Ph. Delespaul

Behavioural sensitization to daily life stress in psychosis.

BACKGROUNDnRecent neurobiological models provide a possible mechanism of daily life stress directly affecting the intensity of psychotic experiences in vulnerable individuals. In order to validate such a mechanism, the impact of daily life stress on psychosis intensity was investigated in two groups at increased risk of onset (relatives) and relapse (patients) of psychosis.nnnMETHODnPatients with psychosis in a clinical state of remission (n = 42), first-degree relatives (n = 47), and control subjects (n = 49) were studied with the Experiencing Sampling Method (ESM is a structured diary technique assessing current context and psychopathology in daily life) to assess (1) appraised subjective stress related to daily activities and events, and (2) intensity of subtle psychotic experiences in daily life.nnnRESULTSnMultilevel regression analyses revealed significant increases in psychosis intensity associated with increases in subjective activity--and event-related stress in patients. First-degree relatives reported increases in psychosis intensity in relation to activity-related stress but not event-related stress. No association was found in control subjects.nnnCONCLUSIONSnSubjects at increased risk for psychosis show continuous variation in the intensity of subtle psychotic experiences associated with minor stresses in the flow of daily life. Behavioural sensitization to environmental stress may therefore be a vulnerability marker for schizophrenia, reflecting dopaminergic hyper-responsivity in response to environmental stimuli.

Mechanisms of gene–environment interactions in depression: evidence that genes potentiate multiple sources of adversity

BACKGROUNDnPrevious work suggests that daily life stress-sensitivity may be an intermediary phenotype associated with both genetic risk for depression and developmental stress exposures. In the current analysis we hypothesized that genetic risk for depression and three environmental exposures over the course of development [prenatal stress, childhood adversity and adult negative life events (NLEs)] combine synergistically to produce the phenotype of stress-sensitivity.nnnMETHODnTwin pairs (n=279) participated in a momentary assessment study using the Experience Sampling Method (ESM), collecting appraisals of stress and negative affect (NA) in the flow of daily life. Prospective data on birthweight and gestational age, questionnaire data on childhood adversity and recent NLEs, and interview data on depression were used in the analyses. Daily life stress-sensitivity was modelled as the effect of ESM daily life stress appraisals on ESM NA.nnnRESULTSnAll three developmental stress exposures were moderated by genetic vulnerability, modelled as dizygotic (DZ) or monozygotic (MZ) co-twin depression status, in their effect on daily life stress-sensitivity. Effects were much stronger in participants with MZ co-twin depression and a little stronger in participants with DZ co-twin depression status, compared to those without co-twin depression. NLE main effects and NLE genetic moderation were reducible to birthweight and childhood adversity.nnnCONCLUSIONSnThe findings are consistent with the hypothesis that adult daily life stress-sensitivity is the result of sensitization processes initiated by developmental stress exposures. Genes associated with depression may act by accelerating the process of stress-induced sensitization.

Is the excess risk of psychosis-like experiences in urban areas attributable to altered cognitive development?

Abstract.Background:Rates of psychotic disorder and related attenuatednpsychotic experiences are higher in urban areas. We examined tonwhat degree differences between urban and rural areas could benattributed to differences in cognitive development.Method:Scores on the nine subscales of the schizotypalnpersonality questionnaire (SPQ) as well as IQ and specificnneuropsychological functions of memory and attention werenassessed in a representative sample of 943 young army conscriptsnfrom the 49 counties of Greece.Results:Young men from urban areas had higher scores on the SPQnsubscale Odd beliefs/magicalnthinking (OR = 1.99, 95% CI: 1.42, 2.78), but lowernscores on Excessive socialnanxiety (OR = 0.63, 95 % CI: 0.49, 0.81) andnNo close friends (OR = 0.42,n95% CI: 0.29, 0.62). Adjustment for demographic factors, IQ andnspecific neuropsychological functions did not change thenresults. When the lower scores on Excessive social anxiety andnNo close friends were takenninto account, the differences on the Oddnbeliefs/magical thinking subscale became even morenpronounced (OR = 2.33, 95% CI: 1.56, 3.49).Conclusions:Young men from urban areas are socially more competent,nbut display higher levels of positive psychotic experiences,nwhich are not mediated by lower IQ or higher levels ofnneuropsychological impairment.

Function assertive community treatment (FACT) and psychiatric service use in patients diagnosed with severe mental illness

AIMnPrevious work suggests that the Dutch variant of assertive community treatment (ACT), known as Function ACT (FACT), may be effective in increasing symptomatic remission rates when replacing a system of hospital-based care and separate community-based facilities. FACT guidelines propose a different pattern of psychiatric service consumption compared to traditional services, which should result in different costing parameters than care as usual (CAU).nnnMETHODSnSouth-Limburg FACT patients, identified through the local psychiatric case register, were matched with patients from a non-FACT control region in the North of the Netherlands (NN). Matching was accomplished using propensity scoring including, among others, total and outpatient care consumption. Assessment, as an important ingredient of FACT, was the point of departure of the present analysis.nnnRESULTSnFACT patients, compared to CAU, had five more outpatient contacts after the index date. Cost-effectiveness was difficult to assess.nnnCONCLUSIONnImplementation of FACT results in measurable changes in mental health care use.

Are social phobia and paranoia related, and which comes first?

Social phobia (SPh) and paranoid symptoms (PS) are associated. They may overlap because they share psychological and behavioural mechanisms such as selective attention for social threats and avoidance behaviour. Possibly, one leads to the other. The aim of this study is to explore the association between SPh and PS in a prospective general population sample. Adults (7076) from the NEMESIS general population were assessed for SPh and PS using the Composite International Diagnostic Interview (CIDI) at baseline, and one and three years later. Odds ratios, dose–response relationships and confidence intervals were calculated. Lifetime SPh and PS were associated (OR=3.08; 95% CI=2.49–3.82; p<.001), with a dose response. SPh emerging after PS was significant (OR=4.07; 95% CI=2.50–6.63; p<.001), also with a dose response, i.e. more PS symptoms yield more SPh symptoms. PS emerging after SPh was not significant. This study confirmed the association of SPh and PS in a general population. Possibly this is caused by shared underlying psychological and behavioural processes. There was some indication that paranoid ideation precedes the development of SPh, but this must be considered with caution. Clinical implications are discussed.

The use of a Cumulative Needs for Care Monitor for individual treatment v. care as usual for patients diagnosed with severe mental illness, a cost-effectiveness analysis from the health care perspective.

AIMSnTo study the systematic assessment of need for care and clinical parameters for use in treatment plans in patients diagnosed with severe mental illness.nnnMETHODSnThe Cumulative Needs for Care Monitor (CNCM) includes various validated instruments, such as the Camberwell Assessment of Need. A Markov-type cost-effectiveness model (health care perspective, 5-year time horizon) was used to compare CNCM with care as usual (CAU). Two studies were used to determine model parameters: a before–after study (n = 2155) and a matched-control study (n = 937).nnnRESULTSnThe CNCM may lead to a gain in psychiatric functioning according to the models. CNCM patients remain in (outpatient) care, while CAU patients drop out more frequently. There is only a small difference in inpatient care. As a result, average costs per patient in the CNCM group are between €2809 (before–after model) and €5251 (matched-control model) higher. The iCER was between €45 127 and €57 839 per life year without psychiatric dysfunction gained.nnnCONCLUSIONSnCNCM may be only cost-effective when willingness to pay for a life year without psychiatric dysfunction is higher than €45 000. However, this result is highly sensitive to the level of psychiatric dysfunctioning in patients who do not receive care.

Naar een Nieuwe GGZ: de huisarts als vragende partij?

De ontwikkeling van een ‘state of the art’ goede GGZ, die aansluit bij de nieuwe wetenschappelijke kennis uit het veld, is gebaseerd op drie pijlers: een nieuwe visie op psychisch lijden, een visie op de organisatie van de zorg en een visie op de veranderde maatschappij en cultuur, onder andere mogelijk gemaakt door internet. Om dit te realiseren pleit de Nieuwe GGZ-beweging voor een presente psychiatrie in de wijk. Hierbij wordt de zorg niet afgewenteld op de huisarts, maar krijgt de huisarts er collega’s bij. Dit doen we door een partnership aan te gaan met patienten en hun betrokkenen en samen als professionals de liaison aan te gaan met het maatschappelijk veld. Hiermee gaan we de uitdaging aan om publieke gezondheid te ontwikkelen die in staat is het psychisch lijden te verminderen en te werken aan een psychisch gezonde wijk, waarbij de inclusie van mensen centraal staat. Dit is de uitdaging van de Nieuwe GGZ-beweging en maakt de samenwerking met de huisarts vanzelfsprekend.