The effect of therapist characteristics on the use and outcome of systematic client feedback in outpatient mental healthcare.

OBJECTIVE: Therapist characteristics are known to affect treatment outcome in general and could also influence the use of systematic client feedback (SCF). The current study explores the effect of feedback orientation, regulatory focus, self-efficacy, attitude towards feedback resources and perceived feedback validity on the use and outcome of SCF in outpatient mental healthcare. METHOD: The data of therapists (n = 12) and patients (n = 504) of two outpatient centres offering brief psychological treatment were analysed when SCF, based on the Partners for Change Outcome Management System (PCOMS), was added to treatment as usual. The data of therapists were obtained through a therapist questionnaire composed of relevant characteristics from feedback studies in social and organizational psychology. The effect on the use of SCF was analysed using logistic regression; whereas, the effect on outcome was assessed using a two-level multilevel analysis. Regular use of SCF and the Outcome Questionnaire (OQ-45) were used as outcome variables. DSM-classification, sex and age of each patient were included as covariates. RESULTS: High perceived feedback validity significantly increased the use of SCF. No significant therapist characteristics effects were found on outcome, but high promotion focus was associated with treating more complex patients. CONCLUSIONS: The perceived feedback validity of SCF is likely to have an influence on its use and is probably affected by the changes in the organizational climate.

Enhancing the effect of psychotherapy through systematic client feedback in outpatient mental healthcare: A cluster randomized trial.

Objective: Systematic client feedback (SCF), the regular monitoring and informing of patients' progress during therapy to patient and therapist, has been found to have effects on treatment outcomes varying from very positive to slightly negative. Several prior studies have been biased by researcher allegiance or lack of an independent outcome measure. The current study has taken this into account and aims to clarify the effects of SCF in outpatient psychological treatment.Method: Outpatients (n = 1733) of four centers offering brief psychological treatments were cluster randomized to either treatment as usual (TAU) or TAU with SCF based on the Partners for Change Outcome Management System (PCOMS). Primary outcome measure was the Outcome Questionnaire (OQ-45). Effects of the two treatment conditions on treatment outcome, patient satisfaction, dropout rate, costs, and treatment duration were assessed using a three-level multilevel analysis. DSM-classification, sex, and age of each patient were included as covariates.Results: In both analyses, SCF significantly improved treatment outcome, particularly in the first three months. No significant effects were found on the other outcome variables.Conclusions: Addition of systematic client feedback to treatment as usual, is likely to have a beneficial impact in outpatient psychological treatment. Implementation requires a careful plan of action.Clinical or methodological significance of this article: This study, with large sample size and several independent outcome measures, provides strong evidence that addition of systematic client feedback to outpatient psychological treatment can have a beneficial effect on treatment outcome (symptoms and wellbeing), particularly in the first three months. However, implementation requires a careful plan of action.

Systematic client feedback to brief therapy in basic mental healthcare: study protocol for a four-centre clinical trial.

INTRODUCTION: The Partners for Change Outcome Management System (PCOMS) is a client feedback-system built on two brief visual analogue self-report scales. Prior studies of PCOMS have found effects varying from significant positive to negative. Aims of present study are; to test the predicted beneficial impact of PCOMS, while accounting for methodological flaws in prior studies and to clarify under which circumstances the addition of PCOMS to therapy has a beneficial effect. METHODS AND ANALYSIS: This study focuses on patients applying for brief, time-limited treatments. Four centres will be randomised to either treatment as usual (TAU) or TAU with PCOMS. All participating patients will be assessed four times. The full staff in the experimental condition will be trained in PCOMS. In the second part of this study, all therapists in the PCOMS condition will fill in a questionnaire concerning the influence of regulatory focus, self-efficacy, external or internal feedback orientation and perceived feedback validity of PCOMS. Finally, patients in the PCOMS condition will be asked to give feedback through a structured interview.The primary outcome measure is the Outcome Questionnaire over the period from beginning to end of therapy. The Mental Health Continuum-Short Form and Consumer Quality Index are also completed. In the primary analysis, outcomes of the two treatment conditions on treatment outcome, patient satisfaction, costs, drop-out and duration will be examined with a three-level (within patient, between patients and between therapists) multilevel analysis. The DSM-classification, sex, education level, age of each patient and therapist factors will be included as covariates. ETHICS AND DISSEMINATION: The Medical Ethics Committee of the University of Twente approved this study (K15-11, METC Twente). Data will be included from 1 January 2016 to 1 July 2019. Study results will be disseminated through peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBER: NTR5466; Pre-results.

Minor neurological dysfunction in children with autism spectrum disorder.

AIM: The aim of this study was to improve the understanding of brain function in children with autism spectrum disorder (ASD) in relation to minor neurological dysfunctions (MNDs). METHOD: We studied MNDs in 122 children (93 males, 29 females; mean age 8 y 1 mo, SD 2 y 6 mo) who, among a total cohort of 705 children (513 males, 192 females; mean age 9 y, SD 2 y 0.5 mo) referred to a regional outpatient non-academic psychiatric centre in the Netherlands, were diagnosed with ASD after an extensive multidisciplinary psychiatric assessment. Children with clear neurological abnormalities (e.g. cerebral palsy or spina bifida) were excluded from the study. MNDs were assessed in all 705 children using the Touwen examination method. Special attention was paid to the severity and type of MND. Data of the children with ASD were compared with neurological morbidity data of children with other psychiatric disorders and with children in the general population, who were born at Groningen University Hospital between 1975 and 1978. RESULTS: Seventy-four percent of the children with ASD showed complex MNDs compared with 52% of the children with other psychiatric disorders and 6% of the reference group (χ(2) =18.0, p<0.001; χ(2) =937.5, p<0.001 respectively). Specific dysfunctions frequently encountered in ASD were dysfunctional posture and muscle tone, fine manipulative disability, dyscoordination, and excessive associated movements. CONCLUSION: These findings suggest a contribution of dysfunctional supraspinal networks involving multiple parts of the brain in the pathogenesis of ASD. This is consistent with findings from neuroimaging studies, and highlights the importance of neurological examinations in paediatric psychiatric assessments.

Minor neurological dysfunction in children with dyslexia.

AIM: to improve understanding of brain function in children with severe dyslexia in terms of minor neurological dysfunctions (MNDs). METHOD: one hundred and four children (81 males, 23 females; age range 7-12y; mean age 9y 7mo, SD 1y 2mo;) with severe dyslexia (the presence of a Full-scale IQ score of ≥ 85, retardation in single-word or text reading of ≥2y), assessed in a department of dyslexia of a third-level regional psychiatric centre, underwent a neurological examination according to Touwen and a multidisciplinary child psychiatric assessment. Special attention was paid to severity and type of MND. Data were compared with neurological morbidity data of children in the general population. RESULTS: most children had MND (87%): 43% had simple MND, 44% complex MND. The incidence of MND was significantly higher (p<0.001) in the children with dyslexia than in the general population (simple MND 15%, complex MND 6%). Children with dyslexia showed especially fine manipulative disability and - to a lesser extent - mild dysfunction in muscle tone regulation and excessive presence of associated movements. A comorbid psychiatric syndrome was diagnosed in 66 children (63%): emotional disturbances (27%), adjustment disorder (42%), hyperkinetic disorder (15%), autism spectrum disorder (3%), specific disturbances of childhood not otherwise specified (13%). The neurological findings of children with dyslexia with and without psychiatric comorbidity were similar. INTERPRETATION: our results demonstrate the importance of neurological and child psychiatric assessment in children with severe dyslexia. Our findings suggest that dysfunction of cortical structures plays a dominant role in dyslexia.

Atherosclerosis in patients with cyanotic congenital heart disease.

BACKGROUND: Cyanotic patients with congenital heart disease (CHD) might be protected against atherosclerosis. METHODS AND RESULTS: Atherosclerotic risk factors and carotid intima - media thickness (IMT) were investigated in adults with cyanotic CHD and in unaffected age- and sex-matched controls. Fifty-four cyanotic patients (30 men, mean age 38, range 19-60 years) and 54 controls were included. Mean transcutaneous saturation of the cyanotic patients was 81+/-6%. Mean carotid IMT adjusted for age was significantly decreased in cyanotic patients compared to controls (0.55+/-0.1 mm vs 0.58+/-0.08 mm: DeltaIMT =0.04 mm [SE 0.015], P=0.01). In cyanotic patients lower total cholesterol levels were observed (4.4+/-1 mmol/L vs 4.9+/-1 mmol/L; P=0.02), as well as lower thrombocyte levels (173+/-81 x 10(9) /L vs 255+/-54 x 10(9) /L; P<0.01), higher bilirubin levels (18.6+/-11 micromol/L vs 12.7+/-6 micromol/L; P<0.01), and lower diastolic and systolic blood pressure (71+/-9 mmHg vs 76+/-9 mmHg, P<0.01; 113+/-14 mmHg vs 124+/-12 mmHg, P<0.01, respectively). CONCLUSIONS: In patients with cyanotic CHD carotid IMT, and hence atherosclerosis disease risk, was decreased. This might be due to a combination of reduced atherosclerotic risk factors such as lower blood pressure, lower total cholesterol levels, higher bilirubin levels and lower thrombocyte levels.

Symptom diagnostics based on clinical records: a tool for scientific research in child psychiatry?

INTRODUCTION: Child psychiatric diagnoses are generally based on a clinical examination and not on standardized questionnaires. The present study assessed whether symptom diagnostics based on clinical records facilitates the use of non-standardized clinical material for research. METHOD: Six hundred and eighty-five children, referred to a third level child psychiatric centre in the Netherlands, were, after extensive multidisciplinary examination, classified according to the multi-axial classification scheme for psychiatric disorders in childhood and adolescence (MAC-ICD-9). By two raters 44 behavioural symptoms were scored based on the clinical records of these children. Interrater agreement on symptoms in 50 records was performed. Principal components analysis on symptom scores of all children was performed; factor scores were related with MAC-ICD-9 classifications. RESULTS: Interrater reliability for behavioural symptoms was excellent (kappa = 0.88). Many children with psychiatric problems suffer from a large number of behavioural symptoms. Factor scores of the symptoms revealed recognizable and well interpretable entities and indicated overlap in symptomatology and comorbidity. CONCLUSION: A symptom-based diagnostic approach based on extensive clinical patient files may provide a special dimension to improve the reliability of psychiatric classification.

An integrative perspective on psychotherapeutic treatments for borderline personality disorder.

Although there is an abundance of literature on the psychotherapeutic treatment of borderline pathology, little is known about differences and similarities between treatments of borderline personality disorder (BPD). Potential differences and similarities are especially important in the absence of evidence of the superiority of one treatment over the other (e.g., Livesley, 2004). This article offers an overview of the theory and practice of contemporary psychotherapeutic treatments of BPD, and delineates similarities and differences between the specific treatments. Results show that similarities concerning (1) the formal characteristics, and (2) the importance of therapeutic techniques in treatments for BPD, outnumber the differences. This article concludes by viewing the similarities and differences from an integrative perspective, and recommendations are given for future work in treating patients with and research on the effectiveness of treatments and treatment techniques for BPD.

Gentamicin-loaded bone cement with clindamycin or fusidic acid added: biofilm formation and antibiotic release.

The formation of staphylococcal biofilms on experimental bone cements, loaded with 0.5 or 1.0 g of active gentamicin and an additional equivalent amount of gentamicin, clindamycin, or fusidic acid was investigated. The biofilms were formed in a modified Robbins device over a 3-day time span and the influence of the additional antibiotics was quantified by expressing the number of colony forming units relative to the corresponding bone cement containing only gentamicin. Combinations of gentamicin with either fusidic acid or clindamycin reduced growth of clinical isolates of both gentamicin-sensitive Staphylococcus aureus and gentamicin-resistant coagulase-negative staphylococci to approximately 28%. To determine whether adding a second antibiotic has influence on the gentamicin release, cement blocks were placed in phosphate buffer and aliquots were taken at designated sampling intervals. The influence of the additional antibiotics was quantified by expressing the percentage released of the total amount of antibiotic incorporated in the different bone cements. After 3 days, all bone cements had released similar percentages of gentamicin, whereas more clindamycin and fusidic acid were released after doubling their concentration in the bone cements. In conclusion, bone cements loaded with combinations of gentamicin and clindamycin or fusidic acid are more effective in preventing biofilm formation than bone cements with gentamicin as a single drug. In addition, the presence of clindamycin or fusidic acid in gentamicin-loaded bone cement has no influence on the total gentamicin release.