Jos de Keijser

RELIABILITY AND VALIDITY OF THE DUTCH VERSION OF THE INVENTORY OF TRAUMATIC GRIEF (ITG)

The psychometric properties of the Dutch version of the Inventory of Traumatic Grief (ITG) were investigated in two studies with bereaved adults who had suffered the loss of a first-degree relative. In Study 1, exploratory factor analysis indicated that the items of the ITG clustered together into one underlying factor. In addition, the internal consistency of the ITG and its short-term temporal stability were found to be high. In Study 2 it was found that the ITG exhibited adequate discriminative, concurrent, and construct validity. Furthermore, an ITG cutoff score for a diagnosis of traumatic grief was determined, with a sensitivity of 86% and a specificity of 76%, providing evidence in favor of the predictive validity of the ITG.

Prolonged Grief Disorder, depression, and posttraumatic stress disorder are distinguishable syndromes.

BACKGROUND This study examined the distinctiveness of symptoms of Prolonged Grief Disorder (PGD), depression, and posttraumatic stress disorder (PTSD). We compared the fit of a one-factor model with the fit of four hierarchical models in which symptoms formed three distinct correlated higher-order dimensions, and PTSD-items were modeled in different ways. METHODS Self-reported data were available from two samples; 572 mourners recruited via the internet and 408 mourners recruited via healthcare workers. RESULTS In Sample 1, the unitary model did not fit the data. The four hierarchical models all fit better. The model in which PTSD-items constituted four lower-order factors of reexperiencing, avoidance, dysphoria, and hyperarousal fit the data best. The fit was further improved, when one weak PGD-item and one weak PTSD-item were removed, and error-terms of similar items were allowed to correlate. Findings from Sample 1 were replicated in Sample 2. LIMITATIONS This study relied on self-reported data. Not all PGD-criteria and depression-criteria were assessed. CONCLUSIONS This is the first confirmatory factor analysis study showing that symptoms of PGD, depression, and PTSD represent distinguishable syndromes. PGD-symptoms should be addressed in the assessment and treatment of bereaved people seeking treatment.

Cognitive behaviour therapy to prevent complicated grief among relatives and spouses bereaved by suicide: cluster randomised controlled trial

Objective To examine the effectiveness of a family based grief counselling programme to prevent complicated grief among first degree relatives and spouses of someone who had committed suicide. Design Cluster randomised controlled trial with follow-up at 13 months after the suicide. Setting General practices in the Netherlands. Participants 122 first degree relatives and spouses of 70 people who committed suicide; 39 families (68 participants) were allocated to intervention, 31 families (54 participants) to control. Intervention A family based, cognitive behaviour counselling programme of four sessions with a trained psychiatric nurse counsellor between three to six months after the suicide. Control participants received usual care. Main outcome measures Self report complicated grief. Secondary outcomes were the presence of maladaptive grief reactions, depression, suicidal ideation, and perceptions of being to blame for the suicide. Results The intervention was not associated with a reduction in complicated grief (mean difference −0.61, 95% confidence interval −6.05 to 4.83; P=0.82). Secondary outcomes were not affected either. When adjusted for baseline inequalities, the intervention reduced the risk of perceptions of being to blame (odds ratio 0.18, 0.05 to 0.67; P=0.01) and maladaptive grief reactions (0.39, 0.15 to 1.01; P=0.06). Conclusions A cognitive behaviour grief counselling programme for families bereaved by suicide did not reduce the risk of complicated grief or suicidal ideation or the level of depression. The programme may help to prevent maladaptive grief reactions and perceptions of blame among first degree relatives and spouses. Trial registration Current Controlled Trials ISRCTN66473618.

The effect of an e-learning supported train-the-trainer programme on implementation of suicide guidelines in mental health care

BACKGROUND Randomized studies examining the effect of training of mental health professionals in suicide prevention guidelines are scarce. We assessed whether professionals benefited from an e-learning supported Train-the-Trainer programme aimed at the application of the Dutch multidisciplinary suicide prevention guideline. METHODS 45 psychiatric departments from all over the Netherlands were clustered in pairs and randomized. In the experimental condition, all of the staff of psychiatric departments was trained by peers with an e-learning supported Train-the-Trainer programme. Guideline adherence of individual professionals was measured by means of the response to on-line video fragments. Multilevel analyses were used to establish whether variation between conditions was due to differences between individual professionals or departments. RESULTS Multilevel analysis showed that the intervention resulted in an improvement of individual professionals. At the 3 month follow-up, professionals who received the intervention showed greater guideline adherence, improved self-perceived knowledge and improved confidence as providers of care than professionals who were only exposed to traditional guideline dissemination. Subgroup analyses showed that improved guideline adherence was found among nurses but not among psychiatrists and psychologists. No significant effect of the intervention on team performance was found. LIMITATIONS The ICT environment in departments was often technically inadequate when displaying the video clips clip of the survey. This may have caused considerable drop-out and possibly introduced selection bias, as professionals who were strongly affiliated to the theme of the study might have been more likely to finish the study. CONCLUSIONS Our results support the idea that an e-learning supported Train-the-Trainer programme is an effective strategy for implementing clinical guidelines and improving care for suicidal patients. TRIAL REGISTRATION Netherlands Trial Register (NTR3092 www.trialregister.nl).

Low implicit self-esteem and dysfunctional automatic associations in social anxiety disorder

BACKGROUND AND OBJECTIVES Negative automatic associations towards the self and social cues are assumed to play an important role in social anxiety disorder. We tested whether social anxiety disorder patients (n = 45) showed stronger dysfunctional automatic associations than non-clinical controls (n = 45) and panic disorder patients (n = 24) and whether there existed gender differences in this respect. METHODS We used a single-target Implicit Association Test and an Implicit Association Test to measure dysfunctional automatic associations with social cues and implicit self-esteem, respectively. RESULTS Results showed that automatic associations with social cues were more dysfunctional in socially anxious patients than in both control groups, suggesting this might be a specific characteristic of social anxiety disorder. Socially anxious patients showed relatively low implicit self-esteem compared to non-clinical controls, whereas panic disorder patients scored in between both groups. Unexpectedly, we found that lower implicit self-esteem was related to higher severity of social anxiety symptoms in men, whereas no such relationship was found in women. CONCLUSIONS These findings support the view that automatic negative associations with social cues and lowered implicit self-esteem may both help to enhance our understanding of the cognitive processes that underlie social anxiety disorder.

Applying computer adaptive testing to optimize online assessment of suicidal behavior: a simulation study

Background The Internet is used increasingly for both suicide research and prevention. To optimize online assessment of suicidal patients, there is a need for short, good-quality tools to assess elevated risk of future suicidal behavior. Computer adaptive testing (CAT) can be used to reduce response burden and improve accuracy, and make the available pencil-and-paper tools more appropriate for online administration. Objective The aim was to test whether an item response–based computer adaptive simulation can be used to reduce the length of the Beck Scale for Suicide Ideation (BSS). Methods The data used for our simulation was obtained from a large multicenter trial from The Netherlands: the Professionals in Training to STOP suicide (PITSTOP suicide) study. We applied a principal components analysis (PCA), confirmatory factor analysis (CFA), a graded response model (GRM), and simulated a CAT. Results The scores of 505 patients were analyzed. Psychometric analyses showed the questionnaire to be unidimensional with good internal consistency. The computer adaptive simulation showed that for the estimation of elevation of risk of future suicidal behavior 4 items (instead of the full 19) were sufficient, on average. Conclusions This study demonstrated that CAT can be applied successfully to reduce the length of the Dutch version of the BSS. We argue that the use of CAT can improve the accuracy and the response burden when assessing the risk of future suicidal behavior online. Because CAT can be daunting for clinicians and applied scientists, we offer a concrete example of our computer adaptive simulation of the Dutch version of the BSS at the end of the paper.

Factors associated with outcome of cognitive–behavioural therapy for complicated grief: A preliminary study

Complicated grief (CG), also called prolonged grief disorder, is a debilitating condition that can develop following a loss. There is growing evidence that cognitive-behavioural interventions are efficacious in the treatment of CG. The present preliminary study used data from 43 patients with CG who were randomly assigned to cognitive-behavioural therapy in an earlier treatment trial to explore (a) predictors of outcome of cognitive-behavioural therapy for CG and (b) the relationship between symptom improvement and changes in loss-related negative cognitions and avoidance behaviours. Analyses showed that worse treatment outcome was associated with lower education attainment, loss of a partner/child (instead of some other relative), early treatment discontinuation, less patient motivation and more severe CG symptoms at pre-treatment. As predicted, stronger reduction in CG severity was significantly associated with stronger reductions in negative cognitions and avoidance. Implications of these findings are discussed.

Improving the application of a practice guideline for the assessment and treatment of suicidal behavior by training the full staff of psychiatric departments via an e-learning supported Train-the-Trainer program : study protocol for a randomized controlled trial

BackgroundIn 2012, in The Netherlands a multidisciplinary practice guideline for the assessment and treatment of suicidal behavior was issued. The release of guidelines often fails to change professional behavior due to multiple barriers. Structured implementation may improve adherence to guidelines. This article describes the design of a study measuring the effect of an e-learning supported Train-the-Trainer program aiming at the training of the full staff of departments in the application of the guideline. We hypothesize that both professionals and departments will benefit from the program.MethodIn a multicenter cluster randomized controlled trial, 43 psychiatric departments spread over 10 regional mental health institutions throughout The Netherlands will be clustered in pairs with respect to the most prevalent diagnostic category of patients and average duration of treatment. Pair members are randomly allocated to either the experimental or the control condition. In the experimental condition, the full staff of departments, that is, all registered nurses, psychologists, physicians and psychiatrists (n = 532, 21 departments) will be trained in the application of the guideline, in a one-day small interactive group Train-the-Trainer program. The program is supported by a 60-minute e-learning module with video vignettes of suicidal patients and additional instruction. In the control condition (22 departments, 404 professionals), the guideline shall be disseminated in the traditional way: through manuals, books, conferences, internet, reviews and so on. The effectiveness of the program will be assessed at the level of both health care professionals and departments.DiscussionWe aim to demonstrate the effect of training of the full staff of departments with an e-learning supported Train-the-Trainer program in the application of a new clinical guideline. Strengths of the study are the natural setting, the training of full staff, the random allocation to the conditions, the large scale of the study and the willingness of both staff and management to participate in the study.Trial registrationDutch trial register: NTR3092

Longitudinal Measurement invariance of the Beck Scale for Suicide Ideation

In mental health care, both clinical and scientific decisions are based on within-subject comparisons of test scores on the same self-report questionnaire at different points in time. To establish the validity of test score comparisons over time, longitudinal measurement invariance should be established. The current study tested whether the 19 item Beck Scale for Suicide Ideation (BSS) is measurement invariant (MI) over time. As the first five items of the scale are often used to screen for the presence of suicidal thoughts, we also tested a model consisting of only the first five items. Psychiatric in- and out-patients (n=475) completed the questionnaire upon admission and after 3 months. By means of confirmatory factor analysis (CFA) we tested whether the parameters of a single factor model were equal over time. All fit indices indicated that both the 19-item questionnaire and the five-item screener were measurement invariant over time. This means that changes in test-scores over time can be attributed to true changes in the construct of interest. These findings legitimate the use of the 19 item scale and the five-item screener in longitudinal assessments.

Psychopathology Among Homicidally Bereaved Individuals A Systematic Review

In the literature on bereavement, claims are made that homicidal loss is associated with posttraumatic stress reactions, depression, and other severe mental health problems. It is surprising that only a few studies have investigated the nature and prevalence of emotional symptoms following homicidal bereavement and a reference to systematic, empirical research is seldom provided. This article reviews the available literature to investigate whether these claims have empirical evidence. Three databases were searched to identify relevant studies. This approach was supplemented with a bibliography search. Eligible studies included English-language peer-reviewed articles that assessed psychopathology in the homicidally bereaved, as defined in the Diagnostic and Statistical Manual of Mental Disorders. Of the 360 potentially relevant articles, 8 studies (13 references) met predefined inclusion criteria. Homicide-related psychopathology among the bereaved assessed in these studies includes posttraumatic stress disorder (PTSD), depression, complicated grief, and substance abuse. Prevalence of lifetime homicide-related PTSD varied from 19.1% to 71% across studies. Current PTSD varied between 5.2% and 6%. The reviewed literature was inconclusive regarding the course of symptoms over time and the severity of psychopathology among the homicidally bereaved, compared to individuals bereaved by other causes of death. A comparison of the nature and prevalence of psychopathology between studies was complicated by unequal sample sizes and type, recruitment strategy, study design, and time since loss. Limitations of the included studies are discussed, as well as implications for clinical practice, policy, and future research.