[Diagnostics and treatment of suicidality; a matter of customization]. / Diagnostiek en behandeling van suïcidaliteit; een kwestie van maatwerk.

This article illustrates the importance of conducting a comprehensive analysis of suicidality through the case study of an adolescent patient dealing with both depressive disorder and obsessive-compulsive disorder. The aim of treating suicidality is to address the underlying psychiatric conditions and factors contributing to the disorder. This necessitates a thorough evaluation of the treatment environment, the establishment of continuous care, and ensuring safety. By utilizing a new model to distinguish various forms of suicidal behavior and examining suicidality as a distinct phenomenon, it becomes possible to create individualized diagnostic and treatment approaches, along with effective risk assessments. In the presented patient, intrusive thoughts significantly impacted her suicidality. The treatment approach for patient A involved employing eye movement dual task (EMDT), exposure therapy and strategies to enhance autonomy. This approach aims to reduce suicidality, facilitate recovery, and alleviate the fear of losing control.

Evidence for Underregistration of Suicide.

In this case report, we will present two cases in which the Dutch municipal coroner registered a natural death, but treating psychiatrists doubted the validity of this decision on the grounds of clinical data and investigation. For both cases, we present evidence that deaths likely resulted from suicide, raising serious doubts about the accuracy of the registered cause of death. According to the WHO bulletin on suicide prevention, the national registration of suicide is unsatisfactory in many countries. The Netherlands is listed by the WHO as having one of the most accurate registration procedures. Nevertheless, there are indications that national registration, even in the Dutch system, is not infallible. In this case report, we present several ways in which the registration process is liable to error and evidence for underregistration of suicide rates.

[Data-guided learning from suicidal incidents by using KEHR SUICIDE. A practice example in a Dutch mental health care facility]. / Datagestuurd leren van suïcidale incidenten met KEHR SUICIDE: GGz Eindhoven als praktijkvoorbeeld.

BACKGROUND: Specific and systematic data on health care providers' behaviour is needed to futher improve the care provided to suicidal patiënts in mental health care facilities.
METHOD: Explorative observational study of all suicidal incidents (n=50) that occurred in a Dutch mental health care facility over a one year period. Incidents were evaluated using KEHR SUICIDE, a questionnaire that assesses to what extent health care providers' conduct was compliant to the suicide practice guideline in the context of patients' suicidal behaviour. Associations between health care providers' and patients' features and guideline compliant behaviours of health care providers were calculated by logistic regression models.
RESULTS: Health care providers showed less guideline compliant behaviour when the patient had a psychotic, substance abuse or development disorder or had no axis 1 disorder. A positive association was found between guideline compliant behaviour and the extent to which the incident had been expected. CONCLUSION Guideline compliant behaviour of mental health care providers appears to be related to the axis 1 disorder of patients in a Dutch mental health care facility. Still, the application of guideline compliant behaviour concerning suïcide incidents shows room for improvement. KEHR SUICIDE is shown to be a helpful tool for multidisciplinary evaluation of suicidal incidents as it provides specific, ready-made information by which mental health care facilities can guide, examine and adjust suicide prevention policy. The outcomes provide hypotheses that may be examined in future research.

[Suicidal behaviour and attempted suicide occurring during assessment by the outreach psychiatric emergency service]. / Het vóórkomen van suïcidaal gedrag en suïcidepogingen bij de psychiatrische crisisdienst.

BACKGROUND: The outreach emergency psychiatric service plays an important role in recognising, arranging interventions and preventing suicide and suicidal behaviour. However, little is known about the assessments that members of the emergency team make when faced with patients showing suicidal behaviour.
AIM: To describe the relationships that are revealed between patient characteristics, suicidal thoughts and attempted suicide during assessments made by the emergency psychiatric service in The Hague.
METHOD: The emergency service kept a detailed record of 14,705 consultations. We compared the characteristics of patients who had suicidal thoughts with those of patients who had no such thoughts and we also compared the characteristics of patients who had attempted to commit suicide with those of patients who had not. We drew these comparisons by using logistic regression models, adjusting for clustering.
RESULTS: 32.2% of the patients showed signs of suicidal behaviour and 9.2 % appeared likely to attempt suicide. Suicidal behaviour occurred most often in patients with depression. Suicidal patients were more often admitted to hospital than were non-suicidal patients and they were more likely to have been referred by a general practitioner or a general hospital. Medication was the most frequent means employed in attempts to commit suicide.
CONCLUSION: In about one third of the consultations of the outreach emergency psychiatric service, the patient showed suicidal behaviour. The actions and the policy of the emergency psychiatric service with regard to suicidal behaviour were diverse and dependent on factors that could change over the course of time.

[The proportion of suicides committed by patients with a mental health disorder for which treatment costs are now no longer reimbursed by health insurance]. / Het aandeel suïcides door patiënten met een stoornis waarvan de ggz-behandeling thans niet meer vergoed wordt.

BACKGROUND: Suffering from a psychiatric disorder is a well-known risk factor for suicide and suicidal behavior. Treatment of psychiatric disorders can reduce the risk of suicidal behavior and suicide. In the Netherlands, however, since 2012 the treatment costs of some psychiatric disorders have no longer been covered by health insurance.
AIM: To find out what proportion of suicides were committed by patients with a psychiatric disorder for which treatment costs are no longer covered by health insurance since the rules changed in 2012.
METHOD: We studied the files of 314 patients who were known to one of the large mental health hospitals in the Netherlands and who had committed suicide between 1 January 1999 and January 2012. We were able to determine the various psychiatric disorders from which the patients were suffering at the time they died.
RESULTS: About 6% of the patients who committed suicide between 1999 and 2012 suffered from a psychiatric disorder for which treatment costs are now no longer covered by health insurance.
CONCLUSION: Given the results of this study, the increased rates of suicide in the Netherlands and the importance of scientific research into the characteristics of suicide, we recommend that patients with suicidal behavior are not excluded from adequate treatment in the event they may or may not have met the criteria for a DSM-IV classification.

[A study of the connection between coercive measures used in a closed acute psychiatric ward and the socio-demographic and clinical characteristics of the patients involved]. / Dwang- en drangmaatregelen binnen een gesloten acute psychiatrische opnameafdeling; relatie met socio-demografische en klinische kenmerken.

BACKGROUND: Admission at a closed acute psychiatric ward is a severe and possibly life changing experience for a patient. Sometimes admission is accompanied by coercive measures. Despite the impact that these measures may have on the patient, very little research has been published concerning this patient population. AIM: To obtain insight into the connection between the socio-demographic characteristics of patients admitted to a closed acute psychiatric ward and the coercive measures to which they were subjected. METHOD: For a year a database was compiled to give us information about the socio-demographic and clinical characteristics of patients admitted to a closed acute psychiatric ward in The Hague in the Netherlands. This record enables us to analyse the relation between these characteristics and coercive measures. RESULTS: The majority of patients admitted were male, single, childless and were unemployed or not in education but were receiving some form of welfare payment. 33% of admissions were in fact re-admissions. 20% of the admissions/re-admissions were secluded during the admission procedure - for the following reasons: symptoms of a psychotic disorder, a manic episode and/or aggression. Secluded patients were younger and had more serious psychiatric problems; they functioned less well and had been in hospital longer than patients who had not been secluded upon admission. During the admission procedure 14% of patients received emergency medication. CONCLUSION: These results have given us more insight into the connection between the use of coercive measures in psychiatry and the socio-demographic characteristics and clinical characteristics of the patients involved. This information could serve as reference material for future research.

[An evaluation of a new Dutch suicide prevention tool (KEHR); datadriven evaluation and learning]. / Pilotstudie naar kwalitatieve evaluatie van het handelen rond suïcide (KEHR); datagestuurd evalueren en leren.

BACKGROUND: Multidisciplinary evaluation of suicide cases effectively decreases the suicide rate in mental health care. A new suicide prevention tool (KEHR) can be used in this connection. KEHR has been developed on the basis of the Dutch multidisciplinary practice guideline on the assessment and treatment of suicidal behaviour. The guideline can serve as a frame of reference for the multidisciplinary evaluation of suicide cases. KEHR aims to provide professionals with a better method for preventing suicide. AIM: To describe and evaluate the recently developed KEHR strategy for reducing the number of suicide cases in mental health care. METHOD: Naturalistic and observational study. In the course of a year 22 out of 23 suicide cases that had occurred in the pilot institution were evaluated with the help of the KEHR system. Outcomes were discussed with members of multidisciplinary teams. Quantitative and qualitative methods were used in the evaluation process. RESULTS: Professionals from the main disciplines involved were very willing to use the new tool and were prepared to reflect on their views on the outcomes. The professionals were ready to learn from the suicide cases. Data collected with the tool provided information that can be used to improve guideline adherence. However, the use of KEHR did not lead automatically to the formulation of adjustments and improvements relating to suicidal patients. A specific procedure for improving individual and team performance needs to be developed and tested thoroughly. CONCLUSION: KEHR is a promising strategy for improving and enhancing the guideline on the diagnosis and treatment of suicidal behaviour of patients in mental health care. Special procedures need to be developed and studied in order to implement the improvements deemed necessary as a result of the pilot study. The KEHR tool (in the Dutch language) is accessible to mental health care workers after online registration (www.mijnkehr.nl).

[Copy number variations and 'schizophrenia']. / Copynumbervariaties en 'schizofrenie'

BACKGROUND: Copy number variations (CNVs) are subtle variations in our genetic material. In view of the scientific claim that schizophrenia depends for 40 to 80% on hereditary factors, we need to find out what role the cnvs play in this process. AIM: To provide an overview of what is currently known about CNVs and to summarise the implications of this information for the conceptualisation of 'schizophrenia' and for the diagnosis and treatment of psychoses. METHOD: We performed a literature search using PubMed. RESULTS: The literature consulted contains discussions of 23 CNVs that are associated with an increased risk of psychosis. However, the relationship between the two variables is heterogeneous and pluriform in the sense that CNVs are often associated with several disorders or their penetrance varies considerably under the influence of gene modifiers and environmental factors. CONCLUSION: Research into CNVs demonstrates that the relationship between psychosis and heredity is of a even more subtle nature than the two pioneers Kraepelin and Rüdin had been able to foresee. It is to be expected that in the near future research will contribute to a deconstruction of the schizophrenia concept, to a blurring of the hitherto sharply defined boundaries between different (particularly severe) mental disorders and to the introduction of genetic counselling into regular psychiatric diagnostic procedures.

[Manic-psychotic symptoms as clinical manifestation of hyperparathyroidism]. / Manisch-psychotische verschijnselen in het kader van hyperparathyreoïdie met aspecifiek beloop.

We discuss the case history of a woman aged 49 years who displayed manic-psychotic symptoms as a clinical manifestation of hyperparathyroidism. Following resection of the parathyroid she developed severe depression. Primary hyperparathyroidism (PHPT) is characterised by an increase of the parathyroid hormone (PTH), which in turn leads to an increase in the plasma calcium. PHPT can be accompanied by various psychiatric symptoms ranging from personality changes and severe depression to obsessive-compulsive and paranoid symptoms.

[Folie à famille: a Surinamese-Hindustani family with a shared paranoid delusion and severe undernourishment]. / Folie à famille: een Surinaams-Hindoestaans gezin met een gedeelde paranoïde waan en ernstige ondervoeding.

Folie à famille is a rare psychiatric condition in which several family members develop similar psychotic symptoms. We describe the case of a family of four with a shared paranoid delusion, who all obtained complete remission after being treated with antipsychotics on different psychiatric wards.

[Diagnostics with the MINI-plus in acute psychiatry]. / Diagnostiek met MINI-plus in de acute psychiatrie.

BACKGROUND: Little is known about diagnostic procedures in acute psychiatry. AIM: To investigate the applicability of a structural diagnostic instrument in this setting and compare the results with clinical judgement. METHOD: The assessment was based on the mini International Neuropsychiatric Interview-plus. RESULTS: There was poor agreement between the mini-plus diagnosis and clinical judgement and co-morbidity was under-reported. CONCLUSION: There is a need for a structural diagnostic instrument and more attention must be given to clinical diagnostic procedures in acute psychiatry.

Reduced cooperativeness and reward-dependence in depression with above-normal plasma vasopressin concentration.

The neuropeptide vasopressin is centrally involved in the regulation of social behaviour and response to stress. We previously found support for a subcategory of depression defined by above-normal plasma vasopressin (AVP) concentration. This subcategory is validated by a positive family history of depression and correlating plasma AVP and cortisol concentrations. The data support the validity of above-normal plasma AVP concentration as a genetically determined biological marker for a subcategory of depression. The aim of the present study was to test whether above-normal plasma AVP concentration in depression is related to personality characteristics reflecting a specific social behaviour style. The data of 78 patients from a previously investigated sample were reanalysed. Fifty-eight patients were available after 2 years, 15 of whom with initially above-normal plasma AVP. The dimensions of the Temperament and Character Inventory (TCI) were scored, with particular focus on the dimensions of Cooperativeness (CO) and Reward-dependence (RD). Normative subjects and other depressed subjects were used as controls. After full remission, patients with initially above-normal AVP had low CO compared with normal and patient controls. During depression, these patients had both low CO and low RD compared with normal controls and low RD compared with patient controls. Low CO is a presumably premorbid trait and reduced RD a state-dependent characteristic in depression with above-normal plasma AVP. The low CO further supports the validity of above-normal plasma AVP concentration as a genetically determined biological marker for a subcategory of depression.

Anxious-retarded depression: relation to two-year outcome of major depressive disorder.

BACKGROUND: Anxious-retarded depression is a two-dimensionally defined subcategory of depression derived from DSM-IV melancholia. It is related to increased plasma vasopressin, correlative plasma vasopressin and cortisol levels, and a positive family history. We now explored its relation with outcome. METHODS: Seventy depressed patients were included to follow-up for two years. Outcome was defined by time until full-remission. Cox regression analyses were used to compare anxious-retarded and non-anxious-retarded patients, as well as melancholic and non-melancholic patients. RESULTS: Anxious-retarded depression had poor outcome. LIMITATIONS: The number of patients was relatively small. CONCLUSION: The poor outcome of anxious-retarded depression further supports its validity.