[Acute mental health-caregivers speaking about Meaning in Life when assessing suicidality: a qualitative study]. / Zingeving en suïcidaliteit volgens crisisdiensthulpverleners: een kwalitatief onderzoek.

BACKGROUND: The Multidisciplinary guideline for diagnostics and treatment of suicidal behaviour recommends paying attention to the patients’ perception of meaning in life (MiL) while examining their suicidality. It is unknown how caregivers do this in practice. AIM: To gain insight into the way and the extent in which clinicians explore MiL with patients being assessed for
suicidality and their experiences with it. METHOD: Qualitative research with in-depth interviews among eleven caregivers in acute mental health of Altrecht: data were thematically analysed both deductively and inductively. RESULTS: Five themes emerged: how aspects of MiL emerge in the conversation about suicidality; the intention to understand suicidality by exploring possible protective factors; the effect on patients; the helping and impeding factors for discussing MiL; the participant’s attitude of being present while speaking about the patient’s MiL. CONCLUSION: Participants experience the conversation about MiL with suicidal patients as relevant. It provides information about protective factors, which contributes to the understanding of suicidality. The concept of MiL requires further operationalisation. Follow-up research into the several aspects of MiL in relation to diagnostics of suicidality is recommended.

[Religious diversity: mosaic and dynamics]. / Levensbeschouwelijke diversiteit: mozaïek en dynamiek.

Background  Diversity manifests itself emphatically in the broad field of spirituality and worldview. Aim  To contribute to the diversity competence of mental health professionals consistent with the intent of the WPA Position Statement on religion and spirituality in psychiatry. Method  Explanation of a number of aspects: the spiritual landscape, the problem of definitions, interpretive power and diversity, and the concept of ‘lived religion’ as an alternative. Results  There is a lot of well-researched material available to enable mental health professionals to work with spiritual and worldview diversity. Conclusion  Diversity can mainly be seen as a challenge to do justice to the person asking for care in all respects.

[Migration background and care needs of patients with severe mental illness: an empirical exploration]. / Migratieachtergrond en zorgbehoeften bij patiënten met een ernstige psychiatrische aandoening.

BACKGROUND: A substantial number of mental health care patients have a migration background. It is not clear whether they are given the right sort of care. AIM: To investigate the differences in care needs between patients from western countries and non-western first- and second-generation migrants with severe mental illness (SMI). METHOD: In a cross-sectional study the Camberwell Assessment of Needs was filled in by 914 patients and also by their mental health professionals. We looked at differences in needs in general and specifically at care needs that were met and that were not met for patients of western origin and first-and second generation non-western migrants. These differences were analysed based on care areas: ‘activities of daily living’, ‘mental health’, ‘rehabilitation’ and ‘services’. RESULTS: According to both patients and mental health workers, there were more needs for care with patients in the first and (to a lesser degree) the second generation of non-western migrants. The number of unmet needs is particularly higher for the domains 'mental health' and 'services' experienced by patients with a first generation migration background. Furthermore, for the first generation, mental health care workers mentioned more unmet needs in the rehabilitation domain. Further professionals proved to be uninformed significantly more often about the needs of patients with a migration background, that specifically does concern the items intimate relationships and sexuality. CONCLUSION: Patients with SMI and a non-western migration history have more (unmet) needs for care than western patients with SMI. * BOTH FIRST AUTHORS.

[The six dimensions of positive health valued by different stakeholders within mental health care]. / De waardering van de zes dimensies van positieve gezondheid in de ggz.

BACKGROUND: In recent years a new concept of health, 'positive health', has been developed, which focusses on a person's resilience instead of merely the absence of disease. A previous survey among a variety of stakeholders in general health care showed that there are differences in how dimensions of positive health are valued. Patients valued the spiritual and societal participation dimension higher than physicians and policymakers. AIM: To investigate how the six dimensions of positive health are valued by patients, health care professionals and policymakers in mental health care in the Netherlands, and to test whether these values differ from such stakeholders in general healthcare. METHOD: In a cross-sectional survey patients (N= 458), healthcare professionals (N=250) and policy makers (N=47) of two mental health care institutions in the Netherlands filled in an online survey. The results were compared to the results of the study by Huber e.a. (2016) by ANCOVA, paired T-tests and cohens' d. RESULTS: Respondents valued all dimensions equally high. No significant differences between groups were found, except for a significant difference on daily functioning. Patients rated this dimension significantly higher than other stakeholders. The equal significance of the six dimensions is in contrast with the findings of a previous survey among stakeholders in general health care. CONCLUSION: In contrast to stakeholders in general health care, those in mental health care valued all dimensions of health of equal and high importance. Only daily functioning was rated lower by professionals and policymakers than by patients.

[Assessment of the suicidal state with the CASE approach: a closer look at the design]. / Beoordeling van de suïcidale toestand met de CASE-benadering.

BACKGROUND: Shawn Shea's Chronological Assessment of Suicide Events (CASE approach) is worldwide, including the Netherlands, a well-known and widely used method for clinical interviewing a patient's suicidal state. However, the original description of the author is not always followed. AIM: Comparing the Dutch CASE approach with the original description. METHOD: The Dutch CASE approach has been explored on the basis of the text of the Dutch multidisciplinary guideline and current handbooks. This approach is compared with the original description. RESULTS: Three differences emerge. The main difference is that in the original CASE approach, seven validity techniques represent the foundation for investigation the suicidal state, while these are missing from the Dutch texts. Second, the chronological interview system in the Netherlands is interpreted differently than in the original CASE approach. Third, in the Netherlands, in contrast to the original approach, risk factors and protective factors are included in the study of the suicidal state. CONCLUSION: In the Netherlands, the CASE approach has been adopted in a simplified form, which is useful as a basic skill in the study of suicidal behavior. The diagnosis of suicidality can gain in depth, especially for advanced mental health professionals, by paying attention in training and education to the interviewing techniques of the original CASE approach.

SARS-CoV-2 monitoring at three sewersheds of different scales and complexity demonstrates distinctive relationships between wastewater measurements and COVID-19 case data.

Wastewater monitoring of SARS-CoV-2 presents a means of tracking COVID-19 community infection dynamics on a broader geographic scale. However, accounting for environmental and sample-processing losses may be necessary for wastewater measurements to readily inform our understanding of infection prevalence. Here, we present measurements of the SARS-CoV-2 N1 and N2 gene targets from weekly wastewater samples at three sites in Hamilton County, Ohio, during an increase and subsequent decline of COVID-19 infections. The concentration of N1 or N2 RNA in wastewater, measured over the course of six months, ranged from below the detection limit to over 104 gene copies/l, and correlated with case data at two wastewater treatment plants, but not at a sub-sewershed-level sampling site. We also evaluated the utility of a broader range of variables than has been reported consistently in previous work, in improving correlations of SARS-CoV-2 concentrations with case data. These include a spiked matrix recovery control (OC43), flow-normalization, and assessment of fecal loading using endogenous fecal markers (HF183, PMMoV, crAssphage). We found that adjusting for recovery, flow, and fecal indicators increased these correlations for samples from a larger sewershed (serving ~488,000 people) with greater industrial and stormwater inputs, but raw N1/N2 concentrations corresponded better with case data at a smaller, residential-oriented sewershed. Our results indicate that the optimal adjustment factors for correlating wastewater and clinical case data moving forward may not be generalizable to all sewersheds.

Religiousness and Symptoms of Depression in Native and Immigrant Chronic Dialysis Patients in the Netherlands.

For immigrant chronic dialysis patients, religious behavior and religious coping may have a different impact on depressive symptoms compared to native patients. This study aims to describe both cross-sectional and longitudinal associations between religious behavior and coping with symptoms of depression for 281 native and 277 immigrant dialysis patients in the Netherlands. A higher prevalence of depressive symptoms was found in immigrant compared to native patients (49% vs. 36%). No significant cross-sectional or longitudinal associations were found in both groups between religious behavior and positive religious coping with depressive symptoms. Strong significant cross-sectional associations were found between negative religious coping items and depressive symptoms in both groups, while no longitudinal associations were found. So, similar impact of religiousness on the presence of depressive symptoms was found for both native and immigrant dialysis patients. Therefore, these results do not explain the higher prevalence of depressive symptoms found in immigrant chronic dialysis patients compared to native patients.

[The role of spirituality in psychiatry: important but still unclear]. / De rol van zingeving in de psychiatrie: belangrijk, maar nog onduidelijk.

BACKGROUND: There is an increasing interest in spirituality in relation to psychiatry.
AIM: Exploring the place and meaning of spirituality in mental healthcare.
METHOD: A narrative review of recent developments and results of scientific studies.
RESULTS: Spirituality is related to better (mental) health, wellbeing and longevity, but definitions and conceptualisation are still unclear. Clinical attention is recommended, including awareness of certain risks, but these are not systematically investigated in psychiatry.
CONCLUSION: Spirituality seems to be an important lifestyle factor, that correlates positively with (mental) health, but there is a need for better definitions, conceptualisation and recommendations based on scientific research. A multidisciplinary guideline for psychiatry seems desirable.

[Reflecting on intramural incidents: how do judges think about intramural crimes in mental health care?] / Reflecties op 'instellingsfeiten': de overwegingen van rechters over strafbare feiten gepleegd in de ggz.

BACKGROUND: Various measures aim to stimulate prosecution of violence and aggression against mental-health workers. Considering a possible increase of inpatient incidents through article 2.3 of the Bill Forensic Care, this is a desirable development. Mental health care and the judiciary seem to have opposing opinions whether the emphasis should lie on care or punishment in handling intramural offense.
AIM: To investigate which arguments judges apply in their trial of intramural incidents, to gain insight into the obstacles which impede awarding punishment during treatment, and to give recommendations for balancing the need for care and the need for punishment.
METHOD: A qualitatively thematic analysis based on semi-structured interviews with eight judges. Themes were based on relevant literature and case reports.
RESULTS: The majority of the judges considered judging intramural incidents complicated because of: 1. insufficient information on possible exclusion of guilt, 2. the fear that punishment will lead to recidivism, and 3. ambiguity on the impact of the crime on the victim. They emphasized that they needed more up-to-date information from the institution. Judges wanted to avert punishment as this may lead to discontinuity of care or worsening of the mental health of the suspect.
CONCLUSION: A verdict can also support a (clinical) mental health treatment. With the arrival of the 'bopz-brigades' (Law bopz: Law on Compulsory Admission to Psychiatric Hospitals) at the Public Prosecution Service, all relevant information from mental health care, police and Public Prosecution can be combined into a claim, leading to a verdict in which care and punishment serve each other optimally.

Lack of meaning, purpose and direction in life in personality disorder: A comparative quantitative approach using Livesley's General Assessment of Personality Disorder.

Meaning in life is a motivational force and an existential theme for many people. The concept of meaning comprises purpose, comprehension and mattering. According to the Section III model of personality disorder (DSM-5), lack of meaning, purpose and direction in life is part of personality dysfunction. The present study aimed to determine the association between personality disorder (PD), personality dysfunction and 'lack of meaning, purpose and direction' as a distinct facet of personality dysfunction, using Livesley's self-report questionnaire-the General Assessment of Personality Disorder. This comparative quantitative study showed significant differences in lack of meaning, purpose and direction between a group of patients with PD (n = 126, PD with depression n = 51 and PD without depression n = 75), a group of non-PD patients (n = 76, with depression n = 27 and without depression n = 49) and a control group (n = 444). The PD groups had similar scores as the non-PD patients with depression. Lack of meaning was significantly associated with 'difficulty setting and attaining goals' in all groups, with 'lack of affiliative relationships' in the PD groups and 'sense of inner emptiness' in the PD group without depression and in controls. © 2019 John Wiley & Sons, Ltd.

[Reformed pietists: higher risk for suicide? A retrospective cohort study on the incidence of suicides in a christian institute for mental health care]. / Bevindelijk gereformeerd: risicofactor voor suïcide? Een retrospectief cohortonderzoek naar de incidentie van suïcides in een christelijke ggz-instelling.

BACKGROUND: In scientific literature, active commitment to a religious community is considered to be a protective factor against suicidal behavior. However, it is assumed that this protective effect does not apply to 'reformed pietists' or strict Calvinists, an orthodox-protestant group in the Netherlands.
AIM: To explore whether the incidence of suicide is higher among reformed pietists than among other Christian patients of Eleos, a Dutch christian institute for mental health care.
METHOD: A retrospective cohort study was conducted over the period 2000-2017. All evaluating reports, which were written after a suicide, were analyzed.
RESULTS: In the period 2000-2017 28 evident suicides were committed. The number of suicides among reformed pietistic patients was about 10 times lower than among other Christian patients.
CONCLUSION: The assumption that reformed pietists run a relatively high risk for suicide does not have adequate grounds. In case of risk assessment, reformed pietistic affiliation might be considered to be more a protecting than a risk-increasing factor for suicide.

[Suicide by a psychiatry resident - reflection and postvention]. / Zelfdoding door een aios psychiatrie ­ reflectie en postventie.

BACKGROUND: After the suicide of a psychiatry resident, the coordinators of her trainee program had to face several questions.
AIM: To articulate some of the main questions and to describe our course of action as a way of 'suicide postvention'.
METHOD: Reflection on an anonymized residency situation.
RESULTS: The central question pertained to the dilemma whether the coordinator, supervisor, or other residents should consider the situation from a therapist viewpoint or as employer-colleague. The last option was formally the most valid, but the dilemma related to other questions, such as about our professional identity as psychiatrists. Postvention occurred in several phases (immediate, recovery, reconstruction) and included several meetings with the residents and supervisors. One meeting was facilitated by the spiritual counseler of the institution.
CONCLUSION: A self-critical approach and our postvention approach seemed to supply a need of attention and care for all residency colleagues involved.

Evaluation of clarity of presentation and applicability of monitoring instructions for patients using lithium in clinical practice guidelines for treatment of bipolar disorder.

OBJECTIVES: Clinical practice guidelines (CPGs) for treatment of bipolar disorder (BD) aim to provide guidance to health care professionals on monitoring of patients using lithium. The aim was to assess the clarity of presentation and applicability of monitoring instructions for patients using lithium in CPGs for treatment of BD. METHODS: CPGs for treatment of BD were selected from acknowledged professional organizations from multiple continents. CPGs were rated on the clarity of presentation and applicability of lithium monitoring instructions using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The applicability of monitoring instructions was assessed according to the Systematic Information for Monitoring (SIM) score. Monitoring instructions were considered applicable when a SIM score of ≥3 was found. RESULTS: The clarity of presentation for six out of the nine CPGs was good (>70%) using the AGREE II tool. Only one CPG scored >70% on applicability. Descriptions of the resource implications and facilitators of and barriers to monitoring were most often missing. All CPGs contained instructions for monitoring of lithium serum levels and renal and thyroid function. Information provided in monitoring instructions (n = 247) was in general applicable to clinical practice (77%) based on the SIM score. Overall, a median SIM score of 3 (interquartile range 3-4) was found. CONCLUSIONS: Improvement of the applicability of CPGs is recommended, and can be achieved by describing the resource implications and facilitators of and barriers to monitoring. In addition, information on critical values and instructions on how to respond to aberrant monitoring parameters are needed. With such improvements, CPGs may better aid health care professionals to monitor patients using lithium.

[The associations between God representations and suicidality among Christian patients with a major depressive disorder]. / De relatie tussen godsrepresentaties en suïcidaliteit bij christelijke patiënten met een depressieve stoornis.

BACKGROUND: Depression strongly increases the risk of suicide. Religion is described as a protective factor against suicide. Considering the emotional blunting associated with depression, it is important to investigate the affective dimension of religion. This dimension is conveyed in God representations.
AIM: To describe what types of God representation occur among Christian patients with major depressive disorder and to determine whether there is a relationship between types of God representation and suicide.
METHOD: Clinical and outpatients with a major depressive disorder (n=155) completed the Questionnaire God Representations and the Paykel Suicide Items. A k-means cluster analysis is applied to examine which types of God representations occur among depressed patients. Whether there is a relationship between the different God representations and suicide is examined by applying a linear regression analysis.
RESULTS: Depressed patients uphold two types of God representation: a positive type (n=82) with positive feelings towards God and where God was experienced as supportive, and a negative type (n=73) with anger and anxiety towards God and where God was experienced as passive. Patients with a negative type of God representation scored significantly higher on suicidality. The severity of depression was the main predictor of suicidality, but God representations were also related with a 4% increase in the explained variance.
CONCLUSION: In Christian patients with major depressive disorder a negative and a positive God representation emerged. Patients with a negative God representation mainly seem to feel abandoned by God. The suicidality is significantly increased in patients with a negative God representation, however, the increase in the proportion of the explained variance is small.

[Evaluation of referral and intervention patterns at the psychiatric emergency service, Utrecht 2009-2015]. / Knooppunt psychiatrische crisisdienst: evaluatie van patiëntenstromen; samenhang tussen aanmeldreden, aanmelder en crisisbeleid, Utrecht 2009-2015.

BACKGROUND: Emergency psychiatric care in the Netherlands is provided mainly by community mental health services. Although these emergency services vary in their approach per region, they show many similarities: they tend to receive referrals from the same type of agencies and they practice similar techniques of crisis management.
AIM: To identify some of the patterns that appear in the type of psychiatric problems encountered, the type of referral agencies involved and in the intervention strategies practiced by the psychiatric emergency service in Utrecht.
METHOD: We studied the medical records of 938 crisis assessments compiled during five measurement periods between 2009 and 2015. From all these crisis assessments we selected one sample relating to patients coming only from the city of Utrecht - 'model city Utrecht' - and a second sample consisting only of patients referred either by HAP (emergency primary care), the police or a general hospital. Then, by using cross-tabulation and a multinomial logistic regression analyses, we were able to identify associations between the type of referral agency, the type of referral problem and the type of intervention.
RESULTS: Patients referred by the police were more often forcefully admitted (compulsory admission: 27%) than patients referred by general practitioners (6%); most of these patients were then treated as outpatients (83%). Another pattern that emerged, was that confused or aggressive patients were admitted to hospital more frequently than suicidal patients (26%, 29% and 8% respectively).
CONCLUSION: Our study and current trends in the clinical practice operated by the emergency psychiatric services reveal significant correlations between the type of referrals and the type of intervention. However, further research is needed in order to develop the 'best practice' for emergency psychiatric care in the future.

[Bad or mad? Thinking in terms of 'bad or mad' and the (possible) prosecution of offenses committed by the mentally ill]. / Bad or mad? Invloed van psychiatrische problematiek bij verdachten op strafrechtvervolging.

BACKGROUND: Psychiatrists working for the outreach emergency services of mental health institutions are regularly asked to assess whether a suspect being held at a police station should be charged and later prosecuted or be admitted to a mental institution. In other words, is the suspect 'suited for detention'. Often the representative of the judicial system and the psychiatrist from the emergency services then discuss whether the suspect would be better served by care under the mental healthcare system or under the criminal judicial system. Compulsorily admission to a mental health institution often leads to exemption from prosecution. AIM: To determine what procedure (prison or clinic) will provide the suspect with appropriate care; to find out how to ensure that mentally-ill perpetrators of offences are not assigned erroneously to psychiatric care (i.e. they are 'psychiatricised') and thereby exempted from prosecution, and to determine whether the term 'suited for detention' is applicable to such a person. METHOD: Data were derived from semi-structured interviews with experts from the acute mental health services, the forensic psychiatric services and the criminal justice system. All topics were based on a literature review and on study of case histories. RESULTS: A decision by the emergency services to admit a suspect to a mental health institution influences the views of the representative of a criminal judicial system with regards to the possible imprisonment of the suspect. Thinking in terms of 'bad or mad' can influence the judicial system to give a psychiatric slant to offences or crimes committed by psychiatric patients. Psychiatrists' interpretation of proper care and often their lack of knowledge about the current care facilities available in prisons meant that psychiatrists were more likely than their forensic colleagues to assign suspects to mental health care. According to forensic psychiatrists, their colleagues from mental health care services should not be concerned about whether a suspect is 'suited' or 'unsuited' for detention; their main concern should be what kind of care and treatment the suspect urgently requires. CONCLUSION: The role of the representative of the emergency services present at the police station is to decide what type of care is required at that particular moment. Care within the judicial system is an important option; that type of care can be obtained by involving forensic colleagues in the decision. Awareness of the importance of a dual track policy (conviction/punishment or care) should help to prevent unjustified 'psychiatrisation', of both minor and serious offenses.

[The type of agent auto-intoxication and the degree of suicidal intent]. / Type geneesmiddel en suïcidale intentie na auto-intoxicatie.

BACKGROUND: The type of the agent used for auto-intoxication may increase or decrease the degree of suicidal intent. AIM: To find out whether the type of agent used for auto-intoxication is linked to the degree of suicidal intent at the moment when a patient is given a psychiatric assessment in a general hospital. METHOD: We studied the files of 211 patients who had been assessed following auto-intoxication. The files provided us with information about the type of agent used, the suicidal intent of the patient at the time and about other recent, relevant risk factors. RESULTS: At the time of the assessment, benzodiazepines were the only auto-intoxication agents used which seemed to predict suicidal intent. CONCLUSION: Although the results need to be verified in further studies, it can be concluded that auto-intoxication induced only by benzodiazepines can be seen as a serious expression of an individual's wish to die.

[Body integrity identity disorder, relief after amputation]. / Blijvende opluchting na beenamputatie bij body integrity identity disorder.

Body integrity identity disorder (BIID) is a rare condition in which a person, for no apparent physical reason, is tormented by the experience that a body-part, such as a limb, does not really belong to the body. Patients experience an intense desire for the limb to be amputated (a 'desire' formerly referred to as 'apotemnophilia'). We report on a 58-year-old male patient with BIID who froze one of his legs so that he could amputate it himself. A surgeon ultimately intervened and amputated the leg professionally. The patient was extremely relieved and was still experiencing relief at a follow-up three years later.

Influence of repeated maximal exercise testing on biomarkers and fatigue in sarcoidosis.

Fatigue in the immune mediated inflammatory disease sarcoidosis is thought to be associated with impaired exercise tolerance. This prospective study assessed fatigue and recuperative capacity after repeated exercise, and examined whether changing concentrations in biomarkers upon exercise are associated with fatigue. Twenty sarcoidosis patients and 10 healthy volunteers performed maximal cardiopulmonary exercise tests on two successive days. Concentrations of cytokines, stress hormones, ACE and CK were assessed before and after the two exercise tests, and 3 days thereafter. All participants completed a sleep diary. Severely fatigued patients showed significant lower VO2 max (p=0.038, p=0.022) and maximal workload (p=0.034, p=0.028) on both exercise tests compared to healthy controls. No impairment of maximal exercise testing was demonstrated during the second cycling test in any group. Fatigue was not correlated with changes in concentrations of biomarkers upon exercise. Severely fatigued patients rated both tests as significantly more fatiguing, and reported significant lower mean subjective night sleeping time during the testing period. Fatigue in sarcoidosis patients cannot be objectified by reduction of exercise capacity after repeated maximal exercise testing, and is not correlated with significant changes in biomarkers. Severe fatigue is only and consistently featured by patient reported outcomes.

[Off-label prescriptions in acute psychiatry: a practice-based evaluation]. / Off-labelmedicatie in de crisisdienst: een praktijkevaluatie.

BACKGROUND: In acute psychiatry the prescribed medication is frequently off-label. AIM: To investigate the indications for off-label prescriptions described in the literature and to evaluate the use of off-label medication in the emergency service of Altrecht, Utrecht, The Netherlands. METHOD: We performed a systematic search of the PubMed database and we evaluated all the records of patients examined by the emergency service during two assessment periods (April 2009 and November 2010). RESULTS: The literature makes no mention of the prescribing of off-label medication in acute psychiatry. In general psychiatry, however, off-label medication is reported mainly for atypical antipsychotics. In the emergency service 41% of the medication prescribed during first contacts with patients was off-label. These prescriptions were most often for antipsychotics (54%) and benzodiazepines (38%) . The most important indications were aggression, agitation and sleep problems. If the term ‘off-label’ is interpreted in a broader sense with respect to antipsychotics for psychosis and hypomania, then 33% of the prescriptions appeared to be off-label. If benzodiazepines prescribed for aggression/agitation were not taken into account, then the proportion of off-label prescriptions decreased to 21%. CONCLUSION: We consider it advisable that the reason for prescribing off-label medication should be clearly documented. New medical guidelines could help by summarising current views on the use of off-label medication.