[Flemish guideline for the prevention and use of seclusion and restraint]. / Vlaamse richtlijn voor de preventie en het gebruik van afzondering en fixatie.

BACKGROUND: International consensus states that seclusion and restraint should only be applied as briefly and as little as possible. However, audits by the Care Inspectorate show that this is not always the case in Flemish mental health care (MHC). AIM: To describe the development of a multidisciplinary guideline for the prevention and application of seclusion and restraint in inpatient MHC, underpinned by both clinical-scientific and legal evidence. METHOD: The GRADE method formed the basis for the development of the guideline. To integrate both types of evidence, two research phases were added. This article provides an overview of the challenges involved in implementing this interdisciplinary method. RESULTS: There are gaps in both clinical-scientific and legal evidence. Nevertheless, the study resulted in a comprehensive guideline because we underpinned the recommendations with practice- and experience-based expertise of the Flemish stakeholders, and integrated the clinical-scientific and legal evidence. CONCLUSION: Focus on implementation research and a clear legal framework for Flanders are necessary to safeguard the (human) rights of MHC users, also in the event of aggression and escalation.

[Vision on and use of physical restraints and 'smart technology' in nursing homes in Flanders]. / Fysieke fixatie en slimme technologie in Vlaamse woonzorgcentra: Resultaten van een surveybevraging bij zorg- en beleidspersoneel over visie en gebruik.

AIM: The STAFF-project investigates in what way 'smart technology' can offer an alternative for physical restraints in nursing homes. A survey is realized aimed at gaining more insight into the vision on and the use of physical restraints and 'smart technology'. METHOD: Two partly overlapping structured questionnaires were developed and sent to nursing home staff in Flanders (Belgium). One hundred fifty six administrators (managers or assistant-managers) and 238 caregiving staff (nurses, nursing aids, paramedical staff and other) completed the online questionnaire. RESULTS: In general there is a low acceptability of physical restraint use, however, a more nuanced picture of acceptability is present depending on the specific motivation for using physical restraints and on the specific means of physical restraints. About half of the administrators say they use smart technology in the nursing home. The two main reasons for not applying (yet) smart technology are 'too high price for smart technology' and 'inadequate infrastructure of the nursing home'. All respondents underscore the importance of multiple strategies to diminish the use of physical restraints in nursing homes. CONCLUSION: Physical restraint use is a complex theme and needs a nuanced analysis and management. This study shows that there is still room for improvement in diminishing the use of physical restraints and that nursing homes in Flanders are open to use smart technology.

The determinants of informal caregivers' burden in the care of frail older persons: a dynamic and role-related perspective.

Research into informal caregivers' burden does not distinguish between different stages of impairment. This study explored the determinants of burden from an in-depth perspective in order to identify which determinants apply to which phases of impairment. METHODS: This was a cross-sectional study including frail older persons aged 65 and above. Instruments used were the interRAI Home Care, the Zarit-12 interview and an ad hoc economic questionnaire. A combination of variables from the Stress Process Model and Role Theory and a sub-group analysis enabled refined multivariate logistic analyses. RESULTS: The study population consisted of 4175 older persons (average age: 81.4 ± 6.8, 67.8% female) and their informal caregivers. About 57% of them perceived burden. Depressive symptoms, behavioral problems, IADL impairment, previous admissions to nursing homes and risk of falls yielded significant odds ratios in relation to informal caregivers' burden for the whole sample. These determinants were taken from the Stress Process Model. When the population was stratified according to impairment, some factors were only significant for the population with severe impairment (behavioral problems OR:2.50; previous admissions to nursing homes OR:2.02) and not for the population with mild or moderate impairment. The informal caregiver being an adult child, which is a determinant from Role Theory, and cohabitation showed significant associations with burden in all strata. CONCLUSION: Determinants of informal caregivers' burden varied according to stages of impairment. The results of this study can help professional caregivers gain a greater insight into which informal caregivers are most susceptible to perceive burden. ABBREVIATIONS: NIHDI: National Institute for Health and Disability Insurance; ZBI12: Zarit Burden Interview - 12 items; InterRAI HC: interRAI Home Care instrument; ADL: Activities of Daily Living; ADLH: interRAI Activities of Daily Living Hierarchy scale; IADL: Instrumental Activities of Daily Living; IADLP: InterRAI Instrumental Activities of Daily Living Performance scale; CPS2: InterRAI Cognitive Performance scale 2; DRS: InterRAI Depression Rating scale.

[Nighttime restlessness in people with dementia in residential care: an explorative field study]. / Nachtelijke onrust bij personen met dementie in woonzorgcentra: een verkennende veldstudie.

Nighttime restlessness in dementia is an underestimated problem. Although little is known about the prevalence and not every person with dementia struggles with it, nighttime restlessness puts a heavy burden on the persons themselves and their caregivers.This field study explores nighttime restlessness in nursing homes based on two research questions: (1) What is nighttime restlessness according to professional caregivers? and (2) How is nighttime restlessness managed?Data were collected through diaries, interviews with caregivers and one night of observation in eight nursing homes.Wandering and screaming seem to be the most prevalent nighttime agitated behaviours. Caregivers identify many possible causes, but spatial and sensory factors, such as light or noise, were rarely mentioned spontaneously. The observations highlighted that a lot of light and noise is prominent and this might be causing nighttime restlessness.Caregivers try several strategies: for example talking with the resident, put on a light and apply medication or physical restraints.The management of nighttime restlessness requires a holistic approach. Caregivers' attention for and efforts to ameliorate the spatial and sensory environment in the management of nighttime restlessness are limited.

Discrimination in the workplace, reported by people with major depressive disorder: a cross-sectional study in 35 countries.

OBJECTIVE: Whereas employment has been shown to be beneficial for people with Major Depressive Disorder (MDD) across different cultures, employers' attitudes have been shown to be negative towards workers with MDD. This may form an important barrier to work participation. Today, little is known about how stigma and discrimination affect work participation of workers with MDD, especially from their own perspective. We aimed to assess, in a working age population including respondents with MDD from 35 countries: (1) if people with MDD anticipate and experience discrimination when trying to find or keep paid employment; (2) if participants in high, middle and lower developed countries differ in these respects; and (3) if discrimination experiences are related to actual employment status (ie, having a paid job or not). METHOD: Participants in this cross-sectional study (N=834) had a diagnosis of MDD in the previous 12 months. They were interviewed using the Discrimination and Stigma Scale (DISC-12). Analysis of variance and generalised linear mixed models were used to analyse the data. RESULTS: Overall, 62.5% had anticipated and/or experienced discrimination in the work setting. In very high developed countries, almost 60% of respondents had stopped themselves from applying for work, education or training because of anticipated discrimination. Having experienced workplace discrimination was independently related to unemployment. CONCLUSIONS: Across different countries and cultures, people with MDD very frequently reported discrimination in the work setting. Effective interventions are needed to enhance work participation in people with MDD, focusing simultaneously on decreasing stigma in the work environment and on decreasing self-discrimination by empowering workers with MDD.

[Risk factors and protective factors relating to suicide in the Netherlands and Flanders]. / Risicofactoren en beschermende factoren inzake suïcide in Nederland en Vlaanderen.

BACKGROUND: The suicide rate is 82% higher in the Flanders region of Belgium than in the Netherlands. AIM: To investigate to what extent Flanders and the Netherlands differ with regard to the risk factors and protective factors relating to suicide and attempted suicide. METHOD: By means of a structured postal questionnaire, we collected data on the following topics from 2999 Flemish and Dutch people between 18 and 64 years: mental well-being and earlier attempts to commit suicide, the help they had received and their intention to seek help for psychological problems, awareness of the mental health care available, satisfaction with the help received, and attitudes to suicide. RESULTS: The incidence of psychological problems and suicidality did not differ significantly between Flanders and the Netherlands. Compared to Flemish people, Dutch people with psychological problems had received more psychological help and more often expressed the intention to seek help in the future. Furthermore, the Dutch were better informed about mental health care, and patient satisfaction was higher in the Netherlands. Compared to the Flemish people, the Dutch had more positive and understanding attitude to suicide. CONCLUSION: In general, risk factors for suicide were similar in the Netherlands and Flanders. However, the Dutch were characterised by more protective factors. We attempt to explain these differences and suggest ways of improving suicidal prevention policy.

The state of the art in European research on reducing social exclusion and stigma related to mental health: a systematic mapping of the literature.

Stigma and social exclusion related to mental health are of substantial public health importance for Europe. As part of ROAMER (ROAdmap for MEntal health Research in Europe), we used systematic mapping techniques to describe the current state of research on stigma and social exclusion across Europe. Findings demonstrate growing interest in this field between 2007 and 2012. Most studies were descriptive (60%), focused on adults of working age (60%) and were performed in Northwest Europe-primarily in the UK (32%), Finland (8%), Sweden (8%) and Germany (7%). In terms of mental health characteristics, the largest proportion of studies investigated general mental health (20%), common mental disorders (16%), schizophrenia (16%) or depression (14%). There is a paucity of research looking at mechanisms to reduce stigma and promote social inclusion, or at factors that might promote resilience or protect against stigma/social exclusion across the life course. Evidence is also limited in relation to evaluations of interventions. Increasing incentives for cross-country research collaborations, especially with new EU Member States and collaboration across European professional organizations and disciplines, could improve understanding of the range of underpinning social and cultural factors which promote inclusion or contribute toward lower levels of stigma, especially during times of hardship.

Attitudes and stigma in relation to help-seeking intentions for psychological problems in low and high suicide rate regions.

PURPOSE: Accessibility and availability of mental health care services are necessary but not sufficient for people to seek help for psychological problems. Attitudes and stigma related to help seeking also determine help seeking intentions. The aim of this study is to investigate how cross-national differences in attitudes and stigma within the general population are related to professional and informal help seeking intentions in low and high suicide rate regions. METHODS: By means of a postal structured questionnaire, data of 2999 Dutch and Flemish respondents between 18 and 65 years were gathered. Attitudes toward help seeking, perceived stigma, self-stigma, shame and intention to seek help were assessed. RESULTS: People in the Netherlands, where suicide rates are low, have more positive attitudes toward help seeking and experience less self stigma and shame compared to the people in Flanders, where suicide rates are relatively high. These attitudinal factors predicted professional as well as informal help seeking intentions. Perceived stigma was negatively associated with informal help seeking. Shame was positively associated with higher intention to use psychotropic drugs and perceived stigma was negatively associated with the intention to seek help from a psychotherapist in Flanders but not in the Netherlands. CONCLUSION: Help seeking for psychological problems prevent these problems to aggravate and it is assumed to be a protective factor for suicide. Our results stress the importance of the promotion of positive attitudes and the reduction of stigma within the general population to facilitate help seeking from professional providers and informal networks. Focusing on these attitudinal factors is believed to be a key aspect of universal mental health and suicide prevention policies.

Evaluating a decision aid for patients with localized prostate cancer in clinical practice.

AIM: The aim of the study was to evaluate the usefulness of a decision aid regarding treatment options for patients with early-stage localized prostate cancer. METHODS: 50 patients with newly diagnosed localized prostate cancer received the decision aid and were interviewed twice: before the decision-making consultation with the physicians and before treatment or, in case of watchful waiting, before the follow-up consultation. The physicians (radiation oncologists and urologists) were interviewed after the consultation. RESULTS: The patients became more active partners in the decision-making process: They were better prepared for the consultation, asked more direct information, and were able to make a more deliberative choice. Generally, the use of the decision aid improved the quality of the consultation and resulted in a treatment decision agreed upon by both parties. Sometimes the consultation turned out to be more time-consuming. The decision aid did not only improve the patient-physician interaction but also helped patients to discuss the disease with their partner and family members. CONCLUSION: The use of the decision aid has a positive impact on the consultation and the decision-making process. The policy of involving patients more actively in the decision process should be further implemented in daily practice.

Ethical dilemmas in community mental health care.

Ethical dilemmas in community mental health care is the focus of this article. The dilemmas are derived from a discussion of the results of a qualitative research project that took place in five countries of the European Union. The different stakeholders are confronted with the following dilemmas: community care versus hospital care (clients); a life with care versus a life without care (informal carers); stimulation of the client toward greater responsibility versus protection against such responsibility (professionals); budgetary control versus financial incentives (policy makers), and respect for the client versus particular private needs (neighbourhood residents). These dilemmas are interpreted against the background of a value based ethical model. This model offers an integral approach to the dilemmas and can be used to determine policy. The dilemmas are discussed here as the result of conflicting values-namely autonomy and privacy, support and safety, justice and participation, and trust and solidarity.

Mental health, burnout and job satisfaction among professionals in sheltered living in Flanders. A pilot study.

BACKGROUND: Interest has been growing over the last few years in the working conditions of professionals who deal with clients with severe and chronic mental illnesses. In this study, the relationship between the affective climate, as measured by the construct of expressed emotion, and professionals' feelings of well-being and burnout was investigated. It was hypothesised that high expressed emotion (EE) (= a high amount of criticism, hostility or emotional overinvolvement) would be related to high burnout scores. METHODS: Fifty-six professionals were interviewed about their schizophrenic clients who resided in sheltered-living houses in Flanders. EE was measured with two instruments, the Camberwell Family Interview (CFI) and the Perceived Criticism Scale (PCS). The professionals' characteristics were mental health (Symptom Checklist, SCL-90), job satisfaction (VEVAK), and burnout (a Dutch version of the Maslach Burnout Inventory, UBOS-C). RESULTS: Little indication was found for an association between EE and working conditions as measured with the CFI. For the PCS, a significant relationship was found between the resident version of the PCS and burnout. The professionals who were perceived by the residents as being very critical were less depersonalised and less emotionally exhausted than those who were not so perceived. CONCLUSIONS: High EE relationships can exist without feelings of stress and burnout.

Predictors of institutionalization of cognitively-impaired elderly cared for by their relatives.

OBJECTIVES: The purpose of this study is to identify risk factors for nursing home placement of cognitively-impaired elderly, with special attention to the role of psychosocial factors such as the caregiver's preference for institutionalization and the quality of the dyadic relationship. METHODS: Partners, children and children-in-law caring for a relative suffering from dementia (n = 144) were interviewed at home. Sociodemographic variables, patient characteristics, characteristics of the caregiving situation, caregiver characteristics, the support with care and the quality of the caregiving relationship are included as predictors of the caregiver's preference for institutionalization and of the actual institutionalization six to nine months later. Data are analyzed using multiple (logistic) regression analyses. RESULTS: The hypothesis that a poor quality of the relationship, besides other determinants, will be predictive of institutionalization received partial support. No relationship is found between the premorbid relationship quality and institutionalization (preference and actual). However, a good current relationship between the caregiver and the patient reduced the risk of nursing home placement. Institutionalization rate was 16.5% and it was predicted by the caregiver's preference for institutionalization, the functional level of the patient, the quality of the current relationship and the performance of accommodation changes at home. CONCLUSION: Research and interventions directed at delaying or preventing institutionalization should pay more attention to the role of psychosocial aspects in the process of nursing home placement. Specifically the relationship quality in terms of criticism or warmth might be a critical factor in the continuation of home care.

Expressed emotion in staff-patient relationships: the professionals' and residents' perspectives.

BACKGROUND: Expressed emotion (EE) is a well-established, important predictor of the relapse rate of patients suffering from schizophrenia and other severe psychiatric disorders. EE measures the quality of the social interaction between a patient and his most important (in)formal caregiver. The aim of this study was to investigate the quality of the relationship in the staff-patient dyad as measured by the concept of EE. METHODS: EE was assessed using the Camberwell Family Interview (CFI, professionals) and the Perceived Criticism Scale (PCS, residents and professionals form) in a sample of 56 professional caregivers and their residents in nine sheltered living facilities in Flanders. RESULTS: Depending on the instrument, high EE was found to exist in one out of six (CFI) or one out of three (PCS) relationships. There was a significant positive correlation between the resident PCS and the critical comment scale of the CFI. CONCLUSIONS: The results of this study support the hypothesis that high levels of EE exist in some staff-resident relationships, which are mainly manifest as frequent critical comments and the presence of hostility. Emotional overinvolvement appears to be exceptional. Compared with the PCS, the CFI provides the most information about the quality of the relationship.

Psychometric Properties of the Psychotherapy Expectancy Inventory-Revised (PEI-R).

The Psychotherapy Expectancy Inventory-Revised (PEI-R) was developed to measure clients' expectations of behavior in counseling. An exploratory factor analysis of the original PEI-R (Rickers-Ovsiankina, Berzins, Geller, & Rogers, 1971) on a sample of clients yielded four factors: approval, advice, audience and relationship (Berzins, 1971). The aim of the study presented in this paper is to examine the internal construct validity of the PEI-R by means of a confirmatory factor analysis on data gathered in a sample of 159 clients. The analysis revealed an adequate model fit for the four-dimensional oblique model. However, detailed inspection of model fit suggest the possibility of a fifth factor. Data concerning the reliability and the relationship with demographics are also provided.