Societal recovery trajectories in people with a psychotic disorder in long term care: a latent class growth analysis.

PURPOSE: For many individuals with a psychotic disorder societal recovery is not accomplished. Research on societal recovery trajectories is mostly focussed on patients with a first episode psychosis. The present study aims to identify distinct societal trajectories in those with long duration of illness, through the identification of patient subgroups that are characterized by homogeneous trajectories. METHODS: Longitudinal data were used from an ongoing dynamic cohort in which people with a psychotic disorder receive yearly measurements to perform a latent class growth analysis. Societal functioning was assessed with the Functional Recovery tool, consisting of three items (1) daily living and self-care, (2) work, study and housekeeping, and (3) social contacts. Furthermore, logistic regression was used to compare subgroups with similar societal recovery at baseline, but distinct trajectories. RESULTS: A total of 1476 people were included with a mean treatment time of 19 years (SD 10.1). Five trajectories of functioning were identified, a high stable (24.5%), a medium stable (28.3%), a low stable (12.7%), a high declining (11.2%) and a medium increasing subgroup (23.3%). Predictors for not deteriorating included happiness, recent hospitalisation, being physically active, middle or higher education and fewer negative symptoms. Predictors for improving included fewer positive and negative symptoms, fewer behavioural problems and fewer physical and cognitive impairments. CONCLUSION: While the majority of individuals show a stable trajectory over four years, there were more patients achieving societal recovery than patients deteriorating. Predictors for improvement are mainly related to symptoms and behavioural problems, while predictors for deteriorating are related to non-symptomatic aspects such as physical activity, happiness and level of education.

Life years lost for users of specialized mental healthcare.

BACKGROUND: Mental disorders are burdensome and are associated with increased mortality. Mortality has been researched for various mental disorders, especially in countries with national registries, including the Nordic countries. Yet, knowledge gaps exist around national differences, while also relatively less studies compare mortality of those seeking help for mental disorders in specialized mental healthcare (SMH) by diagnosis. Additional insight into such mortality distributions for SMH users would be beneficial for both policy and research purposes. We aim to describe and compare the mortality in a population of SMH users with the mortality of the general population. Additionally, we aim to investigate mortality differences between sexes and major diagnosis categories: anxiety, depression, schizophrenia spectrum and other psychotic disorders, and bipolar disorder. METHODS: Mortality and basic demographics were available for a population of N = 10,914 SMH users in the north of The Netherlands from 2010 until 2017. To estimate mortality over the adult lifespan, parametric Gompertz distributions were fitted on observed mortality using interval regression. Life years lost were computed by calculating the difference between integrals of the survival functions for the general population and the study sample, thus correcting for age. Survival for the general population was obtained from Statistics Netherlands (CBS). RESULTS: SMH users were estimated to lose 9.5 life years (95% CI: 9.4-9.6). Every major diagnosis category was associated with a significant loss of life years, ranging from 7.2 (95% CI: 6.4-7.9) years for anxiety patients to 11.7 (95% CI: 11.0-12.5) years for bipolar disorder patients. Significant differences in mortality were observed between male SMH users and female SMH users, with men losing relatively more life years: 11.0 (95% CI: 10.9-11.2) versus 8.3 (95% CI: 8.2-8.4) respectively. This difference was also observed between sexes within every diagnosis, although the difference was insignificant for bipolar disorder. CONCLUSION: There were significant differences in mortality between SMH users and the general population. Substantial differences were observed between sexes and between diagnoses. Additional attention is required, and possibly specific interventions are needed to reduce the amount of life years lost by SMH users.

Cardiovascular risk assessment methods yield unequal risk predictions: a large cross-sectional study in psychiatric secondary care outpatients.

BACKGROUND: Patients with a mental illness are more likely to develop, and die from, cardiovascular diseases (CVD), necessitating optimal CVD-risk (CVR)-assessment to enable early detection and treatment. Whereas psychiatrists use the metabolic syndrome (MetS)-concept to estimate CVR, GPs use absolute risk-models. Additionally, two PRIMROSE-models have been specifically designed for patients with severe mental illness. We aimed to assess the agreement in risk-outcomes between these CVR-methods. METHODS: To compare risk-outcomes across the various CVR-methods, we used somatic information of psychiatric outpatients from the PHAMOUS-, and MOPHAR-database, aged 40-70 years, free of past or current CVD and diabetes. We investigated: (1) the degree-of-agreement between categorical assessments (i.e. MetS-status vs. binary risk-categories); (2) non-parametric correlations between the number of MetS-criteria and absolute risks; and (3) strength-of-agreement between absolute risks. RESULTS: Seven thousand twenty-nine measurements of 3509 PHAMOUS-patients, and 748 measurements of 748 MOPHAR-patients, were included. There was systematic disagreement between the categorical CVR-assessments (all p < 0.036). Only MetS-status versus binary Framingham-assessment had a fair strength-of-agreement (κ = 0.23-0.28). The number of MetS-criteria and Framingham-scores, as well as MetS-criteria and PRIMROSE lipid-scores, showed a moderate-strong correlation (τ = 0.25-0.34). Finally, only the continuous PRIMROSE desk and lipid-outcomes showed moderate strength-of-agreement (ρ = 0.91). CONCLUSIONS: The varying methods for CVR-assessment yield unequal risk predictions, and, consequently, carry the risk of significant disparities regarding treatment initiation in psychiatric patients. Considering the significantly increased health-risks in psychiatric patients, CVR-models should be recalibrated to the psychiatric population from adolescence onwards, and uniformly implemented by health care providers. TRIAL REGISTRATION: The MOPHAR research has been prospectively registered with the Netherlands Trial Register on 19th of November 2014 (NL4779).

Clinical, societal and personal recovery in schizophrenia spectrum disorders across time: states and annual transitions.

BACKGROUND: Recovery in schizophrenia is a complex process, involving clinical, societal and personal recovery. Until now, studies analysed these domains separately, without examining their mutual relations and changes over time. AIMS: This study aimed to examine different states of recovery and transition rates between states. METHOD: The Pharmacotherapy Monitoring and Outcome Survey (2006-2017) yearly assesses patients with schizophrenia in the Northern Netherlands. Data from 2327 patients with one up to 11 yearly measurements on clinical, societal and personal recovery were jointly analysed with a mixture latent Markov model (MLMM). RESULTS: The selected MLMM had four states that differed in degree and pattern of recovery outcomes. Patients in state 1 were least recovered on any domain (16% of measurements), and partly recovered in states 2 (25%; featured by negative symptoms) and 3 (21%; featured by positive symptoms). Patients in state 4 (38%) were most recovered, except for work, study and housekeeping. At the subsequent measurement, the probability of remaining in the same state was 77-89%, transitioning to a better state was 4-12% and transitioning to a worse state was 4-6%; no transitions occurred between states 1 and 4. Female gender, shorter illness duration and less schizophrenia were more prevalent in better states. CONCLUSIONS: Quite a high recovery rate was present among a substantial part of the measurements (38%, state 4), with a high probability (89%) of remaining in this state. Transition rates in the other states might increase to a more favourable state by focusing on adequate treatment of negative and positive symptoms and societal problems.

The development, validity, and reliability of the auditory vocal hallucination rating scale questionnaire (AVHRS-Q).

PURPOSE: The Auditory Vocal Hallucination Rating Scale Questionnaire (AVHRS-Q) is a short self-report measure assessing several characteristics of auditory vocal hallucinations (AVH) that was derived from a validated clinical interview (the auditory vocal hallucination rating scale; AVHRS). This study investigated the internal reliability, convergent validity, and divergent validity of the AVHRS-Q using two clinical samples. METHODS: In sample I, 32 psychiatric patients with AVH were recruited from an academic hospital service and assessed with the AVHRS and the AVHRS-Q. Data for sample II were retrospectively retrieved from a pseudonymised Routine Outcome Monitoring (ROM) database collected in the context of mental healthcare at the same academic hospital service. Data from 82 psychiatric patients with AVH were retrieved, who completed the AVHRS-Q, and measures of psychological distress (the Outcome Questionnaire; OQ-45, and the Symptom Checklist; SCL-90) and quality of life (the Manchester Short Assessment of Quality of Life; MANSA). RESULTS: The AVHRS-Q showed good internal consistency in both samples. Severity scores of the AVHRS-Q were strongly correlated to the severity scores of the AVHRS (r = 0.90, p < 0.01). The AVHRS-Q and AVHRS did not differ in the identification of mild and severe voice-hearers [X2 (1, N = 32) = 15.71]. AVHRS-Q severity scores had moderate correlations with measures of psychological distress (OQ-45, r = 0.43, p < 0.01; SCL-90, r = 0.50, p < 0.05) and quality of life (MANSA, r = - 0.22, p < 0.01). CONCLUSIONS: The AVHRS-Q demonstrated good reliability, convergent validity, and divergent validity, suggesting it can be applied in both clinical and research settings for a quick and reliable assessment of AVH.

Quality of care and its determinants in longer term mental health facilities across Europe; a cross-sectional analysis.

BACKGROUND: The Quality Indicator for Rehabilitative Care (QuIRC) is an international, standardised quality tool for the evaluation of mental health facilities that provide longer term care. Completed by the service manager, it comprises 145 items that assess seven domains of care: living environment; treatments and interventions; therapeutic environment; self-management and autonomy; social interface; human rights; and recovery based practice. We used the QuIRC to investigate associations between characteristics of longer term mental health facilities across Europe and the quality of care they delivered to service patients. METHODS: QuIRC assessments were completed for 213 longer term mental health units in ten countries that were at various stages of deinstitutionalisation of their mental health services. Associations between QuIRC domain scores and unit descriptive variables were explored using simple and multiple linear regression that took into account clustering at the unit and country level. RESULTS: We found wide variation in QuIRC domain scores between individual units, but across countries, fewer than a quarter scored below 50 % on any domains. The quality of care was higher in units that were smaller, of mixed sex, that had a defined expected maximum length of stay and in which not all patients were severely disabled. CONCLUSIONS: This is the first time longer term mental health units across a number of European countries have been compared using a standardised measure. Further use of the QuIRC will allow greater understanding of the quality of care in these units across Europe and provide an opportunity to monitor pan-European quality standards of care for this vulnerable patient group.

Mental health care use in adolescents with and without mental disorders.

The aim of the study was to estimate the proportion of adolescents with and without a psychiatric diagnosis receiving specialist mental health care and investigate their problem levels as well as utilization of other types of mental health care to detect possible over- and undertreatment. Care utilization data were linked to psychiatric diagnostic data of 2230 adolescents participating in the TRAILS cohort study, who were assessed biannually starting at age 11. Psychiatric diagnoses were established at the fourth wave by the Composite International Diagnostic Interview. Self-, parent- and teacher-reported emotional and behavioral problems and self-reported mental health care use were assessed at all four waves. Of all diagnosed adolescents, 35.3 % received specialist mental health care. This rate increased to 54.5 % when three or more disorders were diagnosed. Almost a third (28.5 %) of specialist care users had no psychiatric diagnosis; teachers gave them relatively high ratings on attention and impulsivity subscales. Diagnosed adolescents without specialist mental health care also reported low rates of other care use. We found no indication of overtreatment. Half of the adolescents with three or more disorders do not receive specialist mental health care nor any other type of care, which might indicate unmet needs.

Cause-specific mortality among patients with psychosis: disentangling the effects of age and illness duration.

BACKGROUND: There is a large mortality gap between patients with a nonaffective psychotic disorder and those in the general population, is associated with both natural and nonnatural death causes. OBJECTIVE: This study aims to assess whether mortality risks vary for different causes of death according to the duration since diagnosis and age in a large sample of patients with nonaffective psychotic disorder. METHODS: Data of patients with nonaffective psychotic disorder (n = 12,580) from 3 Dutch psychiatric registers were linked to the cause of death register of Statistics Netherlands and compared with personally matched controls (n = 124,143) from the population register. Death rates were analyzed by duration since the date of the registered diagnosis of the (matched) patient and their age using a Poisson model. RESULTS: Among patients, the rates of all-cause death decreased with longer illness duration. This was explained by lower suicide rates. For example, among those between 40 and 60 years of age, the rate ratios (RR) of suicide during 2-5 and > 5 years were 0.52 and 0.46 (p = 0.002), respectively, when compared with the early years after diagnosis. Compared with controls, patients experienced higher rates of natural death causes during all stages and in all age categories, rate ratios 2.35-5.04; p < 0.001-0.025. There was no increase in these rate ratios with increasing duration or increasing age for patients when compared with controls. CONCLUSIONS: The high risk of natural death causes among patients with nonaffective psychotic disorder is already present at a comparatively young age. This suggests caution in blaming antipsychotics or the accumulating effects of adverse lifestyle factors for premature death. It is better to proactively monitor and treat somatic problems from the earliest disease stages onward.

Flexible Assertive Community Treatment, Severity of Symptoms and Psychiatric Health Service Use, a Real life Observational Study.

BACKGROUND: Introduction of Flexible Assertive Community Treatment (FACT) may be associated with increased remission rates and changes in patterns of care. The present paper reports on differences in psychosocial functioning and health care use between patients in FACT and two groups of patients not currently provided with a specific model of community service. METHODS: The ongoing "Pharmacotherapy Monitoring and Outcome Survey" provided routine outcome measures of patients using antipsychotics in the north of the Netherlands. Level of psychosocial functioning was assessed using the Health of the Nations Outcome Scales (HoNOS) and matched with psychiatric health care consumption obtained from the Psychiatric Case Register. Patients who never received FACT, patients ever in FACT but not at assessment date, and patients in FACT were identified. Data were subjected to multilevel linear regression analysis. RESULTS: Data showed that most patients in FACT also had non-FACT episodes after the start of FACT. Furthermore, patients in FACT displayed higher levels of psychosocial functioning and used more outpatient care than the other two groups. CONCLUSIONS: Patients in FACT receive more outpatient care and have better psychosocial functioning. However, causal inferences cannot be derived from these data. In addition, membership of a FACT-team in this setting did not last indefinitely.

Comparative analysis of algorithm-guided treatment and predefined duration treatment programmes for depression: exploring cost-effectiveness using routine care data.

BACKGROUND: More knowledge on the cost-effectiveness of various depression treatment programmes can promote efficient treatment allocation and improve the quality of depression care. OBJECTIVE: This study aims to compare the real-world cost-effectiveness of an algorithm-guided programme focused on remission to a predefined duration, patient preference-centred treatment programme focused on response using routine care data. METHODS: A naturalistic study (n=6295 in the raw dataset) was used to compare the costs and outcomes of two programmes in terms of quality-adjusted life years (QALY) and depression-free days (DFD). Analyses were performed from a healthcare system perspective over a 2-year time horizon. Incremental cost-effectiveness ratios were calculated, and the uncertainty of results was assessed using bootstrapping and sensitivity analysis. FINDINGS: The algorithm-guided treatment programme per client yielded more DFDs (12) and more QALYs (0.013) at a higher cost (€3070) than the predefined duration treatment programme. The incremental cost-effectiveness ratios (ICERs) were around €256/DFD and €236 154/QALY for the algorithm guided compared with the predefined duration treatment programme. At a threshold value of €50 000/QALY gained, the programme had a probability of <10% of being considered cost-effective. Sensitivity analyses confirmed the robustness of these findings. CONCLUSIONS: The algorithm-guided programme led to larger health gains than the predefined duration treatment programme, but it was considerably more expensive, and hence not cost-effective at current Dutch thresholds. Depending on the preferences and budgets available, each programme has its own benefits. CLINICAL IMPLICATION: This study provides valuable information to decision-makers for optimising treatment allocation and enhancing quality of care cost-effectively.

Role of the police in linking individuals experiencing mental health crises with mental health services.

BACKGROUND: The police are considered frontline professionals in managing individuals experiencing mental health crises. This study examines the extent to which these individuals are disconnected from mental health services, and whether the police response has an influence on re-establishing contact. METHODS: Police records were searched for calls regarding individuals with acute mental health needs and police handling of these calls. Mental healthcare contact data were retrieved from a Psychiatric Case Register. RESULTS: The police were called upon for mental health crisis situations 492 times within the study year, involving 336 individuals (i.e. 1.7 per 1000 inhabitants per year). Half of these individuals (N=162) were disengaged from mental health services, lacking regular care contact in the year prior to the crisis (apart from contact for crisis intervention). In the month following the crisis, 21% of those who were previously disengaged from services had regular care contact, and this was more frequent (49%) if the police had contacted the mental health services during the crisis. The influence of police referral to the services was still present the following year. However, for the majority (58%) of disengaged individuals police did not contact the mental health services at the time of crisis. CONCLUSIONS: The police deal with a substantial number of individuals experiencing a mental health crisis, half of whom are out of contact with mental health services, and police play an important role in linking these individuals to services. Training police officers to recognise and handle mental health crises, and implementing practical models of cooperation between the police and mental health services in dealing with such crises may further improve police referral of individuals disengaged from mental health services.

Supported housing and supported independent living in the Netherlands, with a comparison with England.

Research into community housing programs for people with severe mental illness is underexposed. The Dutch UTOPIA study describes characteristics of their service users, which may predict their allocation to either supported housing or supported independent living programs. Additionally, a comparison is made with English studies. 119 Care coordinators of Dutch residential care institutes and 534 service users participated in a cross-sectional survey which includes socio-demographic data, clinical data, measures of functioning, needs for care and quality of life. Differences between Dutch residents and independent living service users were small, making predictions of care allocation difficult. This similarity suggests a possible lack of methodical assessment in the allocation procedure of people who are eligible for residential housing or independent living programs. This is largely comparable to the English situation. In comparison with their English counterparts, Dutch service users have more met needs and are more engaged in occupational activities.

Treatment plans in psychiatric community housing programs: do they reflect rehabilitation principles?

OBJECTIVE: This study examined the extent to which treatment plans of service users of community housing programs measure up to rehabilitation principles according to the Choose-Get-Keep model of psychiatric rehabilitation. The study evaluates whether these plans correspond with service-user and key-worker perspectives on unmet needs for care. METHOD: A representative sample of key workers and service users of 16 Dutch Regional Institutes for Residential Care (RIRCs) participated in a cross-sectional survey. Sociodemographic and clinical data and an assessment of needs for care of 240 service users were collected. In addition, we received an anonymous copy of each participant's most recent written treatment plan. First, we developed a method to measure adherence to rehabilitation principles of written treatment plans, based on the Choose-Get-Keep model of psychiatric rehabilitation. Next, treatment plans were screened on the degree of adherence, expressed in a score from 0 to 10 for overall quality, and correlated with needs for care. RESULTS: RIRCs mostly seem to succeed in sufficiently integrating rehabilitation principles in their treatment plans. Adherence to rehabilitation principles was neither associated with the service-user perspective nor with the key worker perspective on needs for care. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Rehabilitation principles are rather well documented in the majority of written treatment plans, although apparently without substantial consequences for needs for care among the service users. Further research is needed to validate our method and to investigate not only the adherence to rehabilitation principles in written treatment plans, but also in the actual care provision itself.

Personality traits and coping strategies in recent-onset psychosis: Associations with symptom severity and psychosocial functioning.

BACKGROUND: Personality and coping may be related to symptom severity and psychosocial functioning in patients with recent-onset psychosis. This study aimed to investigate associations of personality traits and coping strategies with concurrent and follow-up symptom severity and functioning in those patients, and identify whether coping mediates relations between personality and symptoms or functioning. METHODS: At baseline, 527 recent-onset psychosis patients (73 % male, mean age = 28 years) received assessments on personality (Neuroticism-Extraversion-Openness - Five-Factor Inventory), coping (Utrecht Coping List), symptom severity (Positive And Negative Syndrome Scale) and psychosocial functioning (Global Assessment of Functioning Scale). Of those, 149 also received symptom and functioning assessments at follow-up. Multivariable linear regression analyses were performed to assess cross-sectional associations of personality and coping with symptoms and functioning at baseline. Longitudinal associations of baseline personality and coping with follow-up symptomatic remission and functioning were analyzed with multivariable linear and binary logistic regression analyses, respectively. Lastly, it was investigated whether coping mediated associations between personality and symptoms or functioning. RESULTS: Higher baseline Agreeableness (B = -0.019, [95%CI: -0.031; -0.007]) and Neuroticism (B = -0.017, [95%CI: -0.028; -0.006]) were associated with lower concurrent symptom severity. Reassuring Thoughts were associated with better functioning at baseline (B = 0.833, [95%CI: 0.272; 1.393]). Neither personality nor coping were associated with follow-up symptomatic remission or functioning. Coping did not mediate associations between personality and symptoms or functioning. CONCLUSION: Only the coping strategy Reassuring Thoughts is associated with better baseline functioning in patients with recent-onset psychosis. Personality traits seem to have limited clinically relevant relations with symptom severity or functioning.

The development of the Quality Indicator for Rehabilitative Care (QuIRC): a measure of best practice for facilities for people with longer term mental health problems.

BACKGROUND: Despite the progress over recent decades in developing community mental health services internationally, many people still receive treatment and care in institutional settings. Those most likely to reside longest in these facilities have the most complex mental health problems and are at most risk of potential abuses of care and exploitation. This study aimed to develop an international, standardised toolkit to assess the quality of care in longer term hospital and community based mental health units, including the degree to which human rights, social inclusion and autonomy are promoted. METHOD: The domains of care included in the toolkit were identified from a systematic literature review, international expert Delphi exercise, and review of care standards in ten European countries. The draft toolkit comprised 154 questions for unit managers. Inter-rater reliability was tested in 202 units across ten countries at different stages of deinstitutionalisation and development of community mental health services. Exploratory factor analysis was used to corroborate the allocation of items to domains. Feedback from those using the toolkit was collected about its usefulness and ease of completion. RESULTS: The toolkit had excellent inter-rater reliability and few items with narrow spread of response. Unit managers found the content highly relevant and were able to complete it in around 90 minutes. Minimal refinement was required and the final version comprised 145 questions assessing seven domains of care. CONCLUSIONS: Triangulation of qualitative and quantitative evidence directed the development of a robust and comprehensive international quality assessment toolkit for units in highly variable socioeconomic and political contexts.

Sensitivity to change of the Beck Depression Inventory versus the Inventory of Depressive Symptoms.

BACKGROUND: In a previous study which made a comparison between disorder-specific and generic instruments to assess outcome of treatments for depression, the Beck Depression Inventory, Second Edition (BDI-II) seemed to be more sensitive to change than the Inventory of Depressive Symptoms- Self Rating (IDS-SR). METHODS: A set with longitudinal data from Routine Outcome Monitoring (n=144) were analyzed with multilevel models with random intercepts. The sensitivity to change of two disorder-specific instruments, the BDI-II and the IDS-SR, were compared head to head. RESULTS: The BDI-II was more sensitive to change when measuring treatment outcome compared to the IDS-SR. The BDI-II decreases significantly more over time than the IDS-SR: the average decrease per week for the IDS-SR is -.012 (95%CI -0.015, -0.009) and for the BDI-II it is -.017 (95%CI -0.021, -0.014). LIMITATIONS: Conclusions can only be preliminary due to a small sample size. CONCLUSIONS: Treatment outcomes measured with questionnaires may differ depending on the degree of sensitivity to change of the instruments.

Real-World Treatment Costs and Care Utilization in Patients with Major Depressive Disorder With and Without Psychiatric Comorbidities in Specialist Mental Healthcare.

BACKGROUND: The majority of patients with major depressive disorder (MDD) have comorbid mental conditions. OBJECTIVES: Since most cost-of-illness studies correct for comorbidity, this study focuses on mental healthcare utilization and treatment costs in patients with MDD including psychiatric comorbidities in specialist mental healthcare, particularly patients with a comorbid personality disorder (PD). METHODS: The Psychiatric Case Register North Netherlands contains administrative data of specialist mental healthcare providers. Treatment episodes were identified from uninterrupted healthcare use. Costs were calculated by multiplying care utilization with unit prices (price level year: 2018). Using generalized linear models, cost drivers were investigated for the entire cohort. RESULTS: A total of 34,713 patients had MDD as a primary diagnosis over the period 2000-2012. The number of patients with psychiatric comorbidities was 24,888 (71.7%), including 13,798 with PD. Costs were highly skewed, with an average ± standard deviation cost per treatment episode of €21,186 ± 74,192 (median €2320). Major cost drivers were inpatient days and daycare days (50 and 28% of total costs), occurring in 12.7 and 12.5% of episodes, respectively. Compared with patients with MDD only (€11,612), costs of patients with additional PD and with or without other comorbidities were, respectively, 2.71 (p < .001) and 2.06 (p < .001) times higher and were 1.36 (p < .001) times higher in patients with MDD and comorbidities other than PD. Other cost drivers were age, calendar year, and first episodes. CONCLUSIONS: Psychiatric comorbidities (especially PD) in addition to age and first episodes drive costs in patients with MDD. Knowledge of cost drivers may help in the development of future stratified disease management programs.

Episode detection based on personalized intensity of care thresholds: a schizophrenia case study.

BACKGROUND: Schizophrenia Spectrum Disorder (SSD) is characterized by its chronic, episodic nature. The clear definition of such episodes is essential for various clinical and research purposes. Most current definitions of episodes in SSD are based on either hospitalizations or on symptom scales. Both have drawbacks; symptom scales are measured infrequently, while hospitalization rates are often affected by policy. This study presents an approach for defining episodes in healthcare data that does not suffer such drawbacks. METHODS: Healthcare use of 13,155 SSD patients in the Northern Netherlands with up to 12 years of follow-up was available. Patient-level structural changes in the trend of healthcare use costs were determined using Exponentially Weighted Moving Average (EWMA) control charts. Control charts restart with updated parameters after a detected structural change. Episodes were defined using these structural changes. The resulting episodes were validated by investigating their association with the Global Assessment of Functioning (GAF) scale. RESULTS: The mean number of episodes was 0.61 (sd: 0.60) per patient per year. For the sub-group without hospitalizations this was 0.51 (sd: 0.71). Average episode duration of the sub-group (147 days, sd: 309.4) was similar to that of the full sample (150 days, sd: 305.5). A significant inverse association was identified between GAF scores and the episode-state indicator. CONCLUSIONS: The repeated application of EWMA control charts based on healthcare-intensity is a feasible and promising tool for quantifying patient-level healthcare episodes. The validation using GAF scores indicates that our episode indicator is associated with lower levels of global functioning. Results for individuals without hospitalizations indicate that the method is robust with regard to changes in healthcare policy.

Satisfaction with social connectedness as a predictor for positive and negative symptoms of psychosis: A PHAMOUS study.

PURPOSE: This study examines satisfaction with social connectedness (SSC) as predictor of positive and negative symptoms in people with a psychotic disorder. METHODS: Data from the Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS) was used from patients assessed between 2014 and 2019, diagnosed with a psychotic disorder (N = 2109). Items about social connectedness of the Manchester short assessment of Quality of Life (ManSA) were used to measure SSC. Linear mixed models were used to estimate the association of SSC with the Positive and Negative Syndrome Scale (PANSS) after one and two years against α = 0.01. Analyses were adjusted for symptoms, time since onset, gender and age. Additionally, fluctuation of positive and negative symptom scores over time was estimated. RESULTS: The mean duration of illness of the sample was 18.8 years (SD 10.7) with >65% showing only small variation in positive and negative symptoms over a two to five-year time period. After adjustment for covariates, SSC showed to be negatively associated with positive symptoms after one year (ß = -0.47, p < 0.001, 95% CI = -0.70, -025) and two years (ß = -0.59, p < 0.001, 95% CI = -0.88, -0.30), and for negative symptoms after one year (ß = -0.52, p < 0.001, 95% CI = -0.77, -0.27). The prediction of negative symptoms was not significant at two years. CONCLUSION: This research indicates that interventions on SSC might positively impact mental health for people with psychosis. SSC is a small and robust predictor of future levels of positive symptoms. Negative symptoms could be predicted by SSC at one year.

The clinical effectiveness of an algorithm-guided treatment program for depression in specialized mental healthcare: A comparison with efficacy trials.

BACKGROUND: Doubts exist on whether effects found in randomized controlled trials (RCTs) are directly generalizable to daily clinical practice. This study aimed (a) to investigate the effectiveness of treatment options within an algorithm-guided treatment (AGT) program for depression and compare their effectiveness with outcomes of efficacy trials and (b) to assess the relation between treatment continuity and outcomes. METHODS: This naturalistic study linked treatment data from January 2012 to November 2014 from a Dutch mental healthcare provider, to routine outcome monitoring (ROM) data (N = 351). Effectiveness of the treatment options (pharmacotherapy, psychotherapy and their combination) was compared to the efficacy reported in the meta-analyses. We included treatment continuity as binary variable "early terminators versus completers of the recommended number of treatment sessions". RESULTS: Remission rates for psychotherapy (38% [95% CI: 32-45]), pharmacotherapy (31% [95% CI: 22-42]) and combination therapy (46% [95% CI: 19-75]) were respectively lower, comparable, and comparable to those reported in the meta-analyses. Similarly, response rates were respectively lower (24% [95% CI: 19-30]), lower (21% [95% CI: 13-31]), and comparable (46% [95% CI: 19-75]) to meta-analyses results. A similar share of early terminators and completers achieved remission and response. LIMITATIONS: A substantial proportion of patients had incomplete ROM data after data linkage. Limited set of patient characteristics to check for selection bias. CONCLUSIONS: Despite the more heterogeneous patient population in clinical practice, the effectiveness of an AGT program, emphasizing strict guideline adherence, approached that found in RCTs. A fixed number of treatment sessions may not suit all individual patients.