André I. Wierdsma

Predicting Adolescent Mental Health Service Use in a Prospective Record‐Linkage Study

OBJECTIVE To test to what extent demographic variables and parent-reported problems and competencies in early adolescence predict incidence of mental health service use across a 5-year period in the general population. METHOD Data on parent-reported problem behavior (Child Behavior Checklist [CBCL]), gathered on 2,496 Dutch young adolescents, aged 10 to 12 years in 1989-1990, were linked to psychiatric case register data over the years 1990-1994. Cox proportional hazards models were used to predict the incidence of using mental health services from problem behavior, competencies, and demographic covariates. RESULTS Almost all CBCL problem scales predicted the incidence of mental health service use significantly. The effect was constant over time for most scales, but it decreased over time for others. CBCL Activities, gender, and one-parent family were significant predictors after accounting for the problem levels. All effects were similar for boys and girls. CONCLUSIONS In many cases, there is a remarkable delay between the awareness of the adolescents problems and seeking and/or receiving professional help. Longitudinal studies that use continuous information on service use yield a more comprehensive picture of the utilization of mental health services than studies that aggregate the information over the follow-up period.

Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment

BACKGROUND Short-term structured risk assessment is presumed to reduce incidents of aggression and seclusion on acute psychiatric wards. Controlled studies of this approach are scarce. AIMS To evaluate the effect of risk assessment on the number of aggression incidents and time in seclusion for patients admitted to acute psychiatric wards. METHOD A cluster randomised controlled trial was conducted in four wards over a 40-week period (n = 597 patients). Structured risk assessment scales were used on two experimental wards, and the numbers of incidents of aggression and seclusion were compared with two control wards where assessment was based purely on clinical judgement. RESULTS The numbers of aggressive incidents (relative risk reduction -68%, P<0.001) and of patients engaging in aggression (relative risk reduction RRR = -50%, P<0.05) and the time spent in seclusion (RRR = -45%, P<0.05) were significantly lower in the experimental wards than in the control wards. Neither the number of seclusions nor the number of patients exposed to seclusion decreased. CONCLUSIONS Routine application of structured risk assessment measures might help reduce incidents of aggression and use of restraint and seclusion in psychiatric wards.

Antidepressant pharmacotherapy failure and response to subsequent electroconvulsive therapy: a meta-analysis.

Failure to respond to antidepressants probably is the most common indication for electroconvulsive therapy (ECT). The literature seems to be divided as to whether medication resistance has a negative influence on the efficacy of subsequent ECT. Therefore, we performed a systematic review to investigate the effect of previous pharmacotherapy failure on the efficacy of ECT. Relevant cohort studies were identified from systematic search of the PubMed electronic database. Seven studies were included in this meta-analysis: the overall remission rate amounts to 48.0% (281/585) for patients with and 64.9% (242/373) for patients without previous pharmacotherapy failure. An exact analysis with the Mantel-Haenszel method (fixed effect model) shows a reduced efficacy of ECT in patients that received previous pharmacotherapy (OR, 0.52; 95% confidence interval [CI], 0.39-0.69). In conclusion, the efficacy of ECT is significantly superior in patients without previous pharmacotherapy failure as compared with medication-resistant patients. Because this finding is based on observational studies, it might be caused by a confounding factor, for example, the presence of psychotic features or the duration of the index episode. Electroconvulsive therapy seems to be an effective treatment for severely depressed patients as well as for patients with previous pharmacotherapy failure.

Reconstructing continuity of care in mental health services: a multilevel conceptual framework.

Continuity of mental health care is a key issue in the organization and evaluation of services for patients with disabling chronic conditions. Over many years, health services researchers have been exploring the conceptual boundaries between continuity of care and other service characteristics. On the basis of papers published over the past decade, we argue that while conceptual consensus is growing, there is room to improve continuity measures, and the development of practical interventions is still at an early stage. There is growing consensus that continuity of care is a multidimensional concept. We identified four core elements: continuous care; care of an individual patient; cross-boundary care; and care recorded objectively. These elements help clarify conceptual boundaries, and incorporate measurement guidelines. With reference to these core elements, we define types of continuity of care, including informational continuity, management continuity, relational continuity and contact continuity. In order to improve continuity of care, better understanding is needed of the complex inter-relationship of core elements and types of continuity. A multilevel perspective on continuity of care can guide research to develop and evaluate new interventions. Achieving continuity of care is hindered by the lack of standard measures and administrative data appropriate to assessing continuity. Account should be taken not only of the nature of the patient population, but also of local conditions. To address these topics and identify best practices, research should be multidisciplinary and take a comparative, naturalistic form.

Criminal Victimisation in People with Severe Mental Illness : A Multi-Site Prevalence and Incidence Survey in the Netherlands

Background Although crime victimisation is as prevalent in psychiatric patients as crime perpetration (and possibly more so), few European figures for it are available. We therefore assessed its one-year prevalence and incident rates in Dutch severely mentally ill outpatients, and compared the results with victimisation rates in the general population. Method This multisite epidemiological survey included a random sample of 956 adult severely mentally ill outpatients. Data on victimisation were obtained using the victimisation scale of the Dutch Crime and Victimisation Survey, which assesses crime victimisation over the preceding 12 months. Comparison data were derived from the nationwide survey on safety and victimisation in the Netherlands. Prevalence and incident rates were weighted for sex, age, ethnicity and socioeconomic status, and compared with a general population sample matched by region (N = 38,227). Results In the past year, almost half of the severely mentally ill outpatients (47%) had been victim of a crime. After control for demographic differences, prevalence rates of overall and specific victimisation measures were significantly higher in severely mentally ill outpatients than in the general population. The relative rates were especially high for personal crimes such as violent threats (RR = 2.12, 95% CI: 1.72–2.61), physical assaults (RR = 4.85, 95% CI: 3.69–6.39) and sexual harassment and assaults (RR = 3.94, 95% CI: 3.05–5.09). In concordance, severely mentally ill outpatients reported almost 14 times more personal crime incidents than persons from the general population (IRR = 13.68, 95% CI: 12.85–14.56). Conclusion Crime victimisation is a serious problem in Dutch severely mentally ill outpatients. Mental-healthcare institutions and clinicians should become aware of their patients’ victimisation risk, and should implement structural measures to detect and prevent (re-)victimisation.

Effects of community-care networks on psychiatric emergency contacts, hospitalisation and involuntary admission

Background: Community-care networks are a partnership between the local police force, housing corporations, general social services, specialised home care and mental healthcare services. The networks were set up to improve the healthcare for patients with (chronic) psychiatric problems through local cooperation between different agencies operating in underprivileged areas. Objective: To evaluate the effects of community-care networks on psychiatric emergency contacts, hospitalisation and involuntary admission. Design: An ecological intervention design was used, comparing neighbourhoods with and without a community-care network. Mean numbers and standardised ratios of psychiatric emergency contacts, hospitalisation rates and involuntary admissions were assessed over a 10-year period, covering the early stages and the years in which community-care networks were fully operational. Setting: Underprivileged neighbourhoods in the city of Rotterdam, The Netherlands. Patients: Inhabitants aged 20–64 years living in these neighbourhoods. Results: Standardised ratios for contact with psychiatric emergency services were higher in the neighbourhoods where community-care networks were set up (standardised ratios = 137, 95% CI 121 to 145 in the network neighbourhoods vs standardised ratios = 107, 95% CI 96 to 119 in the control neighbourhoods). Number of admissions and standardised ratios for involuntary admissions were lower in the community-care network neighbourhoods than in the control neighbourhoods (standardised ratios = 123, 95% CI 95 to 157 vs standardised ratios = 152, 95% CI 120 to 191). Conclusions: Community-care networks have a significant impact on the use of mental healthcare services. These networks may be an important tool in the prevention of involuntary admissions.

Case registers in psychiatry: do they still have a role for research and service monitoring?

Purpose of review To follow up on reviews of case register research. Literature searches over a 2-year period were conducted to determine whether psychiatric case registers still have a role for research and service monitoring. Recent findings Case register research covers a wide range of topics, and is most often found in Denmark where national databases support all kinds of record linkage studies. Typically, case registers are used in studies of treated prevalence and incidence of psychiatric disorders, in research on patterns of care, as sampling frames in epidemiological studies, and in studies on risk factors and treatment outcome. Summary Despite a wide range of research based on administrative data, stakeholders in most countries are probably not well served by current priorities. Few studies investigate longitudinal patterns of service use to evaluate healthcare policies. There is a lack of comparative record linkage studies to inform local authorities on the cooperation between mental healthcare and public services. Implementing standard tools and procedures for routine outcome assessment seems still to be in an early phase in most register areas. When case register staff can capitalize on new opportunities, old and new case registers will continue to be important for research and service monitoring.

High preoperative plasma neopterin predicts delirium after cardiac surgery in older adults

To examine the association between plasma levels of pterins and amino acids and postoperative delirium.

Improved insight affects social outcomes in involuntarily committed psychotic patients: A longitudinal study in the Netherlands

BACKGROUND Lack of insight in schizophrenia is associated with negative social outcomes mediated by symptom severity, but longitudinal studies show contradicting findings. METHOD After commencement of court-ordered admission, adult patients were enrolled in a prospective study. A relatively homogeneous group of 133 patients with schizophrenia or related psychotic disorders was selected to evaluate the impact of illness insight and symptom severity on social outcomes. Interviews at baseline and after 6 and 12months included objective and subjective indicators of insight and social outcomes. Multilevel analyses were used to estimate the effect of insight and change in social outcomes controlling for symptom severity. RESULTS In 12-month follow-up, patients involuntarily hospitalized showed improvement in illness insight, symptom level, and social functioning, and had stable quality of life scores. Illness insight was associated with change in outcomes, independent from symptom severity. Results of the change analyses suggest that in time the association between insight and functioning becomes stronger. In contrast, insight scores were negatively associated with self-report quality of life ratings and markedly ill patients had a more negative perception of their quality of life. CONCLUSIONS Improvement in illness insight was associated with improvement in social functioning, but this was not reflected in improved self-perceived quality of life. Illness insight could result in worrying about relationships, living situation, health and finances. For severely mentally ill patients additional strategies must be found to improve social outcomes. Researchers should be more aware of varying effects for researcher-rated versus self-report indicators of insight and social outcome.

Psychosis and suicide risk by ethnic origin and history of migration in the Netherlands.

BACKGROUND There is an increased incidence of non-affective psychotic disorders (NAPD) among first- and second-generation migrants in Europe. The purpose of this population-based study was to compare the risk of suicide in Dutch natives and immigrants with or without NAPD. METHODS Cases of NAPD (n=12 580) from three Dutch psychiatric registers were linked to the cause of death register of Statistics Netherlands and were compared to matched controls (n=244 792) from the population register, who had no such diagnosis. Hazard ratios (HRs) of suicide were estimated and adjusted for age and gender by Cox regression analysis. RESULTS The presence of NAPD was strongly associated with suicide risk in each ethnic group. However, for all ethnic minority groups the HRs were somewhat lower than among Dutch natives, for whom the HR was 23.4 (95%-CI; 18.5-29.7). A closer examination revealed that suicide risk was influenced by the history of migration. While the risk for immigrants of the first generation, diagnosed with NAPD, was significantly lower than that for native Dutch patients (HR=0.45; 95%-CI: 0.28-0.73), the risk for those of the second generation was more similar to that for the Dutch (HR=0.85; 95%-CI: 0.51-1.40) (P value of history of migration=0.005). CONCLUSION Immigrants diagnosed with NAPD of the first generation appear to be protected against suicide, whereas this protection is waning among those of the second generation. This is the first study worldwide on suicide in migrants with NAPD and the first study of suicide in patients with NAPD in the Netherlands.