied considerably. Reported rates were highly variable, poorly reported and tracked using a diverse array of measures. However, we were able to combine duration measures to examine numbers of restrictive practices per year per 100 000 population for each country. The rates and durations of seclusion and restraint differed by factors of more than 100 between countries, with Japan showing a particularly high number of restraints. CONCLUSIONS: We recommend a common set of international measures, so that finer comparisons within and between countries can be made, and monitoring of trends to see whether alternatives to restraint are successful. These measurements should include information about the total numbers, durations and rates of coercive measures. We urge the World Health Organization to include these measures in their Mental Health Atlas.

Improvement in the quality of life of outpatients with severe mental illness in conjunction with intellectual disabilities and post-traumatic stress disorder.

BACKGROUND: Elucidating the influence of mild intellectual disability (MID; IQ 50-70)/borderline intellectual functioning (BIF; IQ 70-85) and (comorbid) post-traumatic stress disorder (PTSD) on the quality of life of patients with serious mental illness (SMI) could improve their mental health care. METHOD: This study comprises a prospective longitudinal cohort study using routine outcome monitoring data. The cohort comprised 601 patients who had undertaken at least one Manchester Short Assessment of Quality of Life (MANSA). The scores for screeners to detect MID/BIF and PTSD were analysed, and a repeated measures analysis of variance and a multi-level linear regression was performed on the MANSA scores. RESULTS: The average quality of life for all patient groups increased significantly over time. A between-subject effect on quality of life was observed for PTSD, but not MID/BIF. CONCLUSIONS: PTSD but not MID/BIF is associated with a lesser quality of life over time.

"Disruptive Behavior" or "Expected Benefit" Are Rationales of Seclusion Without Prior Aggression.

Objective: In the Netherlands, seclusion of patients with a psychiatric disorder is a last-resort measure to be used only in the event of (imminent) severe danger or harm. Although aggressive behavior is often involved, seclusions not preceded by aggression also seem to occur. We sought insight into the non-aggressive reasons underlying seclusion and investigated the factors associated with it. Method: We included all patients admitted to a Dutch psychiatric hospital in 2008 and 2009. Seclusions had been registered on Argus-forms, and aggression incidents had been registered on the Staff Observation Aggression Scale-Revised (SOAS-R), inspectorate forms and/or patient files. Determinants of seclusion with vs. without prior aggression were analyzed using logistic regression. Reasons for seclusion without prior aggression were evaluated qualitatively and grouped into main themes. Results: Of 1,106 admitted patients, 184 (17%) were secluded at some time during admission. Twenty-one (11.4%) were excluded because information on their seclusion was lacking. In 23 cases (14%), neither SOAS-R, inspectorate forms nor individual patient files indicated any aggression. Univariable and multivariable regression both showed seclusion without preceding aggression to be negatively associated with daytime and the first day of hospitalization. In other words, seclusion related to aggression occurred more on the first day, and during daytime, while seclusion for non-aggressive reasons occurred relatively more after the first day, and during nighttime. Our qualitative findings showed two main themes of non-aggressive reasons for seclusion: "disruptive behavior" and "beneficial to patient." Conclusion: Awareness of the different reasons for seclusion may improve interventions on reducing its use. Thorough examination of different sources showed that few seclusions had not been preceded by aggression. The use of seclusion would be considerably reduced through interventions that prevent aggression or handle aggression incidents in other ways than seclusion. However, attention should also be paid to the remaining reasons for seclusion, such as handling disruptive behavior and focusing on the beneficial effects of reduced stimuli. Future research on interventions to reduce the use of seclusion should not only aim to reduce seclusion but should also establish whether seclusions preceded by aggression decrease different from seclusions that are not preceded by aggression.

Number of Seclusions in the Netherlands Higher in the 7 Years Since the End of a Nationwide Seclusion-Reduction Program.

Introduction: Between 2006 and 2012 the Dutch government funded a nationwide program for reducing the use of seclusion. Although an initial first trend study showed that the reported number of seclusions declined during the program, the objective of a 10% annual decrease was not met. We wished to establish whether the decline had continued after funding ended in 2012. Method: Using quasi Poisson time series modeling, we retrospectively analyzed the nationally reported numbers of seclusion and involuntary medication between 1998 and 2019, i.e., before, during and after the end of the nationwide program, with and without correction for the number of involuntary admissions. Results: With and without correction for the number of involuntary admissions, there were more seclusions in the seven years after the nationwide program than during the nationwide program. Although the reported number of involuntary medications also increased, the rate of increase was slower after the end of the nationwide program than before. Conclusions: Rather than continuing to decrease after the end of the nationwide program, the number of seclusions rose. This may mean that interventions intended to reduce the use of seclusion within this program are not properly sustained in daily clinical care without an ongoing national program.

Impact of the first COVID-19 outbreak on mental health service utilisation at a Dutch mental health centre: retrospective observational study.

BACKGROUND: Previous studies into mental health service utilisation during the COVID-19 pandemic are limited to a few countries or specific type of service. In addition, data on changes in telepsychiatry are currently lacking. AIMS: We aimed to investigate whether the COVID-19 pandemic is associated with changes in mental health service utilisation, including telepsychiatry, and how these changes were distributed among patients with mental illness during the first COVID-19 outbreak. METHOD: This retrospective study obtained routinely assessed healthcare data from a large Dutch mental healthcare institute. Data from the second quarter of 2020 (the first COVID-19 outbreak period) were compared with the pre-pandemic period between January 2018 and March 2020. Time-series analyses were performed with the quasi-Poisson generalised linear model, to examine the effect of the COVID-19 lockdown and the overall trend of mental health service utilisation per communication modality and diagnostic category. RESULTS: We analysed 204 808 care contacts of 28 038 patients. The overall number of care contacts in the second quarter of 2020 remained the same as in the previous 2 years, because the number of video consultations significantly increased (B = 2.17, P = 0.488 × 10-3) as the number of face-to-face out-patient contacts significantly decreased (B = -0.98, P = 0.011). This was true for all different diagnostic categories, although this change was less pronounced in patients with psychotic disorders. CONCLUSIONS: Diminished face-to-face out-patient contacts were well-compensated by the substantial increase of video consultations during the first COVID-19 outbreak in The Netherlands. This increase was less pronounced for psychotic disorders. Further research should elucidate the need for disorder-specific digital mental healthcare delivery.

Increased prevalence of intellectual disabilities in higher-intensity mental healthcare settings.

BACKGROUND: It has been suggested that people with intellectual disabilities have a higher likelihood to develop psychiatric disorders, and that their treatment prognosis is relatively poor. AIMS: We aimed to establish the prevalence of intellectual disability in different mental healthcare settings, and estimate percentage of cognitive decline. We hypothesised that the prevalence of intellectual disabilities increases with intensity of care. METHOD: A cross-sectional study was conducted in different settings in a mental healthcare trust in the Netherlands. We used the Screener for Intelligence and Learning Disabilities (SCIL) to identify suspected mild intellectual disability (MID) or borderline intellectual functioning (BIF). We identified patients with a high level of education and low SCIL score to estimate which patients may have had cognitive decline. RESULTS: We included 1213 consecutive patients. Over all settings, 41.4% of participating patients were positive for MID/BIF and 20.2% were positive for MID only. Prevalence of suspected MID/BIF increased by setting, from 27.1% in out-patient settings to 41.9% in flexible assertive community treatment teams and admission wards, to 66.9% in long-stay wards. Only 85 (7.1%) of all patients were identified as possibly having cognitive decline. Of these, 25.9% were in long-stay wards and had a diagnosis of schizophrenia or substance use disorder. CONCLUSIONS: Low intellectual functioning is common in Dutch mental healthcare settings. Only a modest number of patients were identified as suffering from cognitive decline rather than suspected MID/BIF from birth. Therefore, we recommend improved screening of psychiatric patients for intellectual functioning at the start of treatment.

The Compulsory Care Act: Early Observations and Expectations of In- or Outpatient Involuntary Treatment.

BACKGROUND: On January 1, 2020, the Dutch Compulsory Care Act (WvGGZ) replaced the Special Admissions Act (BOPZ). While the old law only allowed compulsory treatment in hospitals, the new law allows it both inside and outside the hospital. Moreover, the new law prioritizes the patient's own opinion on coercive measures. By following patients' own choices, the Compulsory Care Act is hoped to lead to fewer admission days and less inpatient compulsory treatment in involuntarily admitted patients. METHODS: We studied the seclusion and enforced-medication events before and after January 1, 2020, using coercive measures monitoring data in a Mental Health Trust. Trends in hours of seclusion and the number of enforced-medication events per month from 2012 to 2019 were compared with 2020. We used generalized linear models to perform time series analysis. Logistic regression analyses and generalized linear models were performed to investigate whether patient compilation determined some of the observed changes in seclusion use or enforced-medication events. RESULTS: The mean number of hours of seclusion between 2012 and 2019 was 27,124 per year, decreasing from 48,542 in 2012 to 21,133 in 2019 to 3,844 h in 2020. The mean incidence of enforced-medication events between 2012 and 2019 was 167, increasing from 90 in 2012 to 361 in 2019 and then fell to 294 in 2020. In 2020, we observed 3,844 h of seclusion and 294 enforced-medication events. Near to no outpatient coercion was reported, even though it was warranted. The time series analysis showed a significant effect of the year 2020 on seclusion hours (ß = -1.867; Exp(ß) = 0.155, Wald = 27.22, p = 0.001), but not on enforced-medication events [ß = 0.48; Exp(ß) = 1.616, Wald = 2.33, p = 0.13]. DISCUSSION: There was a reduction in the number of seclusion hours after the introduction of the Compulsory Care Act. The number of enforced-medication events also increased from a very low baseline, but from 2017 onwards. To see whether these findings are consistent over time, they need to be replicated in the near future. CONCLUSION: We observed a significant increase in enforced-medication use and a decrease in seclusion hours. The year 2020 predicted seclusion hours, but not enforced-medication events.

Three Pathways of Seclusion Reduction Programs to Sustainability: Ten Years Follow Up in Psychiatry.

From 2004 onwards, above 50 seclusion reduction programs (SRP) were developed, implemented and evaluated in the Netherlands. However, little is known about their sustainability, as to which extent obtained reduction could be maintained. This study monitored three programs over ten years seeking to identify important factors contributing to this. We reviewed documents of three SRPs that received governmental funding to reduce seclusion. Next, we interviewed key figures from each institute, to investigate the SRP documents and their implementation in practice. We monitored the number of seclusion events and the number of seclusion days with the Argus rating scale over ten years in three separate phases: 2008-2010, 2011-2014 and 2015-2017. As we were interested in sustainability after the governmental funding ended in 2012, our focus was on the last phase. Although in different rate, all mental health institutes showed some decline in seclusion events during and immediately after the SRP. After end of funding one institute showed numbers going up and down. The second showed an increase in number of seclusion days. The third institute displayed a sustained and continuous reduction in use of seclusion, even several years after the received funding. This institute was the only one with an ongoing institutional SRP after the governmental funding. To sustain accomplished seclusion reduction, a continuous effort is needed for institutional awareness of the use of seclusion, even after successful implementation of SRPs. If not, successful SRPs implemented in psychiatry will easily relapse in traditional use of seclusion.

Screening for intellectual disabilities and borderline intelligence in Dutch outpatients with severe mental illness.

BACKGROUND: The reliability and validity of the Screener for Intelligence and Learning Disabilities (SCIL) are unknown in a population of outpatients with severe mental illness. The prevalence of mild or borderline intellectual disabilities (MBID); an umbrella term for people with borderline intellectual functioning (BIF) and mild intellectual disability (MID) in this population is also unknown. METHODS: A total of 625 patients were screened with the SCIL, 201 of which also had IQ test results. RESULTS: Cronbach's alpha of the SCIL was 0.73. The AUC value for detecting MBID was 0.81, and also 0.81 for detecting MID, with percentages of correctly classified subjects (when using the advised cut-off scores) being 73% and 79%, respectively. The SCIL results suggested that 40% of the patients were suspected of MBID and 20% of MID. CONCLUSION: The SCIL seems to be an appropriate screening tool for MBID. It is important to screen for MBID because a substantial proportion of outpatients with severe mental illness appear to be functioning at this level. It is necessary to adapt treatment for these patients.

Skin autofluorescence assessment of cardiovascular risk in people with severe mental illness.

BACKGROUND: People with severe mental illness (SMI) show significantly shorter life expectancy, mostly due to more prevalent cardiovascular disease. Although age is a prominent contributor to contemporary risk assessment and SMI usually affects younger people, these assessments still do not reveal the actual risk. By assessing advanced glycation end products (AGEs), cardiovascular risk can be assessed independent of age. AIMS: To establish whether detection of AGEs with the AGE-reader will give a more accurate cardiovascular risk assessment in people with SMI. METHOD: We compared assessment with the AGE-reader with that of the Systematic Coronary Risk Evaluation (SCORE) table in a group of 120 patients with SMI. RESULTS: The AGE-reader showed an increased cardiovascular risk more often than the SCORE table, especially in the youngest group. CONCLUSIONS: Because of its ease of use and substantiation by studies done on other chronic diseases, we advocate use of the AGE-reader in daily care for patients with SMI to detect cardiovascular risk as early as possible. However, the findings of the current study should be evaluated with caution and should be seen as preliminary findings that require confirmation by a prospective longitudinal cohort study with a substantial follow-up observation period. DECLARATION OF INTEREST: None.

Restraint prevalence and perceived coercion among psychiatric inpatients from South India: A prospective study.

BACKGROUND: The Indian Mental Health Care Act 2017 (MHCA -2017) advocates the duty to provide treatment in the least coercive manner. Little data exists on how Indian patients perceive coercion in medical settings. AIMS: To study the prevalence of restraint in a Indian psychiatric inpatient unit, and to examine the level of perceived coercion correlating to various forms of restraint. METHODOLOGY: This is a hospital based prospective observational study. Two hundred patients were recruited through computer generated random number sampling. In eligible subjects, demographic and clinical data, restraints used and assessments related to perceived coercion were completed within 3 days of admission. Perceived coercion was reassessed at the time or within 3 days before discharge. RESULTS: In 66.5% one or more restraint measures were used, physical restraints in 20%, chemical restraints in 58%, seclusion in 18%, and involuntary medication in 32%. ECT is associated with the lowest level of perceived coercion followed by isolation/seclusion, chemical restraint, involuntary medication and physical restraint. Male gender, being married, rural background, low socioeconomic status, having a mood disorder, and alcohol or drug dependence was associated with an increased risk of physical or chemical restraint. Having a mood disorder, being from a rural area and a lower socioeconomic status was associated with being subjected to more than one form of coercion. CONCLUSION: Restraint measures are more prevalent in psychiatric hospital care in India than in Europe. Physical restraint is particularly associted with higher perceived coercion.

Factors influencing advance directives among psychiatric inpatients in India.

OBJECTIVES: Advance directives are documents stating treatment preferences in case of future lack of decision making capacity. In India, as in many other countries, legislators advocate Psychiatric Advance Directives (PADs), while evidence on its use is limited. This study examined factors influencing PADs by gathering inpatients perspectives on PADs at discharge and investigating patient characteristics associated with the expression of treatment wishes in PADs. METHODS: We conducted a hospital based descriptive study in Bangalore. 200 patients were included. The Mini International Neuropsychiatric Interview, CGI-S and CGI-I (Clinical Global Impression scales), the Insight Scale-2, and an Illness insight assessment were completed within 3days of admission. We used the Bangalore Advance Directive Interview (BADI) to assess attitudes towards PADs. 182 subjects were reassessed within 3days of discharge, along with an interview on their perspectives on PADs. RESULTS: 67% welcomed the need for PADs in India. 95.6% made their own PADs. 80% followed their doctors' advice in their PAD. Subjects lacking insight or remaining symptomatic at discharge opted significantly more often against ECT, antipsychotics, and inpatient care. Linear regression showed that low socio-economic status, unwillingness to stay in hospital, and having received ECT before were inversely associated with the expression of treatment wishes in PADs. CONCLUSIONS: This study's findings are relevant for India and Western countries alike while generating legislation including patients' perspectives. A majority of patients favoured PADs. Absent insight, severe psychopathology and incomplete recovery may negatively influence the way PADs are completed. Therefore, clinicians must assess patient's capacity to formulate PADs carefully, as capacity may significantly influence patients' views. The timing of when to formulate one's PAD within the illness process may be essential.

Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change?

International comparative studies show that Dutch seclusion rates are relatively high. Therefore, several programs to change this practice were developed and implemented. The purpose of this study was to examine the impact of a seclusion reduction program over a long time frame, from 2004 until 2013. Three phases could be identified; the phase of development and implementation of the program (2004-2007), the project phase (2008-2010) and the consolidation phase (2011-2013). Five inpatient wards of a mental health institute were monitored. Each ward had one or more seclusion rooms. Primary outcome were the number and the duration of seclusion incidents. Involuntary medication was monitored as well to rule out substitution of one coercive measure by another. Case mix correction for patient characteristics was done by a multi-level logistic regression analysis with patient characteristics as predictors and hours seclusion per admission hours as outcome. Seclusion use reduced significantly during the project phase, both in number (-73%) and duration (-80%) and was not substituted by the use of enforced medication. Patient compilation as analyzed by the multi- level regression seemed not to confound the findings. Findings show a slight increase in number and seclusion days over the last year of monitoring. Whether this should be interpreted as a continuous or temporary trend remains unclear and is subject for further investigation.

Longer Duration of Untreated Psychosis is Associated with Poorer Outcomes for Patients with Delusional Infestation.

We examined the association between the duration of untreated psychosis and outcome for patients with delusional infestation. This multi-centre international study included 211 consecutive patients. Illness severity was evaluated at first presentation and outcome was measured with the Clinical Global Impression scale (CGI) at baseline and follow-up. A regression analysis showed a clear clinical and statistically significant association between shorter duration of untreated psychosis and better outcome at follow-up. Patients with a duration of untreated psychosis of less than one year showed a CGI-S change from 5.37 to 2.07; those with a duration of untreated psychosis of 1-5 years a change from 5.48 to 2.59, and those with a duration of untreated psychosis of >5 years a change from 5.59 to 3.37. This difference of 1.1 CGI points between the groups resembles a clinically relevant difference in patient outcome. Our results suggest that longer duration of untreated psychosis in patients with delusional infestation is associated with significantly less favour-able clinical outcomes.

Predicting Dropout from Intensive Outpatient Cognitive Behavioural Therapy for Binge Eating Disorder Using Pre-treatment Characteristics: A Naturalistic Study.

BACKGROUND: Dropout rates in binge eating disorder (BED) treatment are high (17-30%), and predictors of dropout are unknown. METHOD: Participants were 376 patients following an intensive outpatient cognitive behavioural therapy programme for BED, 82 of whom (21.8%) dropped out of treatment. An exploratory logistic regression was performed using eating disorder variables, general psychopathology, personality and demographics to identify predictors of dropout. RESULTS: Binge eating pathology, preoccupations with eating, shape and weight, social adjustment, agreeableness, and social embedding appeared to be significant predictors of dropout. Also, education showed an association to dropout. DISCUSSION: This is one of the first studies investigating pre-treatment predictors for dropout in BED treatment. The total explained variance of the prediction model was low, yet the model correctly classified 80.6% of cases, which is comparable to other dropout studies in eating disorders. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Clinical correlates and predictors of perceived coercion among psychiatric inpatients: A prospective pilot study.

BACKGROUND: The current Mental Health Care Bill (MHCB) -2013 in India advocates least restrictive alternatives (LRA) in psychiatric treatment. However, we have little evidence on patient's perspectives of coercion and LRA. METHODOLOGY: This was a hospital-based prospective pilot study. 170 subjects chosen by computer-generated random number sampling were screened. In 83 eligible subjects, all assessments including coercion assessment were completed within 3 days of admission and in 75 subjects reassessment was done within 3 days of discharge. RESULTS: Perceived coercion as measured by the MacArthur Perceived Coercion Scale (MPCS) decreased significantly from 3.72±1.98 at admission to 1.77±1.8 (<0.001) at discharge. This was accompanied by significant increase in global functioning, insight score (from 1.5±1.0 to 3.8±1.1; p<0.001) and as well as decrease in symptom severity (CGI-S) (from 5.9±1.1 to 1.8±1.9; p<0.001). Coercion is predicted by family type, employment status, socio economic status, severity of illness and level of insight. 87% patients reported that their admission was justified even though many felt coerced during hospital stay. CONCLUSION: Coercion is a dynamic state and changes with treatment and care. Clinical care may result in an improvement in global functioning, insight as well as in reduction in severity of illness consequently leading to less coercion. During the time of discharge, majority of patients reported that their admission was justified, even though they felt coerced during hospital stay and agreed for treatment against their will within a safe, standardised coercive practice.

Seclusion Reduction in Dutch Mental Health Care: Did Hospitals Meet Goals?

OBJECTIVE: In 2006, a goal of reducing seclusion in Dutch hospitals by at least 10% each year was set. More than 100 reduction projects in 55 hospitals have been conducted, with €35 million in funding. This study evaluated the results. METHODS: Data (2008 to 2013) were from a national register. Multilevel logistic regression examined determinants of seclusion. RESULTS: Hospital participation in the register ranged from eight in 2008 to 66 in 2013, and admissions ranged from 11,300 to 113,290. The average yearly nationwide reduction of secluded patients was about 9%. Reduction was achieved in half of the hospitals. Some hospitals saw increased rates. In some hospitals where seclusion decreased, use of forced medication increased. Higher seclusion rates were associated with psychotic and bipolar disorders, male gender, and several ward types. CONCLUSIONS: Seclusion decreased significantly, and forced medication increased. Rates varied widely between hospitals. For many hospitals, more efforts to reduce seclusion are needed.