Suicidal Behavior and Difficulty of Patients, as Perceived by Community Mental Health Nurses.

BACKGROUND: Mental health professionals who work in community mental health services play an important role in treating patients after attempted suicide or deliberate self-injury. When such behaviors are interpreted negatively, patients may be seen as difficult, which may lead to ineffective treatment and mutual misunderstanding. OBJECTIVE: The goal of this study was to assess the association between the grading of suicidality and perceived difficulty. We hypothesized that a higher grading of suicidality is associated with increased perceived difficulty. METHODS: We analyzed cross-sectional data from 176 patients who participated in 2 cohort studies: 92 patients in the MATCH-cohort study and 84 patients in the Interpersonal Community Psychiatric Treatment (ICPT) study. The dependent variable was perceived difficulty, as measured by the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ) and the Difficulty Single-item (DSI), a single item measuring the difficulty of the patient as perceived by the professional. Grading of suicidality was considered as the independent variable. Multiple linear and logistic regression was performed. RESULTS: We found a significant association between perceived difficulty (DDPRQ) and high gradings of suicidality (B: 3.96; SE: 1.44; ß: 0.21; P=0.006), increasing age (B: 0.09; SE: 0.03; ß: 0.22; P<0.003), sex (female) (B: 2.33; SE: 0.83; ß: 0.20; P=0.006), and marital status (being unmarried) (B: 1.92; SE: 0.85; ß: 0.17; P=0.025). A significant association was also found between the DSI and moderate (odds ratio: 3.04; 95% CI: 1.355-6.854; P=0.007) and high (odds ratio: 7.11; 95% CI: 1.8.43-24.435; P=0.005) gradings of suicidality. CONCLUSION: In this study, we found that perceived difficulty was significantly associated with moderate and high gradings of suicidality, increasing age, female sex, and being unmarried.

Lower versus higher frequency of sessions in starting outpatient mental health care and the risk of a chronic course; a naturalistic cohort study.

BACKGROUND: An adequate frequency of treatment might be a prerequisite for a favorable outcome. Unfortunately, there is a diversity of factors that interfere with an adequate frequency of sessions. This occurs especially in the first phase of treatment, while the first phase seems vital for the rest of treatment. The aim of this naturalistic study was to explore the impact of the initial frequency of treatment sessions on treatment outcome in a diverse mental health care population. METHODS: Anonymized data were analyzed from 2,634 patients allocated for anxiety disorders, depressive disorders, and personality disorders to outpatient treatment programs in a large general mental health care facility. Patients' treatment outcome was routinely monitored with the Outcome Questionnaire-45 (OQ-45.2), every 12 weeks. Frequency of sessions was assessed for the first three months of treatment. Using Cox-proportional-hazard models, we explored the associations between initial frequency and improvement (reliable significant change) and recovery (reliable and clinically significant change). RESULTS: Improvement and recovery were associated with symptom severity and functional impairment at start of treatment, the year the treatment started, number of measurements, the treatment program (anxiety disorders, depressive disorders, and personality disorders) and receiving group therapy other than psychotherapy. In all diagnostic groups, both improvement and recovery were associated with a higher frequency of sessions during the first three months of treatment. For improvement, this effect diminished after three years in treatment; however, for recovery this association was sustained. CONCLUSIONS: In addition to severity at start of treatment and other predictors of outcome, a low frequency of initial treatment sessions might lead to a less favorable outcome and a more chronic course of the mental disorder. This association seems not to be limited to a specific diagnostic group, but was found in a large group of patients with common mental disorders (depression and anxiety disorders) and patients with a personality disorder. Despite organizational obstacles, more effort should be made to start treatment quickly by an effective frequency of session.

A Cost-Effectiveness Analysis to Evaluate a System Change in Mental Healthcare in the Netherlands for Patients with Depression or Anxiety.

Over the last decade, the Dutch mental healthcare system has been subject to profound policy reforms, in order to achieve affordable, accessible, and high quality care. One of the adjustments was to substitute part of the specialized care for general mental healthcare. Using a quasi-experimental design, we compared the cost-effectiveness of patients in the new setting with comparable patients from specialized mental healthcare in the old setting. Results showed that for this group of patients the average cost of treatment was significantly reduced by, on average, €2132 (p < 0.001), with similar health outcomes as in the old system.

Comparing Methods to Denote Treatment Outcome in Clinical Research and Benchmarking Mental Health Care.

Approaches based on continuous indicators (the size of the pre-to-post-test change; effect size or ΔT) and on categorical indicators (Percentage Improvement and the Jacobson-Truax approach to Clinical Significance) are evaluated to determine which has the best methodological and statistical characteristics, and optimal performance, in comparing outcomes of treatment providers. Performance is compared in two datasets from providers using the Brief Symptom Inventory or the Outcome Questionnaire. Concordance of methods and their suitability to rank providers is assessed. Outcome indicators tend to converge and lead to a similar ranking of institutes within each dataset. Statistically and conceptually, continuous outcome indicators are superior to categorical outcomes as change scores have more statistical power and allow for a ranking of providers at first glance. However, the Jacobson-Truax approach can complement the change score approach as it presents outcome information in a clinically meaningful manner. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONERS MESSAGES: When comparing various indicators or treatment outcome, statistical considerations designate continuous outcomes, such as the effect size of the pre-post change (effect size or ΔT) as the optimal choice. Expressing outcome in proportions of recovered, changed, unchanged or deteriorated patients has supplementary value, as it is more easily interpreted and appreciated by clinicians, managerial staff and, last but not the least, by patients. If categorical outcomes are used with small datasets, true differences in institutional performance may get obscured due to diminished power to detect differences. With sufficient data, outcome according to continuous and categorical indicators converge and lead to similar rankings of institutes' performance.

Review of systematic reviews about the efficacy of non-pharmacological interventions to improve sleep quality in insomnia.

Background Insomnia is a very common condition in various populations. Non-pharmacological interventions might offer (safe) alternatives for hypnotics. Aim To evaluate the evidence for efficacy from systematic reviews about non-pharmacological interventions to improve sleep quality in insomnia by a systematic review of systematic reviews and meta-analyses. Search strategy Search strategies were conducted in the Database of Abstracts of Reviews of Effects (2002-July 2008), The Cochrane Database of Systematic Reviews (2000-July 2008) and PubMed (1950-July 2008). Sleep quality was the outcome measure of interest. Selection criteria Systematic reviews about the efficacy of one or more non-pharmacological interventions for insomnia, concerning both adult and elderly populations, were included. Reviews that included studies performed among populations suffering with severe neurological or cognitive impairments or with addictive disorders were excluded. Data analysis Relevant data were extracted. The quality of the reviews found was appraised by using the Overview Quality Assessment Questionnaire. The evidence was appraised and divided into six classes. Results and conclusions Sixteen reviews about 17 interventions were included. Six reviews were of adequate methodological quality. Of these, only one provided an effect size: a moderate effect was found for music-assisted relaxation. Weak evidence indicating a large effect was found for multicomponent cognitive behavioural therapy, progressive muscle relaxation, stimulus control and 'behavioural only'. Weak evidence indicating a moderate effect was found for paradoxical intention. Finally, weak evidence indicating a moderate to large effect was found for relaxation training. Because of the lack of sufficient methodological quality and the lack of calculated effect sizes, most of the included reviews were not suitable for drawing rigorous conclusions about the effect of non-pharmacological interventions on sleep quality in insomniacs. The non-pharmacological treatment of insomnia would benefit from renewed reviews based on a rigorous methodological approach.

Sodium and potassium intake and risk of cardiovascular events and all-cause mortality: the Rotterdam Study.

BACKGROUND: Dietary electrolytes influence blood pressure, but their effect on clinical outcomes remains to be established. We examined sodium and potassium intake in relation to cardiovascular disease (CVD) and mortality in an unselected older population. METHODS: A case-cohort analysis was performed in the Rotterdam Study among subjects aged 55 years and over, who were followed for 5 years. Baseline urinary samples were analyzed for sodium and potassium in 795 subjects who died, 206 with an incident myocardial infarction and 181 subjects with an incident stroke, and in 1,448 randomly selected subjects. For potassium, dietary data were additionally obtained by food-frequency questionnaire for 78% of the cohort. RESULTS: There was no consistent association of urinary sodium, potassium, or sodium/potassium ratio with CVD and all-cause mortality over the range of intakes observed in this population. Dietary potassium estimated by food frequency questionnaire, however, was associated with a lower risk of all-cause mortality in subjects initially free of CVD and hypertension (RR = 0.71 per standard deviation increase; 95% confidence interval: 0.51-1.00). We observed a significant positive association between urinary sodium/potassium ratio and all-cause mortality, but only in overweight subjects who were initially free of CVD and hypertension (RR = 1.19 (1.02-1.39) per unit). CONCLUSION: The effect of sodium and potassium intake on CVD morbidity and mortality in Western societies remains to be established.