The Overlooked Part of Flexible Assertive Community Treatment-A Retrospective Study on Factors Related to Discharge from FACT for Clients with a Psychotic Disorder.

Flexible assertive community treatment (FACT) is a recovery-based treatment and its manual describes discharge criteria for clients who are recovered. Yet research on discharge is lacking. In this retrospective and observational study, between 2009 and 2019, we explored how sociodemographic, clinical, and treatment factors are associated with planned discharge or no discharge. We included 1734 clients with a psychotic disorder of which 38.5% were discharged after a mutual decision that FACT was no longer necessary. Logistic regression analysis was used to create a discharge profile which was more favorable for discharged clients. They were older at the start of FACT, had lower HoNOS scores, were diagnosed with another psychotic disorder, and had fewer contacts with non-FACT members. Discharge is a part of FACT and is more common than anticipated. While this study provides preliminary answers, further research is necessary to better understand discharge and its associated factors.

Hospital healthcare utilizers with medical and psychiatric claims in the Netherlands: a nationwide study.

BACKGROUND: Psychiatric and medical multimorbidity is associated with low quality of life, poor functioning and excess mortality. Differences in healthcare utilization between those receiving co-occurring medical and psychiatric healthcare (HUMPCs) and those only receiving medical (HUMCs) or only psychiatric healthcare (HUPCs) may indicate differences in care accessibility, help-seeking behavior and the risk patterns of medical illness. We aimed to assess the occurrence of psychiatric diagnostic groups in HUMPCs compared to HUPCs and to compare their medical and psychiatric claims expenditures. METHODS: Using Dutch claims data covering psychiatric and medical hospital care in 2010-2011, healthcare utilization differences between HUMPCs and HUPCs were expressed as differences and ratios, accounting for differences in age and sex between groups. Median claims expenditures were then compared between HUMPCs and HUPCs. RESULTS: HUMPCs had 40% higher median medical cost of claims compared to HUMCs and a 10% increased number of psychiatric claims compared to HUPCs. HUMPCs were more often diagnosed with: organic disorders; behavioral syndromes associated with physiological disturbances and physical factors; mood [affective] disorders; neurotic, stress related and somatoform disorders; and disorders of adult personality and behavior. By contrast, disorders of psychological development, schizophrenia, schizotypal and delusional disorders, behavioral and emotional disorders with usual onset occurring in childhood, and mental and behavioral disorders due to psychoactive substance abuse were less often diagnosed in this group. CONCLUSIONS: Both medical and psychiatric disease become more costly where both are present. For HUMPCs the costs of both medical and psychiatric claims for almost all diagnostic groups were higher than for HUPCs and HUMCs.

Psychiatric Emergencies in Minors: The Impact of Sex and Age.

OBJECTIVE: Little information is available on young children (age 4-12 years) with mental health problems who are seen by the psychiatric emergency services. We therefore described this population to identify (1) variables that differentiated children from those aged 13 to 18 years who had been referred for psychiatric emergency consultation; and (2) to describe sex differences. METHOD: We extracted data for a 9-year period from the records of the mobile psychiatric emergency services in 2 urban areas in the Netherlands. In this period, 79 children aged 4 to 12 years (37.2% girls) and 1695 children aged 12 to 18 years (62.2% girls) had been referred for psychiatric emergency consultation. Demographic and process factors were recorded. Clinical characteristics included diagnostic and statistical manual of mental disorders, 4th edition classifications and the Severity of Psychiatric Illness scale. Logistic regression analyses were used to examine differences between the girls and boys in the 2 age groups. RESULTS: Young children aged 4 to 12 years had been involved in 4.5% of all consultations of minors. In contrast with adolescents, a higher percentage of young children seen for emergency consultation were boys, and a lower percentage was admitted to a psychiatric hospital (7.7%). In boys and girls alike, a DSM classification of behavioral disorder was associated with younger age. CONCLUSIONS: The young group of children referred for psychiatric emergency consultation comprised relatively more children with behavioral disorders. Decisions to refer them for urgent psychiatric consultation seemed to be influenced by the suspicion of psychotic symptoms or of danger to themselves or others.

Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth.

As hospital beds are scarce, and emergency admissions to a psychiatric ward are major life-events for children and adolescents, it is essential to have insight into the decision-making process that leads to them. To identify potentially modifiable factors, we, therefore, studied the contextual and clinical characteristics associated with the voluntary and compulsory emergency admission of minors. We used registry data (2008-2017) on 1194 outpatient emergencies involving children aged 6-18 who had been referred to the mobile psychiatric emergency service in two city areas in The Netherlands. Demographic and contextual factors were collected, as well as clinical characteristics including diagnoses, psychiatric history, Global Assessment of Functioning (GAF), and the Severity of Psychiatric Illness (SPI) scale. Logistic regression analyses were used to identify factors that predict voluntary or compulsory admission. Of 1194 consultations, 227 (19.0%) resulted in an admission, with 137 patients (11.5%) being admitted voluntarily and 90 (7.5%) compulsorily. Independently of legal status, the following characteristics were associated with admission: severity of psychiatric symptoms, consultation outside the patient's home, and high levels of family disruption. Relative to voluntary admission, compulsory admission was associated with more severe psychiatric problems, higher suicide risk, and prior emergency compulsory admission. Two potentially modifiable factors were associated with psychiatric emergency admission: the place where patients were seen for consultation, and the presence of family problems. Psychiatric emergency admissions may be reduced if, whenever possible, minors are seen in their homes and if a system-oriented approach is used.

Evaluation of opening a type III/IV medical psychiatric unit.

OBJECTIVE: The aim of this study is to examine the impact of opening a medical psychiatric unit (MPU) on a variety of outcomes. METHODS: In this non-equivalent groups design, there were two groups: 'pre-MPU' and 'actual MPU'. Staff assessed whether patients in the pre-MPU group were eligible for admission to a planned MPU, resulting in virtual admissions and discharges. The actual MPU group consisted of patients admitted after opening of the MPU. RESULTS: The length of stay (LOS) in the hospital was one day longer for patients in the MPU group (8.68 vs. 9.89, p = .004), but the LOS on the MPU was comparable in both groups (5.63 vs. 6.06, p = .231). The LOS on the intensive care unit (ICU) was longer in the MPU group (0.10 vs. 0.40, p < .001), even as the time patients were physically restraint (0.28 vs. 0.83, p < .001). In the pre-MPU group, the odds were not significantly different for involuntary commitment (OR = 0.92; p = .866) and death within six months after discharge (OR = 1.84; p = .196). CONCLUSIONS: Both physical restraint and ICU admission have a link with patient complexity, it therefore seemed that opening of the MPU resulted in the treatment of more complex patients with a comparable LOS on the MPU.KEY POINTSThe LOS on the MPU was not significantly different between the groups before and after opening of the MPU.Opening of the MPU resulted in the admission of patients that were admitted more days to the ICU and to more days of physically restraint.It can be considered that opening of the MPU resulted in an increased ability to treat complex patients.

An intensive multimodal group programme for patients with psychotic disorders at risk of rehospitalization: a controlled intervention study.

BACKGROUND: On the basis of earlier experiences in Germany and England, we developed an intensive multimodal group programme (FACT Plus) for psychotic-spectrum patients. By combining it with regular Flexible Assertive Community Treatment (FACT) (care as usual), we intended to reduce psychiatric rehospitalizations and mental healthcare costs. METHODS: We included adult patients (>18 years) with a psychotic spectrum disorder who had had at least one psychiatric admission in the 2 years before inclusion. FACT Plus was delivered weekly for 9 months. The intervention group was recruited in northern Rotterdam (the Netherlands), and the control group was recruited in southern Rotterdam. The primary outcome measure was length of stay (LOS) and the secondary outcome measures were mental healthcare costs and compulsory admissions. RESULTS: We included 52 patients in the intervention group and 61 patients in the control group. During the 12-month observation period, the mean LOS per patient was 15.2 (intervention group) and 34.6 (control group). This represents a difference of 19.4 days (56.1%). This result was statistically significant (B = -.859, SE = .497, p = .042) in a regression model correcting for baseline differences between the groups. Mean total mental healthcare costs per patient were €21,098 in the intervention group) versus €25,054 in the control group, a difference of about €4000 per patient (16%). In addition, there were zero compulsory admissions in the intervention group and nine in the control group. CONCLUSIONS: After the addition of FACT Plus to regular FACT, psychiatric LOS was substantially lower in the intervention group than in the control group. This result was accompanied by a limited reduction in mental healthcare costs.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services.

BACKGROUND: The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES. METHODS: Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission. RESULTS: Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder. CONCLUSIONS: While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

The role of adverse childhood experiences and mental health care use in psychological dysfunction of male multi-problem young adults.

Adverse childhood experiences (ACEs) are associated with severe problems later in life. This study examines how eleven types of ACEs and mental health care use history are related to current psychological dysfunction among multi-problem young adults. A sample of 643 multi-problem young adult men (age 18-27) gave informed consent for us to collect retrospective regional psychiatric case register data and filled out questionnaires. ACEs were highly prevalent (mean 3.6, SD 2.0). Logistic regression analysis showed that compared with participants who experienced other ACEs, participants who experienced psychological problems in their family and grew up in a single-parent family were more likely to have used mental health care, and physically abused participants were less likely to have used mental health care. Linear regression analyses showed a dose-response relationship between ACEs and internalizing and externalizing problems. Linear regression analyses on the single ACE items showed that emotional abuse and emotional neglect were positively related to internalizing problems. Emotional and physical abuse and police contact of family members were positively related to externalizing problems. While multi-problem young adults experienced many ACEs, only a few ACEs were related to mental health care use in childhood and adolescence. Long-term negative effects of ACEs on psychological functioning were demonstrated; specifically, emotional abuse and emotional neglect showed detrimental consequences. Since emotional abuse and emotional neglect are not easily identified and often chronic, child health professionals should be sensitive to such problems.

The effect of financial incentives on patients' motivation for treatment: results of "Money for Medication," a randomised controlled trial.

BACKGROUND: Offering financial incentives is an effective intervention for improving adherence in patients taking antipsychotic depot medication. We assessed whether patients' motivation for treatment might be reduced after receiving financial rewards. METHODS: This study was part of Money for Medication, a multicentre, open-label, randomised controlled trial, which demonstrated the positive effects of financial incentives on antipsychotic depot compliance. Three mental healthcare institutions in Dutch secondary psychiatric care services participated. Eligible patients were aged 18-65 years, had been diagnosed with schizophrenia or another psychotic disorder, had been prescribed antipsychotic depot medication or had an indication to start using depot medication, and were participating in outpatient treatment. For 12 months, patients were randomly assigned either to treatment as usual (control group) or to treatment as usual plus a financial reward for each depot of medication received (€30 per month if fully compliant; intervention group). They were followed up for 6 months, during which time no monetary rewards were offered for taking antipsychotic medication. To assess treatment motivation after 0, 12 and 18 months, interviews were conducted using a supplement to the Health of the Nation Outcome Scales (HoNOS) and the Treatment Entry Questionnaire (TEQ). RESULTS: Patients were randomly assigned to the intervention (n = 84) or the control group (n = 85). After 12 months, HoNOS motivation scores were available for 131 patients (78%). Ninety-one percent of the patients had no or mild motivational problems for overall treatment; over time, there were no significant differences between the intervention and control groups. TEQ data was available for a subgroup of patients (n = 61), and showed no significant differences over time between the intervention and control groups for external motivation (ß = 0.37 95% CI: -2.49 - 3.23, p = 0.799); introjected motivation (ß = - 2.39 95% CI: -6.22 - 1.44, p = 0.222); and identified motivation (ß = - 0.91 95% CI: -4.42 - 2.61, p = 0.613). After the 6-month follow-up period, results for the HoNOS and TEQ scores remained comparable. CONCLUSIONS: Offering financial incentives for taking antipsychotic depot medication does not reduce patients' motivation for treatment. TRIAL REGISTRATION: Netherlands Trial registration, number NTR2350 .

Lithium dosing strategies during pregnancy and the postpartum period.

BackgroundLithium is challenging to dose during pregnancy.AimsTo provide guidance for dosing lithium during pregnancy.MethodRetrospective observational cohort study. Data on lithium blood level measurements (n = 1101), the daily lithium dose, dosing alterations/frequency and creatinine blood levels were obtained from 113 pregnancies of women receiving lithium treatment during pregnancy and the postpartum period.ResultsLithium blood levels decreased in the first trimester (-24%, 95% CI -15 to -35), reached a nadir in the second trimester (-36%, 95% CI -27 to -47), increased in the third trimester (-21%, 95% CI -13 to -30) and were still slightly increased postpartum (+9%, 95% CI +2 to +15). Delivery itself was not associated with an acute change in lithium and creatinine blood levels.ConclusionsWe recommend close monitoring of lithium blood levels until 34 weeks of pregnancy, then weekly until delivery and twice weekly for the first 2 weeks postpartum. We suggest creatinine blood levels are measured to monitor renal clearance.

Ethical acceptability of offering financial incentives for taking antipsychotic depot medication: patients' and clinicians' perspectives after a 12-month randomized controlled trial.

BACKGROUND: A randomized controlled trial 'Money for Medication'(M4M) was conducted in which patients were offered financial incentives for taking antipsychotic depot medication. This study assessed the attitudes and ethical considerations of patients and clinicians who participated in this trial. METHODS: Three mental healthcare institutions in secondary psychiatric care in the Netherlands participated in this study. Patients (n = 169), 18-65 years, diagnosed with schizophrenia, schizoaffective disorder or another psychotic disorder who had been prescribed antipsychotic depot medication, were randomly assigned to receive 12 months of either treatment as usual plus a financial reward for each depot of medication received (intervention group) or treatment as usual alone (control group). Structured questionnaires were administered after the 12-month intervention period. Data were available for 133 patients (69 control and 64 intervention) and for 97 clinicians. RESULTS: Patients (88%) and clinicians (81%) indicated that financial incentives were a good approach to improve medication adherence. Ethical concerns were categorized according to the four-principles approach (autonomy, beneficence, non-maleficence, and justice). Patients and clinicians alike mentioned various advantages of M4M in clinical practice, such as increased medication adherence and improved illness insight; but also disadvantages such as reduced intrinsic motivation, loss of autonomy and feelings of dependence. CONCLUSIONS: Overall, patients evaluated financial incentives as an effective method of improving medication adherence and were willing to accept this reward during clinical treatment. Clinicians were also positive about the use of this intervention in daily practice. Ethical concerns are discussed in terms of patient autonomy, beneficence, non-maleficence and justice. We conclude that this intervention is ethically acceptable under certain conditions, and that further research is necessary to clarify issues of benefit, motivation and the preferred size and duration of the incentive. TRIAL REGISTRATION: Nederlands Trial Register, number NTR2350 .

Severe Infections are Common in Thiamine Deficiency and May be Related to Cognitive Outcomes: A Cohort Study of 68 Patients With Wernicke-Korsakoff Syndrome.

BACKGROUND: Wernicke encephalopathy can have different clinical outcomes. Although infections may precipitate the encephalopathy itself, it is unknown whether infections also modify the long-term outcome in patients developing Korsakoff syndrome. OBJECTIVE: To determine whether markers of infection, such as white blood cell (WBC) counts and absolute neutrophil counts in the Wernicke phase, are associated with cognitive outcomes in the end-stage Korsakoff syndrome. METHOD: Retrospective, descriptive study of patients admitted to Slingedael Korsakoff Center, Rotterdam, The Netherlands. Hospital discharge letters of patients with Wernicke encephalopathy were searched for relevant data on infections present upon hospital admission. Patients were selected for further analysis if data were available on WBC counts in the Wernicke phase and at least 1 of 6 predefined neuropsychological tests on follow-up. RESULTS: Infections were reported in 35 of 68 patients during the acute phase of Wernicke-Korsakoff syndrome-meningitis (1), pneumonia (14), urinary tract infections (9), acute abdominal infections (4), sepsis (5) empyema, (1) and infection "of unknown origin" (4). The neuropsychological test results showed significant lower scores on the Cambridge Cognitive Examination nonmemory section with increasing white blood cell counts (Spearman rank correlation, ρ = -0.34; 95% CI: -0.57 to -0.06; 44 patients) and on the "key search test" of the behavioral assessment of the dysexecutive syndrome with increasing absolute neutrophil counts (ρ= -0.85; 95% CI: -0.97 to -0.42; 9 patients). CONCLUSIONS: Infections may be the presenting manifestation of thiamine deficiency. Patients with Wernicke-Korsakoff syndrome who suffered from an infection during the acute phase are at risk of worse neuropsychological outcomes on follow-up.

Working Alliance in Patients with Severe Mental Illness Who Need a Crisis Intervention Plan.

Working alliance has been characterized as an important predictor of positive treatment outcomes. We examined whether illness insight, psychosocial functioning, social support and locus of control were associated with working alliance as perceived by both patient and clinician. We assessed 195 outpatients with psychotic or bipolar disorders. Our findings indicated that patients rated the alliance more positively when they experienced a greater need for treatment, fewer behavioral and social problems, and more psychiatric symptoms. Clinicians rated the alliance more positively in patients who reported fewer social problems and better illness insight. Patients' demographic characteristics, including being female and married, were also positively related to the clinician-rated alliance. Our results suggest that patients and clinicians have divergent perceptions of the alliance. Clinicians may need help developing awareness of the goals and tasks of patients with certain characteristics, i.e., singles, men, those with poor illness insight and those who report poor social functioning.

Efficacy of Tranylcypromine in Bipolar Depression: A Systematic Review.

OBJECTIVE: Currently, there is a paucity of treatment options with limited efficacy for bipolar depression. The monoamine oxidase inhibitor tranylcypromine might be an effective form of treatment. The current systematic review reassesses the efficacy and safety of tranylcypromine in bipolar depression. METHODS: For this systematic review comparing tranylcypromine with placebo or active comparators in bipolar depression, relevant randomized controlled trials were identified from systematic searches of PubMed, EMBASE, and Cochrane library databases. A manual search of the references of the included studies was also performed. RESULTS: Four studies with a total of 145 participants were identified. Response rates were higher in patients treated with tranylcypromine (60.0%-80.7%; overall response rate, 73.7%) compared with placebo, imipramine, and lamotrigine (the latter as add-on to a mood stabilizer) (12.9%-47.6%; overall response rate, 27.5%). The overall switch rate was 6.3% for patients treated with tranylcypromine and 18.4% for patients in the control group. CONCLUSIONS: This systematic review provides evidence for the efficacy and safety of tranylcypromine treatment in bipolar depression. Additional research is required to establish the efficacy of tranylcypromine as add-on to a mood stabilizer.

Decrease in unmet needs contributes to improved motivation for treatment in elderly patients with severe mental illness.

PURPOSE: To investigate the pattern of associations between changes in unmet needs and treatment motivation in elderly patients with severe mental illness. METHODS: Observational longitudinal study in 70 patients treated by an assertive community treatment team for the elderly. Unmet needs and motivation for treatment were measured using the Camberwell assessment of needs for the elderly and the stages-of-change (SoC) scale, respectively, at baseline, after 9 and 18 months. SoC scores were dichotomized into two categories: motivated and unmotivated. Multinomial logistic regression analyses were conducted to determine whether changes in motivation were parallel to or preceded changes in unmet needs. RESULTS: The number of patients who were not motivated for treatment decreased over time (at baseline 71.4 % was not motivated, at the second measurement 51.4 %, and at 18 months 31.4 % of the patients were not motivated for treatment). A decrease in unmet needs, both from 0-9 to 0-18 months was associated with remaining motivated or a change from unmotivated to becoming motivated during the same observational period (parallel associations). A decrease in unmet needs from 0 to 9 months was also associated with remaining motivated or a change from unmotivated to motivated during the 9-18 months follow-up (sequential associations). CONCLUSIONS: Our findings suggest that a decrease in unmet needs is associated with improvements in motivation for treatment.

The effectiveness of assertive community treatment for elderly patients with severe mental illness: a randomized controlled trial.

BACKGROUND: Due to fragmented mental, somatic, and social healthcare services, it can be hard to engage into care older patients with severe mental illness (SMI). In adult mental health care, assertive community treatment (ACT) is an organizational model of care for treating patients with SMI who are difficult to engage. So far all outcome studies of assertive community treatment have been conducted in adults. METHODS: In a randomized controlled trial design we compared the effectiveness of ACT for elderly patients with that of treatment as usual (TAU). Sixty-two outpatients (60 years and older) with SMI who were difficult to engage in psychiatric treatment were randomly assigned to the intervention or control group (32 to ACT for elderly patients and 30 to TAU). Primary outcomes included number of patients who had a first treatment contact within 3 months, the number of dropouts (i.e. those discharged from care due to refusing care or those who unintentionally lost contact with the service over a period of at least 3 months); and patients' psychosocial functioning (HoNOS65+ scores) during 18 months follow-up. Secondary outcomes included the number of unmet needs and mental health care use. Analyses were based on intention-to-treat. RESULTS: Of the 62 patients who were randomized, 26 were lost to follow-up (10 patients in ACT for elderly patients and 16 in TAU). Relative to patients with TAU, more patients allocated to ACT had a first contact within three months (96.9 versus 66.7%; X2 (df = 1) = 9.68, p = 0.002). ACT for elderly patients also had fewer dropouts from treatment (18.8% of assertive community treatment for elderly patients versus 50% of TAU patients; X2 (df = 1) = 6.75, p = 0.009). There were no differences in the other primary and secondary outcome variables. CONCLUSIONS: These findings suggest that ACT for elderly patients with SMI engaged patients in treatment more successfully. TRIAL REGISTRATION: NTR1620.

Money for medication: a randomized controlled study on the effectiveness of financial incentives to improve medication adherence in patients with psychotic disorders.

BACKGROUND: Non-adherence with antipsychotic medication is a frequently occurring problem, particularly among patients with psychotic disorders. Prior research has generally shown encouraging results for interventions based on 'Contingency Management' (CM), in which desirable behaviour is encouraged by providing rewards contingent upon the behaviour. However, little is known about the application of CM on medication adherence in patients with psychotic disorders. An earlier pilot-study by our study group showed promising results in reducing admission days and increasing adherence. The current study is a randomized controlled trial concerning the effectiveness of a CM procedure called 'Money for Medication' (M4M), aimed at improving adherence with antipsychotic depot medication in psychotic disorder patients. METHODS/DESIGN: Outpatients (n =168) with a psychotic disorder will be randomly assigned to either the experimental group (n =84), receiving a financial reward for each accepted antipsychotic medication depot, or the control group (n =84), receiving treatment as usual without financial rewards. Patients are included regardless of their previous adherence. The intervention has a duration of twelve months. During the subsequent six months follow-up, the effects of discontinuing the intervention on depot acceptance will be assessed. The primary goal of this study is to assess the effectiveness of providing financial incentives for improving adherence with antipsychotic depot medication (during and after the intervention). The primary outcome measure is the percentage of accepted depots in comparison to prescription. Secondary, we will consider alternative measures of medication acceptance, i.e. the longest period of uninterrupted depot acceptance and the time expired before depot is taken. Additionally, the effectiveness of the experimental intervention will be assessed in terms of psychosocial functioning, substance use, medication side-effects, quality of life, motivation, cost-utility and patients' and clinicians' attitudes towards M4M. DISCUSSION: This RCT assesses the effectiveness and side-effects of financial incentives in improving adherence with antipsychotic depot medication in patients with psychotic disorders. This study is designed to assess whether M4M is an effective intervention to improve patients' acceptance of their antipsychotic depot medication and to examine how this intervention contributes to patients' functioning and wellbeing. TRIAL REGISTRATION: NTR2350 .

Ethnicity, socioeconomic position and severity of problems as predictors of mental health care use in 5- to 8-year-old children with problem behaviour.

BACKGROUND: Empirical research on mental health care use and its determinants in young school-aged children is still scarce. In this study, we investigated the role of ethnicity, socioeconomic position (SEP) and perceived severity by both parents and teachers on mental health care use in 5- to 8-year old children with emotional and/or behavioural problems. METHODS: Data from 1,269 children with a high score([P90) on the Strengths and Difficulties Questionnaire (SDQ) in the school year 2008­2009 were linked to psychiatric case register data over the years 2010­2011. Cox proportional hazards models were used to predict mental health care use from ethnicity, SEP and perceived severity of the child's problems. RESULTS: During the follow-up period, 117 children with high SDQ scores (9.2 %) had used mental health care for the first time. Ethnic minority children were less likely to receive care than Dutch children (HR Moroccan/Turkish:0.26; 95 % CI 0.13-0.54, HR other ethnicity: 0.26; 95 %CI 0.12-0.58). No socioeconomic differences were found.After correction for previous care use, ethnicity and parental perceived severity, impact score as reported by teachers was significantly associated with mental healthcare use (HR 1.58; 95 % CI 1.01­2.46). CONCLUSIONS: Ethnicity is an important predictor of mental health care use in young children. Already in the youngest school-aged children, ethnic differences in the use of mental health care are present.A distinct predictor of care use in this age group is severity of emotional and behavioural problems as perceived by teachers. Therefore, teachers may be especially helpful in the process of identifying young children who need specialist mental health care.

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.