Contingency Management for Dually Diagnosed Inpatients with Psychosis.

Contingency management (CM) is an evidence-based treatment method in substance abuse treatment. However, little is known about its efficacy in dually diagnosed patients with psychosis and in inpatient settings. Therefore, the aim of this study is to investigate the efficacy of CM for dually diagnosed patients with psychosis in an inpatient setting. Furthermore, we investigate the effect of the nature of the reward used (cash vs. prize) on the efficacy of CM. We made use of an 8-week fish-bowl CM intervention by means of a within-subject reversal design with three treatment phases (baseline-intervention-follow-up). Sixty-seven patients were included in this study, of whom thirty-four completed the protocol. The results show no effect of CM on abstinence nor an interaction with clinical or demographic variables. Cash money is as effective as prizes. Future research should further investigate the effect of psychosis and treatment setting on the efficacy of CM, with special attention for Patient Report Experience and Outcome Measures (PREM/PROM).

Prevalence and clinical characteristics of remission during treatment in generalized anxiety.

OBJECTIVE: Although the remission criteria for generalized anxiety are well defined, there is not much data available on the point prevalence of remission. The Measuring Impact of Remission in Anxiety Disorders in Belgium (MIRABEL) study is a naturalistic study designed to document the point prevalence of remission in patients treated for general anxiety and potential factors affecting this prevalence. METHODS: The study population consisted of 618 adult outpatients being treated for generalized anxiety. The sample is defined by the key symptoms of generalized anxiety disorder rather than by fulfilling the exact DSM-IV-TR diagnostic criteria. Remission was defined as a Hamilton Anxiety Scale (HAM-A) score of less than or equal to 7. To reduce the interrater reliability, the HAM-A was assessed by the attending physicians who had no specific training. Factors investigated as possibly related to remission included sociodemographic, disease and treatment characteristics. RESULTS: The point prevalence of remission in the study population was estimated at 13.3%. Remission prevalence varied with occupational status and severity of the current anxiety episode. Remission prevalence was lower in the presence of comorbidity and was proportional to the number of comorbid symptoms. Remitters took fewer medications but were treated longer. Remission prevalence was higher in patients who were taking antidepressants, but was lower in patients who were taking sedatives. CONCLUSIONS: These findings underline the poor prognosis of generalized anxiety.

Physical Healthcare for People with a Severe Mental Illness in Belgium by Long-Term Community Mental Health Outreach Teams: A Qualitative Descriptive Study on Physicians', Community Mental Health Workers' and Patients' Perspectives.

BACKGROUND: People with a severe mental illness (pSMI) often have comorbid physical health problems, resulting in a lower life expectancy compared to the global population. In Belgium, it remains unclear how to approach health disparities in pSMI in a community setting. This study explores the perspectives of both care professionals and patients on physical healthcare in Belgian community mental services, aiming to identify good practices, barriers and points of improvement. METHODS: An exploratory qualitative design that used a semi-structured focus group interview with physicians combined with individual face-to-face interviews with physicians, mental health professionals and patients. RESULTS: We identified care professional-, patient-related and organizational factors, as well as points of improvement. The identified themes linked to care professionals were communication, task distribution, knowledge, time and stigmatization. The co-location of services was the main theme on an organizational level. CONCLUSIONS: As community-based mental health services in Belgium emerged in the past decade, addressing physical health in pSMI is still challenging. Our findings suggest that there is a need for improvement in the current healthcare provision. Multidisciplinary guidelines, shared patient records, enlarging nurses' tasks, providing financial incentives and a structural integration of primary and psychiatric care were perceived as major points of improvement to the current Belgian healthcare organization.

Physical Healthcare, Health-Related Quality of Life and Global Functioning of Persons with a Severe Mental Illness in Belgian Long-Term Mental Health Assertive Outreach Teams: A Cross-Sectional Self-Reported Survey.

Research shows that care delivery regarding somatic health problems for patients with a severe mental illness (SMI) in community and mental health is difficult to establish. During the last decade, long term mental health outreach teams in Belgium were implemented to provide treatment and follow-up at home. This study aimed to map physical health status, care professionals, health related quality of life and global functioning in persons with SMI in Belgian long term outreach teams for mental health. Using a self-administered questionnaire, 173 persons, 58.1% female with a mean age of 48.3, were questioned. Our findings suggest an undertreatment of somatic comorbid conditions, with only half of physical health complaints being addressed. Although treatment rates for hypertension, when detected were high, treatment of respiratory complaints, pain and fatigue was lacking. Although the majority of respondents responded to have a GP or psychiatrist, contact rates were rather limited. Other disciplines, such as primary care nurses, when present, tend to have more contact with people with SMI. Notably, having regular contacts with GPs seems to improve physical health complaints and/or treatment. Being treated by an outreach team did not show significant correlations with physical health complaints and/or treatment suggesting a more proactive approach by outreach teams or primary care providers is desirable.

Organization of Community Mental Health Services for Persons with a Severe Mental Illness and Comorbid Somatic Conditions: A Systematic Review on Somatic Outcomes and Health Related Quality of Life.

It is well established that persons with a severe mental illness (SMI) have a greater risk of physical comorbid conditions and premature mortality. Most studies in the field of community mental health care (CMHC) have only focused on improving cardiovascular health in people with a SMI using lifestyle approaches. Studies using organizational modifications are rather scarce. This systematic review aimed to synthesize and describe possible organizational strategies to improve physical health for persons with a SMI in CMHC. The primary outcome was Health-related Quality of Life (HR-QOL). Results suggested modest effects on quality of life and were inconsistent throughout all the included studies. Despite these findings, it appears that a more integrated approach had a positive effect on health outcomes, patient satisfaction and HR-QOL. The complexity of the processes involved in community care delivery makes it difficult to compare different models and organizational approaches. Mental health nurses were identified as possible key professionals in care organization, but no clear description of their role was found. This review could provide new insights into contributing factors for integrated care. Future research targeting the identification of the nurses' role and facilitating factors in integrated care, in order to improve treatment and follow-up of somatic comorbidities, is recommended.

Meta-Analysis on the Effect of Contingency Management for Patients with Both Psychotic Disorders and Substance Use Disorders.

BACKGROUND: Substance use disorders (SUD) are highly prevalent among psychotic patients and are associated with poorer clinical and functional outcomes. Effective interventions for this clinical population are scarce and challenging. Contingency management (CM) is one of the most evidence-based treatments for SUD's, however, a meta-analysis of the effect of CM in patients with a dual diagnosis of psychotic disorder and SUD has not been performed. METHODS: We searched PubMed and PsycINFO databases up to December 2020. RESULTS: Five controlled trials involving 892 patients were included. CM is effective on abstinence rates, measured by the number of self-reported days of using after intervention (95% CI -0.98 to -0.06) and by the number of negative breath or urine samples after intervention (OR 2.13; 95% CI 0.97 to 4.69) and follow-up (OR 1.47; 95% CI 1.04 to 2.08). CONCLUSIONS: Our meta-analysis shows a potential effect of CM on abstinence for patients with SUD and (severe) psychotic disorders, although the number of studies is limited. Additional longitudinal studies are needed to confirm the sustained effectivity of CM and give support for a larger clinical implementation of CM within services targeting these vulnerable co-morbid patients.

The impact of perfectionism and anxiety traits on action monitoring in major depressive disorder.

Perfectionism and anxiety features are involved in the clinical presentation and neurobiology of major depressive disorder (MDD). In MDD, cognitive control mechanisms such as action monitoring can adequately be investigated applying electrophysiological registrations of the error-related negativity (ERN) and error positivity (Pe). It is also known that traits of perfectionism and anxiety influence ERN amplitudes in healthy subjects. The current study explores the impact of perfectionism and anxiety traits on action monitoring in MDD. A total of 39 MDD patients performed a flankers task during an event-related potential (ERP) session and completed the multidimensional perfectionism scale (MPS) with its concern over mistakes (CM) and doubt about actions (DA) subscales and the trait form of the State Trait Anxiety Inventory. Multiple regression analyses with stepwise backward elimination revealed MPS-DA to be a significant predictor (R (2):0.22) for the ERN outcomes, and overall MPS (R (2):0.13) and MPS-CM scores (R (2):0.18) to have significant predictive value for the Pe amplitudes. Anxiety traits did not have a predictive capacity for the ERPs. MPS-DA clearly affected the ERN, and overall MPS and MPS-CM influenced the Pe, whereas no predictive capacity was found for anxiety traits. The manifest impact of perfectionism on patients' error-related ERPs may contribute to our understanding of the action-monitoring process and the functional significance of the Pe in MDD. The divergent findings for perfectionism and anxiety features also indicate that the wide range of various affective personality styles might exert a different effect on action monitoring in MDD, awaiting further investigation.

The Interplay of Inflammatory Processes and Cognition in Alcohol Use Disorders-A Systematic Review.

Rationale: Of late, evidence emerges that the pathophysiology of psychiatric diseases and their affiliated symptomatologies are at least partly contributable to inflammatory processes. Also in alcohol use disorders (AUD), this interaction is strongly apparent, with severely immunogenic liver cirrhosis being one of the most critical sequelae of chronic abusive drinking. This somatic immune system activation negatively impacts brain functioning, and additionally, alcohol abuse appears to have a direct detrimental effect on the brain by actively stimulating its immune cells and responses. As cognitive decline majorly contributes to AUD's debility, it is important to know to what extent impairment of cognitive functioning is due to these (neuro-)inflammatory aberrations. Method: We hereby summarize the current existing literature on the interplay between AUD, inflammation, and cognition in a systematic review according to the PRISMA-P guidelines for the systematic review. Main findings: Although literature on the role of inflammation in alcohol use-related cognitive deficiency remains scarce, current findings indicate that pro-inflammatory processes indeed result in exacerbation of several domains of cognitive deterioration. Interestingly, microglia, the immune cells of the brain, appear to exert initial compensatory neuroprotective functionalities upon acute ethanol exposure while chronic alcohol intake seems to attenuate these responses and overall microglial activity. Conclusion: As these results indicate inflammation to be of importance in cognitive impairment following alcohol consumption and might as such provide alternate therapeutic avenues, a considerable increase in research efforts in this domain is urgently required.

Addiction, Anhedonia, and Comorbid Mood Disorder. A Narrative Review.

Background: Recently, anhedonia has been recognized as an important Research Domain Criterion (RDoC) by the National Institute of Mental Health. Anhedonia is proposed to play an essential role in the pathogenies of both addictive and mood disorders, and possibly their co-occurrence with a single individual. However, up to now, comprehensive information about anhedonia concerning its underlying neurobiological circuitries, the neurocognitive correlates, and their role in addiction, mood disorder, and comorbidity remains scarce. Aim: In this literature review of human studies, we bring together the current state of knowledge with respect to anhedonia in its relationship with disorders in the use of substances (DUS) and the comorbidity with mood disorders. Method: A PubMed search was conducted using the following search terms: (Anhedonia OR Reward Deficiency) AND ((Drug Dependence OR Abuse) OR Alcohol OR Nicotine OR Addiction OR Gambling OR (Internet Gaming)). Thirty-two articles were included in the review. Results: Anhedonia is associated with substance use disorders, and their severity is especially prominent in DUS with comorbid depression. Anhedonia may be both a trait and a state dimension in its relation to DUS and tends to impact DUS treatment outcome negatively.

Why Collaborative Care for Depressed Patients is so Difficult: A Belgian Qualitative Study.

Although current guidelines recommend collaborative care for severely depressed patients, few patients get adequate treatment. In this study we aimed to identify the thresholds for interdisciplinary collaboration amongst practitioners when treating severely depressed patients. In addition, we aimed to identify specific and feasible steps that may add to improved collaboration amongst first and second level Belgian health care providers when treating depressed patients. In two standard focus groups (n = 8; n = 12), general practitioners and psychiatrists first outlined current practice and its shortcomings. In a next phase, the same participants were gathered in nominal groups to identify and prioritise steps that could give rise to improved collaboration. Thematic analyses were performed. Though some barriers for interdisciplinary collaboration may seem easy to overcome, participants stressed the importance of certain boundary conditions on a macro- (e.g., financing of care, secure communication technology) and meso-level (e.g., support for first level practitioner). Findings are discussed against the background of frameworks on collaboration in healthcare and recent developments in mental health care.

Collaborative care regarding major depressed patients: A review of guidelines and current practices.

Major Depressive Disorder (MDD) is a severe and common mental disorder. A growing body of evidence suggests that stepped and/or collaborative care treatment models have several advantages for severely depressed patients and caretakers. However, despite the availability of these treatment strategies and guidance initiatives, many depressive patients are solely treated by the general practitioner (GP), and collaborative care is not common. In this paper, we review a selected set of international guidelines to inventory the best strategies for GPs and secondary mental health care providers to collaborate when treating depressed patients. Additionally, we systematically searched the literature, listing potential ways of cooperation, and potentially supporting tools. We conclude that the prevailing guidelines only include few and rather vague directions regarding the cooperation between GPs and specialised mental health practitioners. Inspiring recent studies, however, suggest that relatively little efforts may result in effective collaborative care and a broader implementation of the guidelines in general.

Evolution of First-generation and Second-generation Antipsychotic Prescribing Patterns in Belgium Between 1997 and 2012: A Population-based Study.

INTRODUCTION: In recent decades, a substantial increase in prescriptions of antipsychotics has been reported in several countries. This increase in antipsychotic sales has been attributed to the success of second-generation antipsychotics. METHODS: This national register-based study investigated the evolution of outpatient antipsychotic sales in Belgium between 1997 and 2012. The impact of the specialization of the prescriber and the demographic characteristics of both prescribing doctors and patients were examined. The study used data obtained from the Belgian National Institute for Health and Disability Insurance and IMS Health Belgium. RESULTS: Over this 15-year period, antipsychotic sales increased by 122% in Belgium. This growth was mainly explained by a 3-fold increase in antipsychotic prescriptions by psychiatrists and neurologists. Overall, only 29.5% of prescriptions for antipsychotics were for psychotic disorders and only 26.2% of prescriptions for antipsychotics were for mood disorders, suggesting a large amount of off-label use. A significant shift toward second-generation agents was found in prescriptions by both psychiatrists and general practitioners, although there may have been a small delay in moving toward second-generation agents in the latter group. This increase in second-generation antipsychotic prescribing was mainly due to the steep rise in sales of quetiapine, followed by olanzapine and risperidone. The shift toward the newer products was also mainly seen in younger prescribers. CONCLUSIONS: The results of this study suggest that there has been an increase in adequate management of patients in need of antipsychotic treatment. Nevertheless, very few of the patients received continued treatment throughout the year, which implies that few outpatients with schizophrenia are receiving adequate treatment.

Towards a solution for performance related confounds: frontal, striatal and parietal activation during a continuous spatiotemporal working memory manipulation task.

Working memory plays a role in various forms of psychopathology. However, working memory consists of multiple theoretical components that may be differently taxed by various specific types of task, and brain activation differences between patients and healthy controls may result from differences in task performance. This makes it difficult to interpret such results in terms of disease-related dysfunctions in affected regions or networks. The aim of the current study was to determine the brain activation related to the updating of spatiotemporal content of working memory, in such a way that performance-related confounds in future clinical studies would be minimized. Nineteen healthy volunteers performed a task involving a continuous updating process during fMRI measurement. A frontostriatal network including medial and lateral prefrontal cortex, inferior frontal cortex, premotor cortex, supplementary motor cortex, thalamus and putamen was found to be related to the updating process. The results constrain the set of brain regions plausibly related to the specific updating component of working memory. Further, the task design may be of use in future studies of pathological conditions such as schizophrenia due to the minimization of potential confounds.

Better to give than to take? Interactive social decision-making in severe major depressive disorder.

BACKGROUND: Although recent studies focusing on major depressive disorder (MDD) suggest altered social decision-making, studies using the Ultimatum Game (UG) in patients with severe, clinical MDD do not exist. Moreover, all aforementioned studies so far focused on responder behavior and thus fairness considerations; to this date, no one investigated social interactive behavior which involves proposer behavior possibly requiring second-order mentalizing as well. METHODS: Thirty-nine MDD patients and 22 healthy controls played a modified UG, both in the roles of responder and proposer against the same partner. RESULTS: MDD patients accepted both fair and unfair offers as many times as the healthy controls in their role as responder. Importantly, however, in the role of proposer MDD patients offered significantly more than the control group did. LIMITATIONS: Most patients were treated with psychotropic medication. CONCLUSIONS: Responder behavior demonstrates that MDD patients are capable of making social decisions on fairness considerations in the same way as healthy controls do. The observed proposer behavior, however, could indicate that MDD patients are more focused on avoiding rejection. These findings provide unique evidence that social decision-making--as studied in a realistic context--is disturbed in MDD.

Prefrontal, parietal and basal activation associated with the reordering of a two-element list held in working memory.

A functional specialization in the prefrontal cortex along a dorsal-ventral gradient according to the type of processing in working memory, i.e. manipulation vs. maintenance, has been proposed based on previous neuroimaging studies. This seems particularly important for the further understanding of the functional architecture underlying working memory problems in patient populations. The current study examines the prefrontal involvement in the maintenance and manipulation of serial order of elements in working memory, with a task designed to be as simple as possible, to the aim of possible uses in clinical studies. Subjects held two-element ordered lists in memory and were presented with pseudo-random sequences of "reorder" and "maintain" cues. Reorder cues were found to be associated with activation in the dorsal prefrontal cortex, parietal cortex and the basal ganglia. The results show that the simple task was indeed sufficient to evoke the prefrontal activation of interest, add to the information on functional dorsal-ventral specialization in prefrontal cortex and provide support for a prefrontal-parietal monitoring-manipulation network.